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Kunming P, Xiaotian J, Qing X, Chenqi X, Xiaoqiang D, Qian Zhou L. Impact of pharmacist intervention in reducing vancomycin-associated acute kidney injury: A systematic review and meta-analysis. Br J Clin Pharmacol 2023; 89:526-535. [PMID: 35285970 DOI: 10.1111/bcp.15301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/16/2022] [Accepted: 03/03/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS The aim was to quantify the relationship between pharmacist intervention and vancomycin-associated acute kidney injury (AKI). METHODS Electronic databases were searched up to August 2020 for meta-analyses of cohort studies and/or randomized controlled trials. Studies that compared the incidence of AKI in patients between post- and prepharmacist intervention were investigated. The primary outcome was incidence of AKI. We also evaluated the influence of pharmacist intervention in risk factors of vancomycin-associated AKI. RESULTS The search strategy retrieved 1744 studies and 34 studies with 19 298 participants were included (22 published articles and 12 abstracts from conference proceedings). Compared with the preintervention group, the postintervention group patients had a significantly lower incidence of vancomycin-associated AKI: 7.3% for post- and 9.6% for preintervention (odds ratio [OR] 0.52, 95% confidence interval [CI]; 0.41, 0.67], P < .00001). The rate of attaining target concentration was significantly higher in the post- than preintervention group (OR 2.86, 95% CI [2.23, 3.67], P < .00001). The postintervention group significantly improved the percentage of serum creatinine laboratory tests than preintervention group (OR = 3.24, 95% CI 2.02, 5.19], P < .00001). Patients postintervention had markedly lower risk of mortality than preintervention patients (OR 0.47, 95% CI [0.31, 0.72], P = .0004). CONCLUSION Pharmacist intervention in vancomycin treatment significantly decreased the rate of vancomycin-associated AKI, while improving efficacy and reducing mortality. We speculate that this is because the pharmacist interventions optimized the rationality of vancomycin therapy, monitoring of vancomycin trough concentration and the monitoring of patients' renal function.
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Affiliation(s)
- Pan Kunming
- Department of Pharmacy, ZhongShan Hospital FuDan University, ShangHai, China
| | - Jiang Xiaotian
- Department of Nephrology, ZhongShan Hospital FuDan University, ShangHai, China
| | - Xu Qing
- Department of Pharmacy, ZhongShan Hospital FuDan University, ShangHai, China
| | - Xu Chenqi
- Department of Nephrology, ZhongShan Hospital FuDan University, ShangHai, China
| | - Ding Xiaoqiang
- Department of Nephrology, ZhongShan Hospital FuDan University, ShangHai, China
| | - Lv Qian Zhou
- Department of Pharmacy, ZhongShan Hospital FuDan University, ShangHai, China
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Berwanger JD, Lake MA, Ganguly S, Yang J, Welch CJ, Linnes JC, Bruening M. Microporous affinity membranes and their incorporation into microfluidic devices for monitoring of therapeutic antibodies. Talanta 2023; 252:123842. [DOI: 10.1016/j.talanta.2022.123842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
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Hamad Y, Nickel KB, Burnett YJ, Hamad T, George IA, Olsen MA. Prevalence and risk factors associated with readmission with acute kidney injury in patients receiving vancomycin outpatient parenteral antimicrobial therapy. J Clin Pharm Ther 2022; 47:2188-2195. [PMID: 36257600 PMCID: PMC10336722 DOI: 10.1111/jcpt.13790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/30/2022] [Accepted: 09/24/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Vancomycin is commonly used during outpatient parenteral antimicrobial therapy (OPAT). Therapeutic drug monitoring (TDM) of vancomycin is recommended to ensure effective and safe therapy, as use has been associated with acute kidney injury (AKI). METHODS The MarketScan® Commercial Database was queried from 2010 to 2016 to identify patients aged 18-64 years discharged from an inpatient hospitalization on vancomycin OPAT. The primary endpoint was hospital readmission with AKI within 6 weeks of index hospital discharge. TDM was defined as at least one vancomycin level obtained during outpatient therapy. Bivariate analysis was used to examine associations with outcomes; significant factors were incorporated into a multivariable logistic regression model. RESULTS A total of 14,196 patients were included in the study; median age was 54 years and 53.8% were male. Readmission with AKI occurred in 385 (2.7%) and was independently associated with chronic kidney disease (aOR 2.63 [95%CI 1.96-3.52]), congestive heart failure (1.81 [1.34-2.44]), chronic liver disease (1.74 [1.17-2.59]), hypertension (1.73 [1.39-2.17]), septicemia (1.61 [1.30-2.00]), and concomitant OPAT with IV penicillins (1.73 [1.21-2.49]) while skin and soft tissue infection (0.67 [0.54-0.83]) and surgical site infection (0.74 [0.59-0.93]) were associated with lower risk of readmission with AKI. TDM was not associated with lower risk of readmission with AKI. CONCLUSION Chronic kidney disease, congestive heart failure, hypertension, chronic liver disease, septicemia, and concomitant OPAT with IV penicillins were significantly associated with higher risk of readmission with AKI during vancomycin OPAT.
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Affiliation(s)
- Yasir Hamad
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
- Department of Critical Care Medicine, National Institute of Health Clinical Center, Bethesda, MD
| | - Katelin B Nickel
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Yvonne J Burnett
- University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri
| | - Tarig Hamad
- Università della Calabria, Department of Pharmacy and Health and Nutrition Sciences, Rende, Italy
| | - Ige A George
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Margaret A Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
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Hui KHM, Lui CYG, Wu KLA, Chen J, Cheung YT, Lam TNT. Multi-center prospective population pharmacokinetic study and the performance of web-based individual dose optimization application of intravenous vancomycin for adults in Hong Kong: A study protocol. PLoS One 2022; 17:e0267894. [PMID: 35511796 PMCID: PMC9070875 DOI: 10.1371/journal.pone.0267894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 04/12/2022] [Indexed: 11/18/2022] Open
Abstract
A recent consensus guideline recommends migrating the therapeutic drug monitoring practice for intravenous vancomycin for the treatment of methicillin-resistant Staphylococcus aureus infection from the traditional trough-based approach to the Bayesian approach based on area under curve to improve clinical outcomes. To support the implementation of the new strategy for hospitals under Hospital Authority, Hong Kong, this study is being proposed to (1) estimate and validate a population pharmacokinetic model of intravenous vancomycin for local adults, (2) develop a web-based individual dose optimization application for clinical use, and (3) evaluate the performance of the application by comparing the treatment outcomes and clinical satisfaction against the traditional approach. 300 adult subjects prescribed with intravenous vancomycin and not on renal replacement therapy will be recruited for population pharmacokinetic model development and validation. Sex, age, body weight, serum creatinine level, intravenous vancomycin dosing records, serum vancomycin concentrations etc. will be collected from several electronic health record systems maintained by Hospital Authority. Parameter estimation will be performed using non-linear mixed-effect modeling techniques. The web-based individual dose optimization application is based on a previously reported application and is built using R and the package shiny. Data from another 50 subjects will be collected during the last three months of the study period and treated as informed by the developed application and compared against historical control for clinical outcomes. Since the study will incur extra blood-taking procedures from patients, informed consent is required. Other than that, recruited subjects should receive medical treatments as usual. Identifiable patient data will be available only to site investigators and clinicians in each hospital. The study protocol and informed consent forms have been approved by the Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee (reference number: NTEC-2021-0215) and registered at the Chinese Clinical Trial Registry (registration number: ChiCTR2100048714).
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Affiliation(s)
- Ka Ho Matthew Hui
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Chung Yan Grace Lui
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Ka Lun Alan Wu
- Department of Clinical Pathology, Pamela Youde Nethersole Eastern Hospital, Hong Kong East Cluster, Hospital Authority of Hong Kong, Hong Kong, China
| | - Jason Chen
- Department of Pharmacy, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong East Cluster, Hospital Authority, Hong Kong, China
| | - Yin Ting Cheung
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- * E-mail: (TNTL); (YTC)
| | - Tai Ning Teddy Lam
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- * E-mail: (TNTL); (YTC)
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5
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Olney KB, Wallace KL, Mynatt RP, Burgess DS, Grieves K, Willett A, Mani J, Flannery AH. Comparison of Bayesian-derived and first-order analytic equations for calculation of vancomycin area under the curve. Pharmacotherapy 2022; 42:284-291. [PMID: 35134264 PMCID: PMC9750735 DOI: 10.1002/phar.2670] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Consensus guidelines recommend targeting a vancomycin area under the curve to minimum inhibitory concentration (AUC24 :MIC) ratio of 400-600 to improve therapeutic success and reduce nephrotoxicity. Although guidelines specify either Bayesian software or first-order equations may be used to estimate AUC24 , there are currently no large studies directly comparing these methods. OBJECTIVE To compare calculated vancomycin AUC24 using first-order equations with two-drug concentrations at steady state to Bayesian two- and one-concentration estimations. METHODS This was a single-center, retrospective cohort study of 978 adult hospitalized patients receiving intravenous vancomycin between 2017 and 2019. Patients were included if they received at least 72 h of vancomycin and had two-serum drug concentrations obtained. AUC24 was calculated using first-order analytic (linear), Bayesian two-concentration, and Bayesian one-concentration methods for each patient. The InsightRx™ software platform was used to calculate Bayesian AUC24 . Pearson's correlation and clinical agreement (based on AUC24 classified as subtherapeutic, therapeutic, or supratherapeutic) were used to assess agreement between methods. Bland-Altman plots were used to assess mean difference (MD) and 95% limits of agreement (LOA). RESULTS Excellent agreement was observed between linear and Bayesian two-concentration methods (r = 0.963, clinical agreement = 87.4%) and Bayesian two-concentration and one-concentration methods (r = 0.931, clinical agreement = 88.5%); however, a degree of variability was noted with 95% LOA -99 to 76 (MD = -11.5 mg*h/L) and -92 to 113 (MD = -10.4 mg*h/L), for the respective comparisons. The agreement between linear and Bayesian one-concentration approaches was less than prior comparisons (r = 0.823, clinical agreement = 76.8%) and demonstrated the greatest amount of variability with 95% LOA -197 to 153 (MD = -21.9 mg*h/L). CONCLUSIONS Linear and Bayesian two-concentration methods demonstrated high-level agreement with acceptable variability and may be considered comparable to estimate vancomycin AUC24 . As linear and Bayesian one-concentration methods demonstrated significant variability and suboptimal agreement, concerns exist surrounding the interchangeability of these methods in clinical practice, particularly at higher extremes of AUC24 .
