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Deimel LP, Moynié L, Sun G, Lewis V, Turner A, Buchanan CJ, Burnap SA, Kutuzov M, Kobras CM, Demyaneko Y, Mohammed S, Stracy M, Struwe WB, Baldwin AJ, Naismith J, Davis BG, Sattentau QJ. Covalent penicillin-protein conjugates elicit anti-drug antibodies that are clonally and functionally restricted. Nat Commun 2024; 15:6851. [PMID: 39127707 DOI: 10.1038/s41467-024-51138-7] [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: 12/01/2023] [Accepted: 07/31/2024] [Indexed: 08/12/2024] Open
Abstract
Many archetypal and emerging classes of small-molecule therapeutics form covalent protein adducts. In vivo, both the resulting conjugates and their off-target side-conjugates have the potential to elicit antibodies, with implications for allergy and drug sequestration. Although β-lactam antibiotics are a drug class long associated with these immunological phenomena, the molecular underpinnings of off-target drug-protein conjugation and consequent drug-specific immune responses remain incomplete. Here, using the classical β-lactam penicillin G (PenG), we probe the B and T cell determinants of drug-specific IgG responses to such conjugates in mice. Deep B cell clonotyping reveals a dominant murine clonal antibody class encompassing phylogenetically-related IGHV1, IGHV5 and IGHV10 subgroup gene segments. Protein NMR and x-ray structural analyses reveal that these drive structurally convergent binding modes in adduct-specific antibody clones. Their common primary recognition mechanisms of the penicillin side-chain moiety (phenylacetamide in PenG)-regardless of CDRH3 length-limits cross-reactivity against other β-lactam antibiotics. This immunogenetics-guided discovery of the limited binding solutions available to antibodies against side products of an archetypal covalent inhibitor now suggests future potential strategies for the 'germline-guided reverse engineering' of such drugs away from unwanted immune responses.
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Affiliation(s)
- Lachlan P Deimel
- Sir William Dunn School of Pathology, University of Oxford, Oxford, OX1 3RE, UK.
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, 10065, USA.
| | - Lucile Moynié
- Rosalind Franklin Institute, Harwell Science and Innovation Campus, Oxford, OX11 0FA, UK
| | - Guoxuan Sun
- Rosalind Franklin Institute, Harwell Science and Innovation Campus, Oxford, OX11 0FA, UK
| | - Viliyana Lewis
- Rosalind Franklin Institute, Harwell Science and Innovation Campus, Oxford, OX11 0FA, UK
| | - Abigail Turner
- Rosalind Franklin Institute, Harwell Science and Innovation Campus, Oxford, OX11 0FA, UK
| | - Charles J Buchanan
- Rosalind Franklin Institute, Harwell Science and Innovation Campus, Oxford, OX11 0FA, UK
- Department of Chemistry, University of Oxford, Oxford, OX1 3TA, UK
- Kavli Institute for Nanoscience Discovery, Dorothy Crowfoot Hodgkin Building, University of Oxford, Oxford, OX1 3QU, UK
| | - Sean A Burnap
- Kavli Institute for Nanoscience Discovery, Dorothy Crowfoot Hodgkin Building, University of Oxford, Oxford, OX1 3QU, UK
- Department of Biochemistry, University of Oxford, Oxford, OX1 3QU, UK
| | - Mikhail Kutuzov
- Sir William Dunn School of Pathology, University of Oxford, Oxford, OX1 3RE, UK
| | - Carolin M Kobras
- Sir William Dunn School of Pathology, University of Oxford, Oxford, OX1 3RE, UK
| | - Yana Demyaneko
- Rosalind Franklin Institute, Harwell Science and Innovation Campus, Oxford, OX11 0FA, UK
- Department of Pharmacology, University of Oxford, Oxford, OX1 3QT, UK
| | - Shabaz Mohammed
- Rosalind Franklin Institute, Harwell Science and Innovation Campus, Oxford, OX11 0FA, UK
- Department of Chemistry, University of Oxford, Oxford, OX1 3TA, UK
- Department of Biochemistry, University of Oxford, Oxford, OX1 3QU, UK
| | - Mathew Stracy
- Sir William Dunn School of Pathology, University of Oxford, Oxford, OX1 3RE, UK
| | - Weston B Struwe
- Kavli Institute for Nanoscience Discovery, Dorothy Crowfoot Hodgkin Building, University of Oxford, Oxford, OX1 3QU, UK
- Department of Biochemistry, University of Oxford, Oxford, OX1 3QU, UK
| | - Andrew J Baldwin
- Rosalind Franklin Institute, Harwell Science and Innovation Campus, Oxford, OX11 0FA, UK
- Department of Chemistry, University of Oxford, Oxford, OX1 3TA, UK
- Kavli Institute for Nanoscience Discovery, Dorothy Crowfoot Hodgkin Building, University of Oxford, Oxford, OX1 3QU, UK
| | - James Naismith
- Rosalind Franklin Institute, Harwell Science and Innovation Campus, Oxford, OX11 0FA, UK
| | - Benjamin G Davis
- Rosalind Franklin Institute, Harwell Science and Innovation Campus, Oxford, OX11 0FA, UK.