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Affiliation(s)
- Katie B. Olney
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Katie L. Wallace
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Ryan P. Mynatt
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
| | - David S. Burgess
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Kaitlyn Grieves
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Austin Willett
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Johann Mani
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Alexander H. Flannery
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
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6
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Kim Y, Kim S, Park J, Lee H. Clinical Response and Hospital Costs of Therapeutic Drug Monitoring for Vancomycin in Elderly Patients. J Pers Med 2022; 12:jpm12020163. [PMID: 35207653 PMCID: PMC8875716 DOI: 10.3390/jpm12020163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/01/2022] [Accepted: 01/03/2022] [Indexed: 12/04/2022] Open
Abstract
Cost-effectiveness analysis has been widely used to assess and compare the costs and benefits of a clinical service. The cost-effectiveness of vancomycin therapeutic drug monitoring (TDM) has not been studied in the elderly, who are susceptible to vancomycin-induced adverse effects. This study was performed to evaluate if vancomycin TDM is cost-effective in elderly patients in the Republic of Korea. Using the electronic medical records at a tertiary university hospital, we performed a retrospective observational study to evaluate the cost-effectiveness of vancomycin TDM in 850 elderly patients who underwent vancomycin TDM with an appropriate, recommended dosing regimen and 1094 elderly patients who did not. Cost-effectiveness variables such as clinical outcomes and medical expenses were evaluated using univariate and multivariate analyses. The TDM group spent significantly less than the non-TDM group per patient for total medical expenses (by USD 841.40) and medication expenses (by USD 16.70). However, no significant difference was noted between the TDM and non-TDM groups in clinical outcomes such as microbiological cure, prevention of nephrotoxicity, or reduced mortality, irrespective of admission to the intensive care unit. Vancomycin TDM in elderly patients was associated with economic benefits, but not with better clinical outcomes.
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Affiliation(s)
- Yun Kim
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea; (Y.K.); (J.P.)
- Hanyang Medicine-Engineering-Bio Collaborative & Comprehensive Center for Drug Development (MEBC), Hanyang University, Seoul 04763, Korea
| | - Soohyun Kim
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul 03080, Korea;
- Center for Convergence Approaches in Drug Development, Graduate School of Convergence Science and Technology, Seoul National University, Seoul 03087, Korea
| | - Jinsook Park
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea; (Y.K.); (J.P.)
| | - Howard Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea; (Y.K.); (J.P.)
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul 03080, Korea;
- Center for Convergence Approaches in Drug Development, Graduate School of Convergence Science and Technology, Seoul National University, Seoul 03087, Korea
- Advanced Institute of Convergence Technology, Suwon-si 16229, Korea
- Correspondence: ; Tel.: +82-2-3668-7602
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7
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Silveira ALO, Alves GCDS, Xie J, Roberts JA, Sanches C. Vancomycin population pharmacokinetic modeling in children using Bayesian estimation and a Non Parametric Approach. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902020000x2e19313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - Jiao Xie
- The University of Queensland, Australia
| | - Jason A Roberts
- The University of Queensland, Australia; Royal Brisbane and Women’s Hospital, Australia; Royal Brisbane and Women’s Hospital, Australia; The University of Queensland, Australia
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Sandaradura I, Alffenaar JW, Cotta MO, Daveson K, Day RO, Van Hal S, Lau C, Marriott DJE, Penm J, Roberts JA, Tabah A, Williams P, Imani S. Emerging therapeutic drug monitoring of anti-infective agents in Australian hospitals: Availability, performance and barriers to implementation. Br J Clin Pharmacol 2021; 88:669-679. [PMID: 34289135 DOI: 10.1111/bcp.14995] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/29/2021] [Accepted: 07/03/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS The purpose of the study was to assess the status of emerging therapeutic drug monitoring (TDM) of anti-infective agents in Australian hospitals. METHODS A nationwide cross-sectional survey of all Australian hospitals operating in the public and private health sector was conducted between August and September 2019. The survey consisted of questions regarding institutional TDM practice for anti-infective agents and clinical vignettes specific to β-lactam antibiotics. RESULTS Responses were received from 82 unique institutions, representing all Australian states and territories. All 29 (100%) of principal referral (major) hospitals in Australia participated. Five surveys were partially complete. Only 25% (20/80) of hospitals had TDM testing available on-site for any of the eight emerging TDM candidates considered: β-lactam antibiotics, anti-tuberculous agents, flucytosine, fluoroquinolones, ganciclovir, human immunodeficiency virus (HIV) drugs, linezolid and teicoplanin. A considerable time lag was noted between TDM sampling and reporting of results. With respect to β-lactam antibiotic TDM, variable indications, pharmacodynamic targets and sampling times were identified. The three greatest barriers to local TDM performance were found to be (1) lack of timely assays/results, (2) lack of institutional-wide expertise and/or training and (3) lack of guidelines to inform ordering of TDM and interpretation of results. The majority of respondents favoured establishing national TDM guidelines and increasing access to dose prediction software, at rates of 89% and 96%, respectively. CONCLUSION Translating emerging TDM evidence into daily clinical practice is slow. Concerted efforts are required to address the barriers identified and facilitate the implementation of standardised practice.
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Affiliation(s)
- Indy Sandaradura
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia.,Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Sydney, NSW, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia
| | - Jan-Willem Alffenaar
- Department of Pharmacy, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, NSW, Australia
| | - Menino O Cotta
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases, Canberra Hospital, Canberra, ACT, Australia.,Queensland Statewide Antimicrobial Stewardship Program, Metro North Hospital and Health Services, Brisbane, QLD, Australia
| | - Richard O Day
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia.,School of Medical Sciences, The University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sebastiaan Van Hal
- Department of Infectious Diseases and Microbiology, New South Wales Health Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Cindy Lau
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Department of Pharmacy, St Vincent's Hospital, Sydney, NSW, Australia
| | - Deborah J E Marriott
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Microbiology, SydPath, St Vincent's Hospital, Sydney, NSW, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Department of Pharmacy, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Paul Williams
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Sahand Imani
- Northern Sydney Local Health District, Hornsby Ku-ring-gai Hospital, Sydney, NSW, Australia
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9
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Lechtig-Wasserman S, Liebisch-Rey H, Diaz-Pinilla N, Blanco J, Fuentes-Barreiro YV, Bustos RH. Carbapenem Therapeutic Drug Monitoring in Critically Ill Adult Patients and Clinical Outcomes: A Systematic Review with Meta-Analysis. Antibiotics (Basel) 2021; 10:antibiotics10020177. [PMID: 33578672 PMCID: PMC7916352 DOI: 10.3390/antibiotics10020177] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 11/16/2022] Open
Abstract
Drug monitoring is one strategy of antibiotic stewardship to face antimicrobial resistance. This strategy could have a determinant role in critically ill patients treated with carbapenems to overcome pharmacokinetic variability, reduce the risk of subtherapeutic dosage or toxicity, and reduce the risks inherent to treatment. However, the effectiveness of therapeutic drug monitoring (TDM) is unknown. This paper aims to identify TDM effectiveness in critically ill patients treated with carbapenems. English and ClinicalTrials.gov databases were searched to identify relevant studies evaluating carbapenem TDM. Randomized controlled trials (RCTs) and comparative cohort studies were selected for inclusion if they compared carbapenem TDM to standard care in adult critically ill or sepsis/septic shock patients. The primary outcome was mortality. Secondary outcomes included morbidity, clinical cure, microbiological eradication, antimicrobial resistance, drug-related side effects, and achievement of target plasma concentrations. Overall, performing carbapenem TDM was not associated with a decrease in mortality. However, it could be evidence for a relationship with clinical cure as well as target attainment. Some studies found favorable outcomes related to clinical and microbiological responses, such as lower procalcitonin levels at the end of the monitored therapy compared to standard care. For the primary and secondary outcomes analyzed, strong evidence was not identified, which could be due to the size, risk of bias, and design of selected studies.
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10
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Therapeutic Drug Monitoring Coupled With Bayesian Forecasting Could Prevent Vancomycin-Associated Nephrotoxicity in Renal Insufficiency Patients: A Prospective Study and Pharmacoeconomic Analysis. Ther Drug Monit 2020; 42:600-609. [DOI: 10.1097/ftd.0000000000000750] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Patel J, Lucas CJ, Ryan J, Jenkins M, Martin JH. Vancomycin therapeutic drug monitoring in paediatrics. J Paediatr Child Health 2020; 56:563-570. [PMID: 31721353 DOI: 10.1111/jpc.14683] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 10/13/2019] [Accepted: 10/21/2019] [Indexed: 11/29/2022]
Abstract
AIM Vancomycin guidelines for therapeutic drug monitoring (TDM) aim to maximise efficacy while minimising toxicity and resistance. Vancomycin is effective against Staphylococcus aureus when it achieves area under the concentration-time curve (AUC)/minimum inhibitory concentration (MIC) > 400. Studies in children have shown that target trough concentrations poorly correlate to AUC/MIC > 400; however, they are used in practice for clinical convenience. This review in paediatric inpatients aims to audit performance against TDM guidelines and consider what changes are needed to optimise vancomycin monitoring. METHODS Vancomycin prescriptions in patients younger than 18 years old were collected over a 15-month period. Primary outcome measures were vancomycin initial dose (mg/kg/day) and the timing and result of first trough concentration (mg/L). Secondary outcome measures were the numbers achieving recommended targets and whether appropriate dose adjustments were made in response to TDM. RESULTS A total of 133 courses reached the time when TDM should occur. Average patient age was 6.5 years, and the average initial dose was 52.55 mg/kg/day (range 19.05-86.54 mg/kg). Only 25% of courses (n = 34) had a trough concentration measured at the recommended time. The mean trough concentration was 11.6 mg/L (range < 2.0-39.7). Of 40 patients with a low trough concentration, 50% continued without dose adjustment. CONCLUSION As shown in the literature, there is a poor correlation between the vancomycin dose given and the trough concentration achieved. Given that recommendations for trough concentration monitoring are designed to simplify the process yet are poorly adhered to, a strategic plan to address these issues is needed.
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Affiliation(s)
- Joanne Patel
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Division of Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Catherine J Lucas
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Division of Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Jessica Ryan
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Division of Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia.,Cancer Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Paediatrics, John Hunter Children's Hospital, Kookaburra Cct, New Lambton Heights, New South Wales, Australia
| | - Michelle Jenkins
- Division of Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Jennifer H Martin
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Division of Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
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12
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He N, Su S, Yan Y, Liu W, Zhai S. The Benefit of Individualized Vancomycin Dosing Via Pharmacokinetic Tools: A Systematic Review and Meta-analysis. Ann Pharmacother 2019; 54:331-343. [PMID: 31694384 DOI: 10.1177/1060028019887363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Various pharmacokinetic (PK) equations and software have been developed to individualize vancomycin dosing. However, the benefit of using any PK information to guide vancomycin dosing has not been fully elucidated. Objective: To appraise available evidence on the effectiveness and safety of individualized vancomycin dosing via PK tools. Methods: PubMed, EMBASE, the Cochrane Library, and 2 Chinese literature databases were searched through August 1, 2019. Randomized controlled trials (RCTs) and cohort studies that reported the PK and clinical outcomes of individualized vancomycin dosing versus empirical dosing were included. Pooled risk ratios (RRs) and mean differences were calculated for dichotomous and continuous outcomes, respectively. Results: A total of 21 studies involving 4346 patients were finally included, of which 3 were RCTs and 18 were cohort studies. Meta-analysis revealed that PK-guided vancomycin dosing significantly increased the attainment of target trough concentration (RR = 1.59; 95% CI = 1.49-1.70) and decreased the incidence of nephrotoxicity (RR = 0.57; 95% CI = 0.46-0.71). Additionally, the available evidence showed that target area under the curve/minimum inhibitory concentration attainment rate and time to target concentration could improve. However, the evidence on clinical outcomes was scarce, and no significant differences were detected in clinical response rate, microbiological eradication rate, mortality, and length of hospital stay between PK-guided vancomycin dosing and empirical dosing strategies. Conclusion and Relevance: Individualized vancomycin dosing via PK tools significantly increases the attainment of target trough concentration and decreases the incidence of nephrotoxicity. Evidence on clinical effectiveness was limited and showed no significant benefit. Further well-designed studies are warranted to assess its clinical effectiveness and inform routine care.
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Affiliation(s)
- Na He
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Shan Su
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Yingying Yan
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Wenxi Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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13
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Claeys KC, Hopkins TL, Brown J, Heil EL. Pharmacists' perceptions of implementing a pharmacist‐managed area under the concentration time curve‐guided vancomycin dosing program at a large academic medical center. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kimberly C. Claeys
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland
| | - Teri L. Hopkins
- Department of Pharmacy South Texas Veterans Health Care System San Antonio Texas
| | - Jessica Brown
- Department of Epidemiology and Public Health University of Maryland School of Medicine Baltimore Maryland
| | - Emily L Heil
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland
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14
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Al-Sulaiti FK, Nader AM, Saad MO, Shaukat A, Parakadavathu R, Elzubair A, Al-Badriyeh D, Elewa H, Awaisu A. Clinical and Pharmacokinetic Outcomes of Peak-Trough-Based Versus Trough-Based Vancomycin Therapeutic Drug Monitoring Approaches: A Pragmatic Randomized Controlled Trial. Eur J Drug Metab Pharmacokinet 2019; 44:639-652. [PMID: 30919233 PMCID: PMC6746691 DOI: 10.1007/s13318-019-00551-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Vancomycin therapeutic drug monitoring (TDM) is based on achieving 24-h area under the concentration-time curve to minimum inhibitory concentration cure breakpoints (AUC24/MIC). Approaches to vancomycin TDM vary, with no head-to-head randomized controlled trial (RCT) comparisons to date. OBJECTIVES We aimed to compare clinical and pharmacokinetic outcomes between peak-trough-based and trough-only-based vancomycin TDM approaches and to determine the relationship between vancomycin AUC24/MIC and cure rates. METHODS A multicentered pragmatic parallel-group RCT was conducted in Hamad Medical Corporation hospitals in Qatar. Adult non-dialysis patients initiated on vancomycin were randomized to peak-trough-based or trough-only-based vancomycin TDM. Primary endpoints included vancomycin AUC24/MIC ratio breakpoint for cure and clinical effectiveness (therapeutic cure vs therapeutic failure). Descriptive, inferential, and classification and regression tree (CART) statistical analyses were applied. NONMEM.v.7.3 was used to conduct population pharmacokinetic analyses and AUC24 calculations. RESULTS Sixty-five patients were enrolled [trough-only-based-TDM (n = 35) and peak-trough-based-TDM (n = 30)]. Peak-trough-based TDM was significantly associated with higher therapeutic cure rates compared to trough-only-based TDM [76.7% vs 48.6%; p value = 0.02]. No statistically significant differences were observed for all-cause mortality, neutropenia, or nephrotoxicity between the two groups. Compared to trough-only-based TDM, peak-trough-based TDM was associated with less vancomycin total daily doses by 12.05 mg/kg/day (p value = 0.027). CART identified creatinine clearance (CLCR), AUC24/MIC, and TDM approach as significant determinants of therapeutic outcomes. All patients [n = 19,100%] with CLCR ≤ 7.85 L/h, AUC24/MIC ≤ 1256, who received peak-trough-based TDM achieved therapeutic cure. AUC24/MIC > 565 was identified to be correlated with cure in trough-only-based TDM recipients [n = 11,84.6%]. No minimum AUC24/MIC breakpoint was detected by CART in the peak-trough-based group. CONCLUSION Maintenance of target vancomycin exposures and implementation of peak-trough-based vancomycin TDM may improve vancomycin-associated cure rates. Larger scale RCTs are warranted to confirm these findings.
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Affiliation(s)
- Fatima Khalifa Al-Sulaiti
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, P.O. Box 2713, Doha, Qatar
- Qatar National Research Fund, Qatar Foundation, Doha, Qatar
| | | | - Mohamed Omar Saad
- Clinical Pharmacy Department, Al-Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Adila Shaukat
- Infectious Diseases Department, Al-Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rakesh Parakadavathu
- Infectious Diseases Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Elzubair
- Clinical Pharmacy Department, Al-Khor Hospital, Hamad Medical Corporation, Al-Khor, Qatar
| | - Daoud Al-Badriyeh
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Hazem Elewa
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Ahmed Awaisu
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, P.O. Box 2713, Doha, Qatar.
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15
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de Velde F, Mouton JW, de Winter BCM, van Gelder T, Koch BCP. Clinical applications of population pharmacokinetic models of antibiotics: Challenges and perspectives. Pharmacol Res 2018; 134:280-288. [PMID: 30033398 DOI: 10.1016/j.phrs.2018.07.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/05/2018] [Accepted: 07/05/2018] [Indexed: 11/26/2022]
Abstract
Because of increasing antimicrobial resistance and the shortage of new antibiotics, there is a growing need to optimize the use of old and new antibiotics. Modelling of the pharmacokinetic/pharmacodynamic (PK/PD) characteristics of antibiotics can support the optimization of dosing regimens. Antimicrobial efficacy is determined by susceptibility of the drug to the microorganism and exposure to the drug, which relies on the PK and the dose. Population PK models describe relationships between patients characteristics and drug exposure. This article highlights three clinical applications of these models applied to antibiotics: 1) dosing evaluation of old antibiotics, 2) setting clinical breakpoints and 3) dosing individualization using therapeutic drug monitoring (TDM). For each clinical application, challenges regarding interpretation are discussed. An important challenge is to improve the understanding of the interpretation of modelling results for good implementation of the dosing recommendations, clinical breakpoints and TDM advices. Therefore, also background information on PK/PD principles and approaches to analyse PK/PD data are provided.
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Affiliation(s)
- Femke de Velde
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands.
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands; Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
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16
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Truong WR, Yamaki J. The Hospital Antimicrobial Use Process: From Beginning to End. Open Forum Infect Dis 2018; 5:ofy098. [PMID: 29977958 PMCID: PMC6016413 DOI: 10.1093/ofid/ofy098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 04/27/2018] [Indexed: 11/14/2022] Open
Abstract
Hospital antimicrobial stewardship (AMS) programs are responsible for ensuring that all antimicrobials are utilized in the most appropriate and safe manner to improve patient outcomes, prevent adverse drug reactions, and prevent the development of antimicrobial resistance. This Perspectives article outlines the hospital antimicrobial use process (AUP), the foundational system that ensures that all antimicrobials are utilized in the most appropriate and safe manner. The AUP consists of the following steps: antimicrobial ordering, order verification, preparation and delivery, administration, monitoring, and discharge prescribing. AMS programs should determine how each step contributes to how an antimicrobial is used appropriately or inappropriately at their institution. Through this understanding, AMS programs can integrate stewardship activities at each step to ensure that every opportunity is taken to optimize antimicrobial use during a patient's treatment course. Hence, approaching AMS through the framework of a hospital's AUP is essential to improving appropriate antimicrobial use.