- Department of Chemistry, University of Oxford, Oxford, OX1 3TA, UK.
- Department of Pharmacology, University of Oxford, Oxford, OX1 3QT, UK.
| | - Quentin J Sattentau
- Sir William Dunn School of Pathology, University of Oxford, Oxford, OX1 3RE, UK.
- The Max Delbrück Centre for Molecular Medicine, Campus Berlin-Buch, 13125, Berlin, Germany.
- Experimental and Clinical Research Center (ECRC), Charité Universitätsmedizin Berlin and Max-Delbrück-Center for Molecular Medicine, Lindenberger Weg 80, 13125, Berlin, Germany.
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Tang BH, Li QY, Liu HX, Zheng Y, Wu YE, van den Anker J, Hao GX, Zhao W. Machine Learning: A Potential Therapeutic Tool to Facilitate Neonatal Therapeutic Decision Making. Paediatr Drugs 2024; 26:355-363. [PMID: 38880837 DOI: 10.1007/s40272-024-00638-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/18/2024]
Abstract
Bacterial infection is one of the major causes of neonatal morbidity and mortality worldwide. Finding rapid and reliable methods for early recognition and diagnosis of bacterial infections and early individualization of antibacterial drug administration are essential to eradicate these infections and prevent serious complications. However, this is often difficult to perform due to non-specific clinical presentations, low accuracy of current diagnostic methods, and limited knowledge of neonatal pharmacokinetics. Although neonatal medicine has been relatively late to embrace the benefits of machine learning (ML), there have been some initial applications of ML for the early prediction of neonatal sepsis and individualization of antibiotics. This article provides a brief introduction to ML and discusses the current state of the art in diagnosing and treating neonatal bacterial infections, gaps, potential uses of ML, and future directions to address the limitations of current studies. Neonatal bacterial infections involve a combination of physiologic development, disease expression, and treatment response outcomes. To address this complex relationship, future models could consider appropriate ML algorithms to capture time series features while integrating influences from the host, microbes, and drugs to optimize antimicrobial drug use in neonates. All models require prospective clinical trials to validate their clinical utility before clinical use.
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Affiliation(s)
- Bo-Hao Tang
- Department of Pharmacy, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiu-Yue Li
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hui-Xin Liu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yi Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yue-E Wu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, Pharmacology and Physiology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Departments of Genomics and Precision Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.
| | - Wei Zhao
- Department of Pharmacy, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.