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Affiliation(s)
| | - Jason Yamaki
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, California
- Department of Pharmacy, Hoag Memorial Hospital Presbyterian, Newport Beach, California
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17
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Hill JD, Williams JP, Barnes JF, Greenlee KM, Cardiology BCPSAQ, Leonard MC. Development of a pharmacy resident rotation to expand decentralized clinical pharmacy services. Am J Health Syst Pharm 2017; 74:1085-1092. [DOI: 10.2146/ajhp160135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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18
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Doernberg SB, Chambers HF. Antimicrobial Stewardship Approaches in the Intensive Care Unit. Infect Dis Clin North Am 2017; 31:513-534. [PMID: 28687210 DOI: 10.1016/j.idc.2017.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antimicrobial stewardship programs aim to monitor, improve, and measure responsible antibiotic use. The intensive care unit (ICU), with its critically ill patients and prevalence of multiple drug-resistant pathogens, presents unique challenges. This article reviews approaches to stewardship with application to the ICU, including the value of diagnostics, principles of empirical and definitive therapy, and measures of effectiveness. There is good evidence that antimicrobial stewardship results in more appropriate antimicrobial use, shorter therapy durations, and lower resistance rates. Data demonstrating hard clinical outcomes, such as adverse events and mortality, are more limited but encouraging; further studies are needed.
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Affiliation(s)
- Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California, 513 Parnassus Avenue, Box 0654, San Francisco, CA 94143, USA.
| | - Henry F Chambers
- Division of Infectious Diseases, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, Room 3400, Building 30, 1001 Potrero Avenue, San Francisco, CA 94110, USA
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19
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Han Z, Pettit NN, Landon EM, Brielmaier BD. Impact of Pharmacy Practice Model Expansion on Pharmacokinetic Services: Optimization of Vancomycin Dosing and Improved Patient Safety. Hosp Pharm 2017. [DOI: 10.1310/hpx5204-273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
| | - Natasha N. Pettit
- Infectious Diseases, The University of Chicago Medicine, Department of Pharmacy Services, Chicago, Illinois
| | - Emily M. Landon
- Hospital Epidemiologist, The University of Chicago Medicine, Department of Medicine, Section of Infectious Diseases and Global Health, Chicago, Illinois
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20
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Awdishu L, Mehta RL. The 6R's of drug induced nephrotoxicity. BMC Nephrol 2017; 18:124. [PMID: 28372552 PMCID: PMC5379580 DOI: 10.1186/s12882-017-0536-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 03/25/2017] [Indexed: 01/05/2023] Open
Abstract
Drug induced kidney injury is a frequent adverse event which contributes to morbidity and increased healthcare utilization. Our current knowledge of drug induced kidney disease is limited due to varying definitions of kidney injury, incomplete assessment of concurrent risk factors and lack of long term outcome reporting. Electronic surveillance presents a powerful tool to identify susceptible populations, improve recognition of events and provide decision support on preventative strategies or early intervention in the case of injury. Research in the area of biomarkers for detecting kidney injury and genetic predisposition for this adverse event will enhance detection of injury, identify those susceptible to injury and likely mitigate risk. In this review we will present a 6R framework to identify and mange drug induced kidney injury – risk, recognition, response, renal support, rehabilitation and research.
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Affiliation(s)
- Linda Awdishu
- UC San Diego Skaggs School of Pharmacy, San Diego, USA. .,UC San Diego School of Medicine, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
| | - Ravindra L Mehta
- UC San Diego School of Medicine, 9500 Gilman Dr, La Jolla, CA, 92093, USA
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21
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Han Z, Pettit NN, Landon EM, Brielmaier BD. Impact of Pharmacy Practice Model Expansion on Pharmacokinetic Services: Optimization of Vancomycin Dosing and Improved Patient Safety. Hosp Pharm 2017; 52:273-279. [PMID: 28515506 PMCID: PMC5424831 DOI: 10.1310/hpj5204-273] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: The impact of pharmacy interventions on optimizing vancomycin therapy has been described, however interventions vary among studies and the most optimal pharmacy practice model (PPM) for pharmacokinetic (PK) services has not been established. Objective: The purpose of this study is to demonstrate the value of 24 hours a day, 7 days a week (24/7) PK services. Methods: New PK services were implemented in 2 phases with institutional PPM expansion. Phase 1 included universal monitoring by pharmacists with recommendations made to prescribers during business hours. Phase 2 expanded clinical pharmacists' coverage to 24/7 and provided an optional 24/7 pharmacist-managed PK consult service. We compared vancomycin therapeutic trough attainment, dosing, and clinical and safety outcomes between phases 1 and 2 in adult inpatients receiving therapeutic intravenous vancomycin. Results. One hundred and fifty patients were included in each phase. Phase 2 had a greater proportion of vancomycin courses with therapeutic initial trough concentrations (27.5% vs 46.1%; p = 0.002), higher initial trough concentrations (10.9 mcg/mL vs 16.4 mcg/mL; p < 0.001), and optimized initial vancomycin dosing (13.5 mg/kg vs 16.2 mg/kg; p < 0.001). Phase 2 also saw significant reduction in the incidence of vancomycin-associated nephrotoxicity (21.1% vs 11.7%; p = 0.038). Dose optimization and improvement in initial target trough attainment were most notable among intensive care unit (ICU) patients. Conclusions. Our study demonstrated that 24/7 PK services implemented with institutional PPM expansion optimized vancomycin target trough attainment and improved patient safety.
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Brent J, Burkhart K, Dargan P, Hatten B, Megarbane B, Palmer R, White J. Adverse Drug Reactions in the Intensive Care Unit. CRITICAL CARE TOXICOLOGY 2017. [PMCID: PMC7153447 DOI: 10.1007/978-3-319-17900-1_33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.
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Affiliation(s)
- Jeffrey Brent
- Department of Medicine, Division of Clinical Pharmacology and Toxicology, University of Colorado, School of Medicine, Aurora, Colorado USA
| | - Keith Burkhart
- FDA, Office of New Drugs/Immediate Office, Center for Drug Evaluation and Research, Silver Spring, Maryland USA
| | - Paul Dargan
- Clinical Toxicology, St Thomas’ Hospital, Silver Spring, Maryland USA
| | - Benjamin Hatten
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Bruno Megarbane
- Medical Toxicological Intensive Care Unit, Lariboisiere Hospital, Paris-Diderot University, Paris, France
| | - Robert Palmer
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Julian White
- Toxinology Department, Women’s and Children’s Hospital, North Adelaide, South Australia Australia
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23
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Okada N, Fushitani S, Azuma M, Nakamura S, Nakamura T, Teraoka K, Watanabe H, Abe M, Kawazoe K, Ishizawa K. Clinical Evaluation of Pharmacist Interventions in Patients Treated with Anti-methicillin-Resistant Staphylococcus aureus Agents in a Hematological Ward. Biol Pharm Bull 2016; 39:295-300. [PMID: 26830489 DOI: 10.1248/bpb.b15-00774] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The therapeutic effects of anti-methicillin-resistant Staphylococcus aureus (MRSA) agents, vancomycin (VCM), teicoplanin (TEIC), and arbekacin (ABK), depend on their concentrations in blood. Therefore, therapeutic drug monitoring (TDM) is important when these antibiotics are used. In the hematological ward at Tokushima University Hospital, pharmacists have ordered the measurement of blood VCM, TEIC, and ABK concentrations to promote the use of TDM in accordance with an agreed protocol since 2013. Moreover, the infection control team includes several medical disciplines and has advised on the optimal treatment using VCM, TEIC, and ABK since 2013. This study aimed to investigate the clinical effectiveness of these pharmacist interventions. We retrospectively studied 145 cases in which patients were treated with VCM, TEIC, or ABK between January 2012 and December 2013 in the hematological ward at Tokushima University Hospital. The patients were divided into a control group (71 cases) and an intervention group (74 cases), and their clinical outcomes were compared. The rate of achievement of effective drug concentrations significantly increased in the intervention group (74%), compared to the rate in the control group (55%). Moreover, univariate and multivariate Cox proportional hazard regression revealed that pharmacist intervention and appropriate concentrations of anti-MRSA agents were independent factors associated with reduced hospitalization periods in patients with lymphoma. Our study revealed that proactive pharmacist intervention may improve the therapeutic effect of anti-MRSA agents in hematology ward patients.
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Affiliation(s)
- Naoto Okada
- Department of Pharmacy, Tokushima University Hospital
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Punyawudho B, Singkham N, Thammajaruk N, Dalodom T, Kerr SJ, Burger DM, Ruxrungtham K. Therapeutic drug monitoring of antiretroviral drugs in HIV-infected patients. Expert Rev Clin Pharmacol 2016; 9:1583-1595. [PMID: 27626677 DOI: 10.1080/17512433.2016.1235972] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) may be beneficial when applied to antiretroviral (ARV). Even though TDM can be a valuable strategy in HIV management, its role remains controversial. Areas covered: This review provides a comprehensive update on important issues relating to TDM of ARV drugs in HIV-infected patients. Articles from PubMed with keywords relevant to each topic section were reviewed. Search strategies limited to articles published in English. Expert commentary: There is evidence supporting the use of TDM in HIV treatment. However, some limitations need to be considered. The evidence supporting the use of routine TDM for all patients is limited, as it is not clear that this strategy offers any advantages over TDM for selected indications. Selected groups of patients including patients with physiological changes, patients with drug-drug interactions or toxicity, and the elderly could potentially benefit from TDM, as optimized dosing is challenging in these populations.
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Affiliation(s)
- Baralee Punyawudho
- a Department of Pharmaceutical Care, Faculty of Pharmacy , Chiang Mai University , Chiang Mai , Thailand
| | - Noppaket Singkham
- a Department of Pharmaceutical Care, Faculty of Pharmacy , Chiang Mai University , Chiang Mai , Thailand
| | | | - Theera Dalodom
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand
| | - Stephen J Kerr
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand.,c The Kirby Institute, University of New South Wales , Sydney , Australia.,d Department of Global Health, Academic Medical Center , University of Amsterdam, Amsterdam Institute for Global Health and Development , Amsterdam , The Netherlands
| | - David M Burger
- e Radbound University Medical Center , Nijmegen , The Netherlands
| | - Kiat Ruxrungtham
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand.,f Faculty of Medicine , Chulalongkorn University , Bangkok , Thailand
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25
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Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW, Jenkins TC, Lipsett PA, Malani PN, May LS, Moran GJ, Neuhauser MM, Newland JG, Ohl CA, Samore MH, Seo SK, Trivedi KK. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62:e51-77. [PMID: 27080992 PMCID: PMC5006285 DOI: 10.1093/cid/ciw118] [Citation(s) in RCA: 1814] [Impact Index Per Article: 226.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 12/11/2022] Open
Abstract
Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.
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Affiliation(s)
- Tamar F Barlam
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lilian M Abbo
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Conan MacDougall
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco
| | - Audrey N Schuetz
- Department of Medicine, Weill Cornell Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Edward J Septimus
- Department of Internal Medicine, Texas A&M Health Science Center College of Medicine, Houston
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Timothy H Dellit
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle
| | - Yngve T Falck-Ytter
- Department of Medicine, Case Western Reserve University and Veterans Affairs Medical Center, Cleveland, Ohio
| | - Neil O Fishman
- Department of Medicine, University of Pennsylvania Health System, Philadelphia
| | | | | | - Pamela A Lipsett
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland
| | - Preeti N Malani
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor
| | - Larissa S May
- Department of Emergency Medicine, University of California, Davis
| | - Gregory J Moran
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Sylmar
| | | | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Missouri
| | - Christopher A Ohl
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew H Samore
- Department of Veterans Affairs and University of Utah, Salt Lake City
| | - Susan K Seo
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, New York
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Cardile AP, Tan C, Lustik MB, Stratton AN, Madar CS, Elegino J, Hsue G. Optimization of time to initial vancomycin target trough improves clinical outcomes. SPRINGERPLUS 2015. [PMID: 26203410 PMCID: PMC4506278 DOI: 10.1186/s40064-015-1146-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Outcomes data for the efficacy of interventions designed to decrease the time to initial target vancomycin troughs are sparse. OBJECTIVE A vancomycin therapeutic drug monitoring (TDM) program was initiated to reduce the time to initial target troughs and to examine the impact on clinical outcomes. METHODS Single-center, pre- and post-intervention observational study in a 250 bed teaching facility. Adult inpatients treated with physician-guided, vancomycin therapy (historical control, CTRL) were compared to high trough, pharmacist-guided vancomycin therapy (TDM). Nephrotoxicity analyses were conducted to the ensure safety of the TDM. Clinical outcome analysis was limited to patients with normal renal function and culture-confirmed gram positive infections and a pre-defined MRSA subset. RESULTS 340 patients met initial inclusion criteria for the nephrotoxicity analysis (TDM, n = 173; CTRL, n = 167). Acute kidney injury occurrence was similar between the CTRL (n = 20) and TDM (n = 23) groups (p = 0.7). Further exclusions yielded 145 patients with gram positive infections for clinical outcomes evaluation (TDM, n = 66; CTRL, n = 75). The time to initial target trough was shorter in the TDM group (3 vs. 5 days, p < 0.001). Patients in the TDM group discharged from the hospital more rapidly, 7 vs. 14 days (Hazards Ratio (HR), 1.41; 95% Confidence Interval [CI] 1.08-1.83; p = 0.01), reached clinical stability faster, 4 vs. 8 days (HR, 1.51; 95% CI 1.08-2.11; p = 0.02), and had shorter courses of vancomycin, 4 vs. 7 days (HR, 1.5; 95% CI 1.15-1.95; p = 0.003). In the MRSA infection subset (TDM, n = 36; CTRL, n = 35), patients in the TDM group discharged from the hospital more rapidly, 7 vs. 16 days (HR, 1.89; 95% CI 1.08-3.3; p = 0.03), reached clinical stability faster, 4 vs. 6 days (HR, 2.69; 95% CI 1.27-5.7; p = 0.01), and had shorter courses of vancomycin, 5 vs. 8 days (HR, 2.52; 95% CI 1.38-4.6; p = 0.003). Attaining initial target troughs in <5 days versus ≥5 days was associated with improved clinical outcomes. All cause in-hospital mortality, and vancomycin treatment failure occurred at comparable rates between groups. CONCLUSIONS Interventions designed to decrease the time to reach initial target vancomycin troughs can improve clinical outcomes in gram positive infections, and in particular MRSA infections.
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Affiliation(s)
- Anthony P Cardile
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Christopher Tan
- Department of Pharmacy, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Michael B Lustik
- Department of Clinical Investigation, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Amy N Stratton
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Cristian S Madar
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Jun Elegino
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Günther Hsue
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA ; Department of Infectious Diseases, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
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Lie K, Mees A, Ford V, McCauley L, Roberts M, Clifford RM. Low Adherence to Vancomycin Guidelines at an Australian Paediatric Hospital. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2011.tb00104.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | | | | | | | | | - Rhonda M Clifford
- School of Biomolecular, Biomedical and Chemical SciencesUniversity of Western Australia Crawley Western Australia
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Scaglione F, Paraboni L. Influence of pharmacokinetics/pharmacodynamics of antibacterials in their dosing regimen selection. Expert Rev Anti Infect Ther 2014; 4:479-90. [PMID: 16771624 DOI: 10.1586/14787210.4.3.479] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The choice of antimicrobial dosing in clinical practice in the past was based upon a 'penicillin mentality', that is, on the assumption that the in vivo antimicrobial efficacy is dependent on the duration of drug levels above the minimum inhibitory concentration of target microorganisms. Really, a rational antimicrobial therapy is strongly related to a basic understanding of the influence the patient has on the antibiotic (pharmacokinetics [PKs]) and the patient's response to the specific drug effects (pharmacodynamics [PDs]). PK/PD parameters are essential in facilitating the translation of microbiological activity into clinical situations, ensuring a successful outcome. This review will analyze the typical patterns of antimicrobial activity and the corresponding PK/PD parameters, with a special focus on a PK/PD dosing approach with the most commonly utilized antimicrobial agent classes.
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Affiliation(s)
- Francesco Scaglione
- University of Milan, Department of Pharmacology, Chemotherapy and Toxicology, Faculty of Medicine, Via Vanvitelli 32, 20129, Milan, Italy.
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Ye ZK, Tang HL, Zhai SD. Benefits of therapeutic drug monitoring of vancomycin: a systematic review and meta-analysis. PLoS One 2013; 8:e77169. [PMID: 24204764 PMCID: PMC3799644 DOI: 10.1371/journal.pone.0077169] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 09/09/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The necessity of therapeutic drug monitoring (TDM) for vancomycin is controversial. The objective of the current review was to evaluate the available evidence for the necessity of TDM in patients given vancomycin to treat Gram-positive infections. METHODS Medline, Embase, Web of Sciences, the Cochrane Library and two Chinese literature databases (CNKI, CBM) were searched. Randomized controlled studies and observational studies that compared the clinical outcomes of TDM groups vs. non-TDM groups were included. Two reviewers independently extracted the data. The primary outcome was clinical efficacy of therapy. Secondary outcomes included vancomycin associated nephrotoxicity, duration of vancomycin therapy, length of hospital stay, and mortality. Meta-analysis was performed using the Mantel-Haenszel fixed effect method (FEM). Odds ratios (ORs) or weighted mean differences (WMD) with 95% confidence intervals (95%CIs) were calculated for categorical and continuous outcomes, respectively. RESULTS One randomized controlled trial (RCT) and five cohort studies were included in the meta-analysis. Compared with non-TDM groups, TDM groups had significantly higher rates of clinical efficacy (OR = 2.62, 95%CI 1.34-5.11 P = 0.005) and decreased rates of nephrotoxicity (OR = 0.25, 95%CI 0.13-0.48 P<0.0001). Subgroup analyses showed that TDM group had significantly higher rates of clinical efficacy in both cohort studies subgroup (OR = 3.04, 95%CI 1.34-6.90) and in Asian population subgroup (OR = 3.04, 95%CI 1.34-6.90). TDM group had significantly decreased rates of nephrotoxicity in all subgroup. There was no significant difference in duration of vancomycin therapy (WMD = -0.40, 95%CI -2.83-2.02 P = 0.74) or length of stay (WMD = -1.01, 95%CI -7.51-5.49 P = 0.76) between TDM and non-TDM groups. Subgroup analyses showed there were no differences in duration of vancomycin therapy. Only one study reported mortality rates. CONCLUSIONS Studies to date show that TDM significantly increases the rate of clinical efficacy and decreases the rate of nephrotoxicity in patients treated with vancomycin.
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Affiliation(s)
- Zhi-Kang Ye
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Hui-Lin Tang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Suo-Di Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
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Suryadevara M, Steidl KE, Probst LA, Shaw J. Inappropriate vancomycin therapeutic drug monitoring in hospitalized pediatric patients increases pediatric trauma and hospital costs. J Pediatr Pharmacol Ther 2012; 17:159-65. [PMID: 23118668 DOI: 10.5863/1551-6776-17.2.159] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES The objective of this study was to measure the appropriateness of vancomycin monitoring in a pediatric tertiary care center and to evaluate the effectiveness of two interventions, autonomous pharmacy therapeutic drug monitoring and health care provider education, in reducing avoidable pediatric patient trauma and hospital cost. METHODS A retrospective chart review evaluating vancomycin therapeutic drug monitoring (TDM) in pediatric inpatients was performed before and after the introduction of an autonomous pharmacy TDM program and health care provider (HCP) education. RESULTS Thirty-five patients were included in our study, prior to any intervention. Of these, 9% of patients had trough concentrations appropriately deferred. Of the total of 64 trough concentrations obtained, 94% were considered to be inappropriate. After the start of the autonomous pharmacy TDM program, of the 54 eligible patients (111 troughs), 9% had trough concentrations appropriately deferred, and 34% were inappropriate. In the 3-month period following the introduction of HCP education in combination with pharmacy TDM, we identified 27 eligible patients. Among those, 15% of the patients had trough concentrations appropriately deferred. Of the 43 trough concentrations obtained, only 9% were considered to be inappropriate. The combination of pharmacy TDM with HCP education decreased annualized hospital cost by 60%, from $13,080 to $5232. CONCLUSIONS Inappropriate vancomycin TDM occurs commonly in our institution, resulting in unnecessary hospital cost and patient trauma. The combination of pharmacy TDM and HCP education significantly improved clinical practice; however, results were short-lived. Further interventions, such as computer based order entry, will likely be needed to reinforce and improve long-term TDM practice in pediatric patients.