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Abuhammad S, Alwedyan D, Hamaideh S, AL-Jabri M. Knowledge, Attitude, and Practices of Mothers Working as Nurses Toward Multidrug-Resistant: Impact of an Educational Program in Neonatal Intensive Care Unit. Infect Drug Resist 2024; 17:1937-1950. [PMID: 38770367 PMCID: PMC11104437 DOI: 10.2147/idr.s461188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/10/2024] [Indexed: 05/22/2024] Open
Abstract
Objective This study seeks to assess the influence of an educational program on enhancing the knowledge, attitudes, and practices of NICU nurses regarding MDROs. Methodology Quasi-experimental design that investigated the efficacy of an educational intervention in shaping the knowledge, attitudes, and practices of mothers working as nurses in NICU toward MDROs was used. A total of 168 nurses participated, divided into 84 intervention groups and 84 non-educational groups. Results The analysis of overall knowledge scores before and after the educational interventions revealed a significant improvement in post-education knowledge scores (Mean = 16.94) compared to pre-education scores (Mean = 12.9929; t(83) = 40.119, p < 0.001). Attitude scores exhibited a notable improvement post-education, with mean scores increasing from 46.64 in the pretest to 58.45 in the posttest. The total attitude shift was statistically significant (t(83) = 104.23, p < 0.001 0). Regarding overall practice, the data suggests a positive impact of education on neonatal nurses' practices related to antibiotic usage (t(3) = 149.31, p < 0.001). A significant positive correlation was found between post-knowledge and post-attitude (r = 0.251, p = 0.021). Conclusion Based on the study findings, the MDROs educational program demonstrated its effectiveness in improving nurses' knowledge and attitudes toward MDROs, serving as a valuable educational resource for nurses. Given the increasing demand for nurses with MDROs knowledge, attitude, and practice in NICU, and considering the documented positive impact on protecting neonates from fatal infections, enhancing nurses' knowledge, attitudes, and practices toward MDROs has become imperative.
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Affiliation(s)
- Sawsan Abuhammad
- Department of Maternal and Child Health, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Dalya Alwedyan
- Department of Maternal and Child Health, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Shaher Hamaideh
- Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
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Gotta V, Bielicki JA, Paioni P, Csajka C, Bräm DS, Berger C, Giger E, Buettcher M, Posfay-Barbe KM, Van den Anker J, Pfister M. Pharmacometric in silico studies used to facilitate a national dose standardisation process in neonatology - application to amikacin. Swiss Med Wkly 2024; 154:3632. [PMID: 38635904 DOI: 10.57187/s.3632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND AIMS Pharmacometric in silico approaches are frequently applied to guide decisions concerning dosage regimes during the development of new medicines. We aimed to demonstrate how such pharmacometric modelling and simulation can provide a scientific rationale for optimising drug doses in the context of the Swiss national dose standardisation project in paediatrics using amikacin as a case study. METHODS Amikacin neonatal dosage is stratified by post-menstrual age (PMA) and post-natal age (PNA) in Switzerland and many other countries. Clinical concerns have been raised for the subpopulation of neonates with a post-menstrual age of 30-35 weeks and a post-natal age of 0-14 days ("subpopulation of clinical concern"), as potentially oto-/nephrotoxic trough concentrations (Ctrough >5 mg/l) were observed with a once-daily dose of 15 mg/kg. We applied a two-compartmental population pharmacokinetic model (amikacin clearance depending on birth weight and post-natal age) to real-world demographic data from 1563 neonates receiving anti-infectives (median birth weight 2.3 kg, median post-natal age six days) and performed pharmacometric dose-exposure simulations to identify extended dosing intervals that would ensure non-toxic Ctrough (Ctrough <5 mg/l) dosages in most neonates. RESULTS In the subpopulation of clinical concern, Ctrough <5 mg/l was predicted in 59% versus 79-99% of cases in all other subpopulations following the current recommendations. Elevated Ctrough values were associated with a post-natal age of less than seven days. Simulations showed that extending the dosing interval to ≥36 h in the subpopulation of clinical concern increased the frequency of a desirable Ctrough below 5 mg/l to >80%. CONCLUSION Pharmacometric in silico studies using high-quality real-world demographic data can provide a scientific rationale for national paediatric dose optimisation. This may increase clinical acceptance of fine-tuned standardised dosing recommendations and support their implementation, including in vulnerable subpopulations.
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Affiliation(s)
- Verena Gotta
- SwissPedDose/SwissPedNet collaboration expert team, Zürich/Basel/Lausanne, Switzerland
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
- Pediatric Clinical Pharmacy, University of Basel Children's Hospital, Basel Switzerland
| | - Julia Anna Bielicki
- Paediatric Research Centre and Paediatric Infectious Diseases and Vaccinology Division, University of Basel Children's Hospital, Basel, Switzerland
- Centre for Neonatal and Paediatric Infection, St George's University, London, United Kingdom
| | - Paolo Paioni
- SwissPedDose/SwissPedNet collaboration expert team, Zürich/Basel/Lausanne, Switzerland
- Division of Infectious Diseaeses, University Children's Hospital Zurich, Zurich, Switzerland
| | - Chantal Csajka
- SwissPedDose/SwissPedNet collaboration expert team, Zürich/Basel/Lausanne, Switzerland
- Centre for Research and Innovation, University Hospital and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva and University of Lausanne, Geneva/Lausanne, Switzerland
| | - Dominic Stefan Bräm
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Christoph Berger
- Division of Infectious Diseaeses, University Children's Hospital Zurich, Zurich, Switzerland
- SwissPedDose, Zurich, Switzerland
| | | | - Michael Buettcher
- SwissPedDose/SwissPedNet collaboration expert team, Zürich/Basel/Lausanne, Switzerland
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
- Paediatric Infectious Diseases, Lucerne Children's Hospital, Cantonal Hospital Lucerne, and Faculty of Health Sciences and Medicine, University Lucerne, Lucerne, Switzerland
| | - Klara M Posfay-Barbe
- General Pediatrics and Pediatric Infectious Diseases Unit, Department of Woman, Child and Adolescent, University Hospitals of Geneva and Medical School of Geneva, Geneva, Switzerland
| | - John Van den Anker
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
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5
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Baltogianni M, Dermitzaki N, Kosmeri C, Serbis A, Balomenou F, Giapros V. Reintroduction of Legacy Antibiotics in Neonatal Sepsis: The Special Role of Fosfomycin and Colistin. Antibiotics (Basel) 2024; 13:333. [PMID: 38667009 PMCID: PMC11047481 DOI: 10.3390/antibiotics13040333] [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: 03/12/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 04/29/2024] Open
Abstract
Neonatal sepsis is a leading cause of morbidity and mortality in neonates, particularly in low- and middle-income countries. The emergence of antimicrobial resistance is a rapidly growing global problem. A significant proportion of the pathogens that commonly cause neonatal sepsis are resistant to multiple antibiotics. Therefore, for the empirical treatment of neonatal sepsis, the repurposing of older antibiotics that are effective against multidrug-resistant pathogens is being investigated. This review aims to provide an overview of current research and experience using the repurposed antibiotics colistin and fosfomycin for the empirical treatment of neonatal sepsis. Based on current knowledge, colistin and fosfomycin may be potentially helpful for the empirical treatment of sepsis in neonates due to their efficacy against a wide range of pathogens and acceptable safety profile.
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Affiliation(s)
- Maria Baltogianni
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (M.B.); (N.D.); (F.B.)
| | - Niki Dermitzaki
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (M.B.); (N.D.); (F.B.)
| | - Chrysoula Kosmeri
- Department of Paediatrics, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (C.K.); (A.S.)
| | - Anastasios Serbis
- Department of Paediatrics, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (C.K.); (A.S.)
| | - Foteini Balomenou
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (M.B.); (N.D.); (F.B.)
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (M.B.); (N.D.); (F.B.)
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Sheikh S, Vishwas G, Aggarwal M, Bhattacharya S, Kumari P, Parashar L, Meshram G. Antibiotic point prevalence survey at a tertiary healthcare hospital in India: Identifying strategies to improve the antibiotic stewardship program immediately after a COVID-19 wave. Infect Prev Pract 2022; 4:100253. [PMID: 36276168 PMCID: PMC9562613 DOI: 10.1016/j.infpip.2022.100253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/25/2022] [Indexed: 11/06/2022] Open
Abstract
Background The COVID-19 pandemic has substantially affected the antibiotic stewardship activities in most hospitals of India. Aims We conducted an antibiotic point prevalence survey (PPS) immediately after the decline of a major COVID-19 wave at a dedicated COVID-19 hospital. By doing so we aimed to identify the antibiotic prescription patterns, identify factors influencing the choice of antibiotics, and identify/develop strategies to improve the antibiotic stewardship program in such setups. Methods The PPS was single-centred, cross-sectional, and retrospective in nature. Patients admitted in various wards and intensive care units (ICUs) between September 2021 to October 2021 were included in our PPS. Results Of the included 460 patients, 192 were prescribed antibiotics. Of these 192 patients, ICU-admitted patients had the highest number of antibiotics prescribed i.e. 2.09 ± 0.92. Only a minor fraction (7.92 %) of antibiotics prescriptions were on the basis of culture reports. Most of the antibiotics were prescribed empirically by the parenteral route. The most common group of antibiotics prescribed were third-generation cephalosporins. Carbapenems were the most common designated antibiotics prescribed. A large number of patients (22.40 %) were prescribed a double anaerobic coverage. Conclusion The strategies that we identified to improve the antibiotic stewardship program at our institute included reviving the culture of sending culture reports to prescribe antibiotics, improving surgical prophylaxis guidelines, training resident doctors to categorize antibiotic prescriptions appropriately, closely monitoring prescriptions providing double anaerobic coverage, and improving the electronic medical record system for improving prescription auditing.