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Affiliation(s)
- Manika Suryadevara
- Department of Pediatrics, SUNY Upstate Medical University, New York, New York
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The role of MAPK in drug-induced kidney injury. JOURNAL OF SIGNAL TRANSDUCTION 2012; 2012:463617. [PMID: 22523682 PMCID: PMC3317229 DOI: 10.1155/2012/463617] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 11/02/2011] [Accepted: 11/04/2011] [Indexed: 12/23/2022]
Abstract
This paper focuses on the role that mitogen-activated protein kinases (MAPKs) play in drug-induced kidney injury. The MAPKs, of which there are four major classes (ERK, p38, JNK, and ERK5/BMK), are signalling cascades which have been found to be broadly conserved across a wide variety of organisms. MAPKs allow effective transmission of information from the cell surface to the cytosolic or nuclear compartments. Cross talk between the MAPKs themselves and with other signalling pathways allows the cell to modulate responses to a wide variety of external stimuli. The MAPKs have been shown to play key roles in both mediating and ameliorating cellular responses to stress including xenobiotic-induced toxicity. Therefore, this paper will discuss the specific role of the MAPKs in the kidney in response to injury by a variety of xenobiotics and the potential for therapeutic intervention at the level of MAPK signalling across different types of kidney disease.
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Boumis E, Gesu G, Menichetti F, Ranieri M, Rinaldi M, Suter F, Nicastri E, Lauria FN, Carosi G, Moroni M, Ippolito G. Consensus document on controversial issues in the diagnosis and treatment of bloodstream infections and endocarditis. Int J Infect Dis 2010; 14 Suppl 4:S23-38. [DOI: 10.1016/j.ijid.2010.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Rybak M, Lomaestro B, Rotschafer JC, Moellering R, Craig W, Billeter M, Dalovisio JR, Levine DP. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2009; 66:82-98. [PMID: 19106348 DOI: 10.2146/ajhp080434] [Citation(s) in RCA: 1294] [Impact Index Per Article: 86.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Michael Rybak
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Science, Wayne State University, Detroit, MI, USA
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Niu SC, Deng ST, Lee MH, Ho C, Chang HY, Liu FH. Modified vancomycin dosing protocol for treatment of diabetic foot infections. Am J Health Syst Pharm 2008; 65:1740-3. [PMID: 18769001 DOI: 10.2146/ajhp080004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The clinical efficacy of a modified vancomycin dosing protocol with a conventional regimen for managing patients with diabetic foot infections caused by methicillin-resistant Staphylococcus aureus (MRSA) was evaluated. METHODS This prospective study was conducted from January 2002 to December 2004 at the diabetic ward of Chang Gung Memorial Hospital--Linkou in Taiwan. All diabetic patients with MRSA-related diabetic foot infections confirmed by wound cultures were enrolled in this study. Patients treated with the conventional protocol (from 2002 to 2003) received vancomycin 10-15 mg/kg (up to 1 g) over 60 minutes every 12 hours if their serum creatinine (SCr) concentration was 0.4-1.4 mg/dL according to the estimation of creatinine clearance (CL(cr)). Patients treated with the modified vancomycin dosing protocol (from 2003 to 2004) received vancomycin according to their SCr level, age, and concurrent gentamicin dosage. Data analyzed included patients' age, sex, body weight, SCr level, CL(cr), serum vancomycin peak and trough levels, vancomycin dosage, treatment period, and duration of hospital stay. RESULTS A total of 85 patients were enrolled in this study. The conventional protocol group achieved substantially higher serum vancomycin levels than those recommended by the British National Formulary (BNF). Although the vancomycin dosage in the modified protocol was lower than that in the conventional protocol, trough and peak vancomycin levels remained within the range recommended by the BNF. The duration of hospitalization and treatment did not significantly differ between the two groups. CONCLUSION A modified vancomycin dosing protocol for treating diabetic foot infections caused by MRSA was superior to the conventional dosing regimen in achieving therapeutic serum levels of vancomycin.
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Affiliation(s)
- Su-Chen Niu
- Department of Pharmacy, Chang Gung Memorial Hospital, Taipei, Taiwan
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Scaglione F, Paraboni L. Pharmacokinetics/pharmacodynamics of antibacterials in the Intensive Care Unit: setting appropriate dosing regimens. Int J Antimicrob Agents 2008; 32:294-301. [PMID: 18621508 DOI: 10.1016/j.ijantimicag.2008.03.015] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 03/26/2008] [Indexed: 12/18/2022]
Abstract
Patients admitted to Intensive Care Units (ICUs) are at very high risk of developing severe nosocomial infections. Consequently, antimicrobials are among the most important and commonly prescribed drugs in the management of these patients. Critically ill patients in ICUs include representatives of all age groups with a range of organ dysfunction related to severe acute illness that may complicate long-term illness. The range of organ dysfunction, together with drug interactions and other therapeutic interventions (e.g. haemodynamically active drugs and continuous renal replacement therapies), may strongly impact on antimicrobial pharmacokinetics in critically ill patients. In the last decade, it has become apparent that the intrinsic pharmacokinetic (PK) and pharmacodynamic (PD) properties are the major determinants of in vivo efficacy of antimicrobial agents. PK/PD parameters are essential in facilitating the translation of microbiological activity into clinical situations, ensuring a successful outcome. In this review, we analyse the typical patterns of antimicrobial activity and the corresponding PK/PD parameters, with a special focus on a PK/PD dosing approach of the antimicrobial agent classes commonly utilised in the ICU setting.
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Affiliation(s)
- Francesco Scaglione
- Department of Pharmacology, Chemotherapy and Toxicology, Faculty of Medicine, University of Milan, Milan, Italy.
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36
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Bond CA, Raehl CL. 2006 National Clinical Pharmacy Services Survey: Clinical Pharmacy Services, Collaborative Drug Management, Medication Errors, and Pharmacy Technology. Pharmacotherapy 2008; 28:1-13. [DOI: 10.1592/phco.28.1.1] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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von Gunten V, Reymond JP, Beney J. Clinical and economic outcomes of pharmaceutical services related to antibiotic use: a literature review. ACTA ACUST UNITED AC 2007; 29:146-63. [PMID: 17273907 DOI: 10.1007/s11096-006-9042-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2005] [Accepted: 06/20/2006] [Indexed: 10/23/2022]
Abstract
AIM OF THE REVIEW To identify and review the clinical and economic impact of pharmacists' interventions on antibiotic use. METHOD A literature search was conducted on Medline (1966-2003) to identify original articles measuring the impact of pharmacists' interventions on antimicrobial therapy at patient's or prescriber's level. RESULTS Forty-three articles were included: 20 uncontrolled before-after studies, four controlled before-after studies, five controlled trials, 12 randomized controlled trials and two interrupted time series (ITS). The described interventions were grouped into four categories: patient-specific recommendations (pharmacists' interventions concerning patient-specific drug therapy), implementation of policies, education, and therapeutic drug monitoring. These interventions were often combined to provide a multifaceted intervention, making it difficult to isolate the impact of one specific intervention. Measured outcomes were: appropriateness of prescribing (evaluated in 17 studies, 16 showing significant improvement), costs (analysed in 22 studies, nine showing a statistically significant reduction in costs after or with the intervention), and length of hospital stay (mixed results). Other measured outcomes were: drug use, prescriptions, length of treatment, dose intervals, switch to oral route, mortality rate, and treatment failure. CONCLUSION Over the years, the number of studies and quality of methodology has increased. The most frequently observed outcomes with a positive impact were appropriateness of prescribing and cost savings. The vast majority of studies used multiple interventions, in conjunction with pharmacists' recommendations to physicians. Coupled with the use of practice guidelines or educational strategies, these interventions demonstrated a positive impact on economic or clinical outcomes. However, the data are still sparse and sometimes contradictory; therefore, further studies with randomized controlled designs are needed.
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Affiliation(s)
- Vera von Gunten
- Division of Pharmacy, Institut Central des Hôpitaux Valaisans, Sion, Switzerland.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe the most prevalent mechanisms of drug-induced acute kidney injury, to define the risk factors for nephrotoxicity, and to analyze the available evidence for preventive measures. RECENT FINDINGS Drug toxicity remains an important cause of acute kidney injury that, in many circumstances, can be prevented or at least minimized by vigilance and early intervention. Recent studies have resulted in increased insight into the subcellular mechanisms of drug nephrotoxicity. Further improvement is to be expected from the identification of early markers of nephrotoxicity and an increasing involvement of a clinical pharmacist. SUMMARY The main mechanisms of nephrotoxicity are vasoconstriction, altered intraglomerular hemodynamics, tubular cell toxicity, interstitial nephritis, crystal deposition, thrombotic microangiopathy, and osmotic nephrosis. Before prescribing a potentially nephrotoxic drug, the risk-to-benefit ratio and the availability of alternative drugs should be considered. Modifiable risk factors should be corrected. The correct drug dosage should be prescribed. Patients should be pre-hydrated and the glomerular filtration rate should be frequently monitored during the administration of a potentially nephrotoxic drug. Studies are needed to further elucidate the mechanisms of nephrotoxicity to design more-rational prevention and treatment strategies. Computer-based prescriber-order entry and an appropriately trained intensive care unit pharmacist are particularly helpful to minimize medication errors and adverse drug events.
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Affiliation(s)
- Miet Schetz
- Department of Intensive Care Medicine, University Hospital, Gasthuisberg, Leuven, Belgium.