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Affiliation(s)
- S. Sheikh
- Department of Pharmacology, Employees' State Insurance Corporation Medical College and Hospital, Faridabad 121001, India,Department of Pharmacology, Dr. Baba Saheb Ambedkar Medical College and Hospital, Sector-6, Rohini, Delhi 110085, India
| | - G. Vishwas
- Department of Pharmacology, Employees' State Insurance Corporation Medical College and Hospital, Faridabad 121001, India
| | - M. Aggarwal
- Department of Pharmacology, Employees' State Insurance Corporation Medical College and Hospital, Faridabad 121001, India
| | - S. Bhattacharya
- Department of Pharmacology, Employees' State Insurance Corporation Medical College and Hospital, Faridabad 121001, India
| | - P. Kumari
- Department of Pharmacology, Employees' State Insurance Corporation Medical College and Hospital, Faridabad 121001, India
| | - L. Parashar
- Department of Community Medicine, Employees' State Insurance Corporation Medical College and Hospital, Faridabad 121001, India
| | - G.G. Meshram
- Department of Pharmacology, Employees' State Insurance Corporation Medical College and Hospital, Faridabad 121001, India,Department of Pharmacology, Maulana Azad Medical College and Associated Hospitals, New Delhi 110002, India,Corresponding author. Address: Department of Pharmacology, Maulana Azad Medical College and Associated Hospitals, New Delhi 110002. India. Tel.: +918376010560
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Aurich B, Apele‐Freimane D, Banaschewski T, Chouchana L, Day S, Kaguelidou F, Kelly LE, Kindblom JM, Neubert A, Wong ICK. c4c: Paediatric pharmacovigilance: Methodological considerations in research and development of medicines for children - A c4c expert group white paper. Br J Clin Pharmacol 2022; 88:4997-5016. [PMID: 34699077 PMCID: PMC9788092 DOI: 10.1111/bcp.15119] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 12/30/2022] Open
Abstract
Children frequently respond differently to therapies compared to adults. Differences also exist between paediatric age groups for pharmacokinetics and pharmacodynamics in both efficacy and safety. Paediatric pharmacovigilance requires an understanding of the unique aspects of children with regard to, for example, drug response, growth and development, clinical presentation of adverse drug reactions (ADRs), how they can be detected and population-specific factors (e.g., more frequent use of off-label/unlicensed drugs). In recognition of these challenges, a group of experts has been formed in the context of the conect4children (c4c) project to support paediatric drug development. This expert group collaborated to develop methodological considerations for paediatric drug safety and pharmacovigilance throughout the life-cycle of medicinal products which are described in this article. These considerations include practical points to consider for the development of the paediatric section of the risk management plan (RMP), safety in paediatric protocol development, safety data collection and analysis. Furthermore, they describe the specific details of post-marketing pharmacovigilance in children using, for example, spontaneous reports, electronic health care records, registries and record-linkage, as well as the use of paediatric pharmacoepidemiology studies for risk characterisation. Next the details of the assessment of benefit-risk and challenges related to medicinal product formulation in the context of a Paediatric Investigation Plan (PIP) are presented. Finally, practical issues in paediatric signal detection and evaluation are included. This paper provides practical points to consider for paediatric pharmacovigilance throughout the life-cycle of medicinal products for RMPs, protocol development, safety data collection and analysis and PIPs.