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Pea F, Viale P, Furlanut M. Antimicrobial therapy in critically ill patients: a review of pathophysiological conditions responsible for altered disposition and pharmacokinetic variability. Clin Pharmacokinet 2006; 44:1009-34. [PMID: 16176116 DOI: 10.2165/00003088-200544100-00002] [Citation(s) in RCA: 228] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Antimicrobials are among the most important and commonly prescribed drugs in the management of critically ill patients. Selecting the appropriate antimicrobial at the commencement of therapy, both in terms of spectrum of activity and dose and frequency of administration according to concentration or time dependency, is mandatory in this setting. Despite appropriate standard dosage regimens, failure of the antimicrobial treatment may occur because of the inability of the antimicrobial to achieve adequate concentrations at the infection site through alterations in its pharmacokinetics due to underlying pathophysiological conditions. According to the intrinsic chemicophysical properties of antimicrobials, hydrophilic antimicrobials (beta-lactams, aminoglycosides, glycopeptides) have to be considered at much higher risk of inter- and intraindividual pharmacokinetic variations than lipophilic antimicrobials (macrolides, fluoroquinolones, tetracyclines, chloramphenicol, rifampicin [rifampin]) in critically ill patients, with significant frequent fluctuations of plasma concentrations that may require significant dosage adjustments. For example, underexposure may occur because of increased volume of distribution (as a result of oedema in sepsis and trauma, pleural effusion, ascites, mediastinitis, fluid therapy or indwelling post-surgical drainage) and/or enhanced renal clearance (as a result of burns, drug abuse, hyperdynamic conditions during sepsis, acute leukaemia or use of haemodynamically active drugs). On the other hand, overexposure may occur because of a drop in renal clearance caused by renal impairment. Care with all these factors whenever choosing an antimicrobial may substantially improve the outcome of antimicrobial therapy in critically ill patients. However, since these situations may often coexist in the same patient and pharmacokinetic variability may be unpredictable, the antimicrobial policy may further benefit from real-time application of therapeutic drug monitoring, since this practice, by tailoring exposure to the individual patient, may consequently be helpful both in improving the outcome of antimicrobial therapy and in containing the spread of resistance in the hospital setting.
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Affiliation(s)
- Federico Pea
- Department of Experimental and Clinical Pathology and Medicine, Medical School, Institute of Clinical Pharmacology and Toxicology, University of Udine, Udine, Italy
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40
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Bond CAC, Raehl CL. Clinical and economic outcomes of pharmacist-managed aminoglycoside or vancomycin therapy. Am J Health Syst Pharm 2005; 62:1596-605. [PMID: 16030370 DOI: 10.2146/ajhp040555] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The associations between pharmacist-managed aminoglycoside or vancomycin therapy for hospitalized Medicare patients who had diagnoses indicating probable treatment with these antibiotics and the major health care outcomes of death rate, length of stay, Medicare charges, hearing loss, and renal impairment were explored. METHODS Pharmacist management of drug therapy was evaluated in a study population composed of 199,082 Medicare patients treated in 961 hospitals. RESULTS In hospitals that did not have pharmacist-managed aminoglycoside or vancomycin therapy, death rates were 6.71% higher (1,048 excess deaths [chi(2) (1) = 43.801, p < 0.0001]), length of stay was 12.28% higher (131,660 excess patient days [U = 4.701 x 10(9), p < 0.0001]), total Medicare charges were 6.30% higher (140,745,924 US dollars in excess total Medicare charges [U = 4.864 x 10(9), p < 0.0001]), drug charges were 8.15% higher (34,769,250 US dollars in excess drug charges [U = 4.785 x 10(9), p < 0.0001]), laboratory charges were 7.80% higher (22,530,474 US dollars in excess laboratory charges [U = 4.860 x 10(9), p < 0.0001]), hearing loss was 46.42% higher (134 more patients with hearing loss [chi(2) = 54.423, df = 1, p < 0.0001]), renal impairment was 33.95% higher (2,801 more patients with renal impairment [chi(2) = 118.13, df = 1, p < 0.0001]), and the death rate in patients who developed complications was 10.15% higher (231 excess deaths [chi(2) = 22.345, df = 1, p < 0.0001]) than in hospitals with pharmacists managing these drugs. CONCLUSION The presence of pharmacist-managed aminoglycoside or vancomycin therapy was associated with significant improvement in health care and economic outcomes for Medicare patients who received these drugs.
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Affiliation(s)
- C A Cab Bond
- Department of Pharmacy Practice, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA.
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41
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King DW, Smith MA. Proliferative responses observed following vancomycin treatment in renal proximal tubule epithelial cells. Toxicol In Vitro 2005; 18:797-803. [PMID: 15465645 DOI: 10.1016/j.tiv.2004.03.013] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2003] [Accepted: 03/25/2004] [Indexed: 11/25/2022]
Abstract
Vancomycin (VAN) is a glycopeptide antibiotic used to treat gram-positive infections. Nephrotoxicity is a common side effect observed with vancomycin therapy. However, the mechanism of vancomycin-induced nephrotoxicity has not been fully characterized. In this study we examined the effect of vancomycin on cellular proliferation in renal proximal tubule cells. A dose- and time-dependent increase in cell number and total cellular protein was observed following vancomycin exposure. Vancomycin exposure also caused an increase in BrdU incorporation followed by the accumulation of renal proximal tubule cells in G(2)/M phase of the cell cycle. These effects were inhibited by pretreatment with the mitogen-activated protein kinase inhibitor, PD098059, suggesting an association between the cell proliferative effect of VAN and the induction of the mitogen-activated protein kinase signaling pathway. Mitochondrial function in renal proximal tubule cells was assessed using oxygen consumption and ATP concentrations. We observed an increase in oxygen consumption and ATP concentrations following short-term exposure to vancomycin. Together, our data suggest that vancomycin treatment produces alterations in mitochondrial function that coincide with a cell proliferative response in renal proximal tubule epithelial cells.
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Affiliation(s)
- D W King
- School of Public Health, University of Texas-Houston Health Science Center, Houston, TX 77030, USA.
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42
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Abstract
There are a number of effective but highly toxic drugs that exhibit a narrow therapeutic index and marked interpatient pharmacokinetic variability. Individualized therapy with such drugs requires therapeutic drug monitoring (TDM) to obtain the desired clinical effects safely. Cost-effectiveness analysis in health care is still at an early stage of development, especially for TDM. A systematic review was carried out to document studies that have addressed the cost-effectiveness of TDM. The Cochrane database and Medline were searched. References identified by this approach were then searched manually for relevant articles. Very few studies have been performed that document the cost-effectiveness of TDM, and TDM has been demonstrated to be cost-effective only for aminoglycosides. For the other classes of drugs that are monitored, the rationale for TDM has been supported, but appropriate cost-effectiveness analyses have not been performed. Because the use of many of these drugs without TDM would increase the risk of under- or overdosing, emphasis should not be placed solely on cost-effectiveness but rather on how such interventions can be applied in the most cost-effective and clinically useful manner.
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Affiliation(s)
- D J Touw
- Apotheek Haagse Ziekenhuizen, 2504 AC Den Haag, The Netherlands.
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Takada M, Goto T, Kotake T, Saito M, Kawato N, Nakai M, Gunji T, Shibakawa M. Appropriate dosing of antiarrhythmic drugs in Japan requires therapeutic drug monitoring*. J Clin Pharm Ther 2005; 30:5-12. [PMID: 15658999 DOI: 10.1111/j.1365-2710.2004.00612.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In general, drugs are used in accordance with an approved dosage regimen in expectation of an appropriate balance between efficacy and toxicity. However, dose control of drugs with a narrow therapeutic range and marked intersubject variability in pharmacokinetics should be established through individualization of dosing based on therapeutic drug monitoring (TDM). The purpose of this study was to examine differences between the approved dosage regimen and the doses of antiarrhythmic drugs and digoxin used in clinical practice and to examine the influence of TDM on dosing. METHODS Prescription research of antiarrhythmic drugs was performed at five national hospitals in Japan. Prescriptions for antiarrhythmic drugs (cibenzoline, disopyramide, pirmenol, mexiletine, aprindine, flecainide, pilsicainide, amiodarone and digoxin) were counted for the study period. The mean dose and dose distribution of the drugs were determined in each hospital. Comparisons were made of mean dose obtained in the study with the dosage approved by the authority. In addition, the percentage of patients that received TDM was determined. RESULTS A difference was seen between the approved dosage and the actual dose. For all drugs except flecainide, the mean dose was smaller than the approved dosage. For all drugs except digoxin, remarkable variations were seen in the dose distribution among the hospitals. Digoxin showed a similar dose distribution among the five hospitals. Overall, the percentage of patients that received TDM was low except for Hospital A. However, TDM of digoxin was relatively common at four of the hospitals. CONCLUSIONS It is concluded that, with the exception of digoxin, the appropriate dosing regimen for antiarrhythmic drugs is not yet established. The establishment of appropriate dosing regimens for antiarrhythmic drugs requires the more widespread adoption of TDM.
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Affiliation(s)
- M Takada
- Department of Pharmacy, National Cardiovascular Center, Suita-city, Osaka, Japan.
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Calis KA, Hutchison LC, Elliott ME, Ives TJ, Zillich AJ, Poirier T, Townsend KA, Woodall B, Feldman S, Raebel MA. Healthy People 2010: Challenges, Opportunities, and a Call to Action for America’s Pharmacists. Pharmacotherapy 2004; 24:1241-94. [PMID: 15460187 DOI: 10.1592/phco.24.13.1241.38082] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Shah NP, Reddy P, Paladino JA, McKinnon PS, Klepser ME, Pashos CL. Direct medical costs associated with using vancomycin in methicillin-resistant Staphylococcus aureus infections: an economic model. Curr Med Res Opin 2004; 20:779-90. [PMID: 15200734 DOI: 10.1185/030079904125003638] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To quantify the direct medical costs associated with using vancomycin, as inpatient treatment, in methicillin-resistant Staphylococcus aureus infections, in four clinical indications: complicated skin and soft tissue infections (SSTI), bacteremia, infective endocarditis (IE), and hospital-acquired pneumonia (HAP). RESEARCH DESIGN AND METHODS A decision-analytic model was constructed to evaluate the cost of administering intravenous vancomycin. Cost inputs included hospitalization, drug procurement, materials, preparation and administration, renal function and drug monitoring, treating adverse events, and treatment failure. Probabilities and lengths of stay and treatment were obtained from the literature, an antimicrobial therapy database and clinical expert opinion. Univariate and multivariate sensitivity analyses were conducted to confirm the robustness of the baseline scenario. MAIN OUTCOME MEASURES The cost of using vancomycin in the four indications, including and excluding hospital cost. RESULTS Whereas the drug acquisition price of vancomycin 1g is US dollars 9.01 per dose, when all costs associated with using vancomycin were included, the cost per dose rose to US dollars 29-US dollars 43 per patient. Total costs per patient receiving multiple doses in a single course of treatment, excluding hospital room costs, were for SSTI, bacteremia, IE, and HAP,US dollars 779, US dollars 749, US dollars 2261, and US dollars 768, respectively. Total costs, including hospital length of stay, were for SSTI US dollars 23616, bacteremia US dollars 26446, IE US dollars 48925, and HAP US dollars 22493. In univariate analyses varying per diem hospital costs and length of stay had the greatest impact. Results of the multivariate analysis were comparable to the costs in the baseline scenario for all indications. CONCLUSIONS This analysis highlights the importance of capturing all costs associated with using a drug and not simply focusing on drug acquisition cost. Future economic analyses should identify and account for the key cost burdens of a particular treatment to calculate its true cost.
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Affiliation(s)
- Nisha P Shah
- Health Economic Research and Quality of Life Evaluation Services (HERQuLES), Abt Associates Inc., Cambridge MA, USA
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Slavik RS, Jewesson PJ. Selecting antibacterials for outpatient parenteral antimicrobial therapy : pharmacokinetic-pharmacodynamic considerations. Clin Pharmacokinet 2003; 42:793-817. [PMID: 12882587 DOI: 10.2165/00003088-200342090-00002] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Some infectious diseases require management with parenteral therapy, although the patient may not need hospitalisation. Consequently, the administration of intravenous antimicrobials in a home or infusion clinic setting has now become commonplace. Outpatient parenteral antimicrobial therapy (OPAT) is considered safe, therapeutically effective and economical. A broad range of infections can be successfully managed with OPAT, although this form of treatment is unnecessary when oral therapy can be used. Many antimicrobials can be employed for OPAT and the choice of agent(s) and regimen should be based upon sound clinical and microbiological evidence. Assessments of cost and convenience should be made subsequent to these primary treatment outcome determinants. When designing an OPAT treatment regimen, the pharmacokinetic and pharmacodynamic characteristics of the individual agents should also be considered. Pharmacokinetics (PK) is the study of the time course of absorption, distribution, metabolism and elimination of drugs (what the body does to the drug). Clinical pharmacokinetic monitoring has been used to overcome the pharmacokinetic variability of antimicrobials and enable individualised dosing regimens that attain desirable antimicrobial serum concentrations. Pharmacodynamics (PD) is the study of the relationship between the serum concentration of a drug and the clinical response observed in a patient (what the drug does to the body). By combining pharmacokinetic properties (peak [C(max)] or trough [C(min)] serum concentrations, half-life, area under the curve) and pharmacodynamic properties (susceptibility results, minimum inhibitory concentrations [MIC] or minimum bactericidal concentrations [MBC], bactericidal or bacteriostatic killing, post-antibiotic effects), unique PK/PD parameters or indices (t > MIC, C(max)/MIC, AUC(24)/MIC) can be defined. Depending on the killing characteristics of a given class of antimicrobials (concentration-dependent or time-dependent), specific PK/PD parameters may predict in vitro bacterial eradication rates and correlate with in vivo microbiologic and clinical cures. An understanding of these principles will enable the clinician to vary dosing schemes and design individualised dosing regimens to achieve optimal PK/PD parameters and potentially improve patient outcomes. This paper will review basic principles of useful PK/PD parameters for various classes of antimicrobials as they may relate to OPAT. In summary, OPAT has become an important treatment option for the management of infectious diseases in the community setting. To optimise treatment course outcomes, pharmacokinetic and pharmacodynamic properties of the individual agents should be carefully considered when designing OPAT treatment regimens.
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Affiliation(s)
- Richard S Slavik
- Clinical Service Unit Pharmaceutical Sciences, Vancouver Hospital and Health Sciences Centre, and Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Iwamoto T, Kagawa Y, Kojima M. Clinical efficacy of therapeutic drug monitoring in patients receiving vancomycin. Biol Pharm Bull 2003; 26:876-9. [PMID: 12808304 DOI: 10.1248/bpb.26.876] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Efficacy of therapeutic drug monitoring (TDM) of vancomycin (VCM) was retrospectively investigated in 184 patients with methicillin-resistant Staphylococcus aureus (MRSA) infection. The incidence of nephrotoxicity was compared between the patients who received TDM practice (TDM group, n=73) and did not (non-TDM group, n=111). Creatinine clearance (CLcr) values decreased significantly after the VCM therapy in the non-TDM group (p<0.05). The patients with MRSA bacteremia or pneumonia were classified into two groups according to peak concentrations of VCM: above 25 microg/ml (Group A: n=29) and below (Group B: n=24). Mean duration of VCM therapy (14.1 d) in Group A was significantly shorter than that (27.0 d) in Group B. Mean cumulative total VCM doses (13.3 g) in Group A was significantly less than that (25.0 g) in Group B. These results indicate that monitoring peak concentration is essential to obtain better clinical effects for VCM therapy, and that the peak concentration above 25 microg/ml is more effective.
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Affiliation(s)
- Takuya Iwamoto
- Department of Hospital Pharmacy, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
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Taber DJ, Fann AL, Malat G, Dupuis RE. Evaluation of estimated and measured creatinine clearances for predicting the pharmacokinetics of vancomycin in adult liver transplant recipients. Ther Drug Monit 2003; 25:67-72. [PMID: 12548147 DOI: 10.1097/00007691-200302000-00010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study examined the pharmacokinetics and dosing requirements of vancomycin in adult liver transplant recipients and also evaluated the predictability of determining vancomycin-dosing requirements utilizing an estimated creatinine clearance (CrCl) approach. Twenty adult liver transplant recipients were included in this analysis. Vancomycin pharmacokinetic parameters and dosing requirements calculated from estimated CrCl and population-based pharmacokinetic equations were compared with values calculated using serum concentrations and assuming a one-compartment model. Compared with the values obtained using equations to estimate the CrCl and vancomycin pharmacokinetics (t, Cl, and Vd), the actual values were statistically different for half-life and clearance (11.0 vs. 16.4 hours and 52 vs. 36 mL/min, respectively; P < 0.01). Additionally, CrCl that were estimated using population-based formulas significantly overestimated actual CrCl calculated using 24-hour urine collections (65-78 vs. 43 mL/min; P < 0.05). The results from this study indicate that serum creatinine concentrations do not adequately predict glomerular filtration rates (GFR) or vancomycin clearance in adult liver transplant recipients. Based on these results, the use of 24-hour urine CrCl to predict GFR and serum concentrations to properly dose vancomycin is advocated.
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Affiliation(s)
- David J Taber
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, USA.
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Abstract
Genetic variability in drug response occurs as a result of molecular alterations at the level of drug-metabolising enzymes, drug targets/receptors, and drug transport proteins. In this paper, we discuss the possibility that therapeutic drug monitoring (TDM) in the future will involve not the mere measurement and interpretation of drug concentrations but will include both traditional TDM and pharmacogenetics-oriented TDM. In contrast to traditional TDM, which cannot be performed until after a drug is administered to the patient. pharmacogenetics-oriented TDM can be conducted even before treatment begins. Other advantages of genotyping over traditional TDM include, but are not limited to, the following: (i) it does not require the assumption of steady-state conditions (or patient compliance) for the interpretation of results; (ii) it can often be performed less invasively (with saliva, hair root or buccal swab samples); (iii) it can provide predictive value for multiple drugs [e.g. a number of cytochrome P450 (CYP) 2D6, CYP2C 19 or CYP2C9 substrates] rather than a single drug; (iv) it provides mechanistic, instead of merely descriptive, information; and (v) it is constant over an individual's lifetime (and not influenced by concurrent drug administration, alteration in hormonal levels or disease states). Pharmacogenetic information can be applied a priori for initial dose stratification and identification of cases where certain drugs are simply not effective. However, traditional TDM will still be required for all of the reasons that we use it now. In current clinical practice, pharmacogenetic testing is performed for only a few drugs (e.g. mercaptopurine, thioguanine, azathioprine, trastuzumab and tacrine) and in a limited number of teaching hospitals and specialist academic centres. We propose that other drugs (e.g. warfarin, phenytoin, codeine, oral hypoglycaemics, tricyclic antidepressants, aminoglycosides, digoxin, cyclosporin, cyclophosphamide, ifosfamide, theophylline and clozapine) are potential candidates for pharmacogenetics-oriented TDM. However, prospective studies of phaymacogenetics-oriented TDM must be performed to determine its efficacy and cost effectiveness in optimising therapeutic effects while minimising toxicity. In the future, in addition to targeting a patient's drug concentrations within a therapeutic range, pharmacists are likely to be making dosage recommendations for individual drugs on the basis of the individual patient's genotype. As we enter the era of personalised drug therapy, we will be able to identify not only the best drug to be administered to a particular patient, but also the most effective and safest dosage from the outset of therapy.
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Affiliation(s)
- M H Ensom
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, Canada.
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Abstract
In the 30 years that therapeutic drug monitoring (TDM) has moved from an abstract consideration to a routine intervention, issues remain over justifying the benefits in the light of the ever-increasing competition for budgetary resources. Resolving the issues is constrained by various methodological concerns. These include considerations such as: (i) the changed environment of knowledge and practice during the generation in which TDM has been used and evaluated; (ii) the predominance of studies using system-related rather than patient-centred outcomes; (iii) using a timeframe for analysis that is too short; (iv) a lack of rigour in many of the pharmacoeconomic analyses; and (v) excessive use of a site-specific rather than a societal perspective. Current observation suggests that the greatest benefit of TDM accrues from targeted or specialty populations: those with severely decompensated renal function, those at the extremes of age, and those using immunosuppressive, some antineoplastic, some psychotherapeutic and some anticonvulsant drugs. In these situations, safe and humane practice considers TDM a necessity without respect to cost. But for many routine situations with drugs for which TDM has commonly been used in the past, present reliance on the intervention may have become excessive in the light of today's knowledge base of practitioners.
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Affiliation(s)
- G E Schumacher
- National Education and Research Center for Outcomes, Assessment in Healthcare, Northeastern University, Bouve College of Health Sciences, School of Pharmacy, Boston, Massachusetts 02115, USA.
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