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Affiliation(s)
- Beate Aurich
- Department of PharmacologySaint‐Louis HospitalParisFrance
| | - Dina Apele‐Freimane
- Neonatal Intensive Care, Women and Child Health ClinicPauls Stradins Clinical University HospitalRigaLatvia
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry, Central Institute of Mental Health, Medical Faculty MannheimUniversity of HeidelbergMannheimGermany
| | - Laurent Chouchana
- Regional Center of Pharmacovigilance, Department of PharmacologyCochin Hospital, APHP, Centre, Université de ParisParisFrance
| | - Simon Day
- Clinical Trials Consulting and Training LimitedNorth MarstonUK
| | - Florentia Kaguelidou
- Department of Pediatric Pharmacology and Pharmacogenetics, APHP, Robert Debré Hospital; Center of Clinical Investigations, INSERM CIC1426Université de ParisParisFrance
| | - Lauren E. Kelly
- Department of Paediatrics and Child Health, Max Rady College of MedicineUniversity of ManitobaWinnipegCanada
| | - Jenny M. Kindblom
- Paediatric Clinical Research Center, Queen Silvia Children's HospitalSahlgrenska University HospitalGothenburgSweden
| | - Antje Neubert
- Department of Paediatrics and Adolescent MedicineUniversity Hospital Erlangen, Friedrich‐Alexander University Erlangen‐Nürnberg (FAU)ErlangenGermany
| | - Ian C. K. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of MedicineThe University of Hong KongChina,Research Department of Practice and Policy, School of PharmacyUCLLondonUK
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Simeoli R, Cairoli S, Decembrino N, Campi F, Dionisi Vici C, Corona A, Goffredo BM. Use of Antibiotics in Preterm Newborns. Antibiotics (Basel) 2022; 11:antibiotics11091142. [PMID: 36139921 PMCID: PMC9495226 DOI: 10.3390/antibiotics11091142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022] Open
Abstract
Due to complex maturational and physiological changes that characterize neonates and affect their response to pharmacological treatments, neonatal pharmacology is different from children and adults and deserves particular attention. Although preterms are usually considered part of the neonatal population, they have physiological and pharmacological hallmarks different from full-terms and, therefore, need specific considerations. Antibiotics are widely used among preterms. In fact, during their stay in neonatal intensive care units (NICUs), invasive procedures, including central catheters for parental nutrition and ventilators for respiratory support, are often sources of microbes and require antimicrobial treatments. Unfortunately, the majority of drugs administered to neonates are off-label due to the lack of clinical studies conducted on this special population. In fact, physiological and ethical concerns represent a huge limit in performing pharmacokinetic (PK) studies on these subjects, since they limit the number and volume of blood sampling. Therapeutic drug monitoring (TDM) is a useful tool that allows dose adjustments aiming to fit plasma concentrations within the therapeutic range and to reach specific drug target attainment. In this review of the last ten years’ literature, we performed Pubmed research aiming to summarize the PK aspects for the most used antibiotics in preterms.
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Affiliation(s)
- Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Nunzia Decembrino
- Neonatal Intensive Care Unit, University Hospital “Policlinico-San Marco” Catania, Integrated Department for Maternal and Child’s Health Protection, 95100 Catania, Italy
| | - Francesca Campi
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Carlo Dionisi Vici
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
- Correspondence: ; Tel.: +39-0668592174; Fax: + 39-0668593009
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Soeorg H, Padari H, Kipper K, Ilmoja ML, Lutsar I, Metsvaht T. Pharmacokinetics of Gentamicin Components C1, C1a, and C2/C2a/C2b and Subsequent Decline in Glomerular Filtration Rate in Neonates. AAPS J 2022; 24:77. [DOI: 10.1208/s12248-022-00727-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/13/2022] [Indexed: 11/30/2022] Open
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Daniels EA, McPherson CC, Newland JG, Lee BR. Variation in ampicillin dosing for lower respiratory tract infections and neonatal bacterial infections in US children's hospitals. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e85. [PMID: 36483411 PMCID: PMC9726562 DOI: 10.1017/ash.2022.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE We examined ampicillin dosing in pediatric patients across 3 conditions: (1) bacterial lower respiratory tract infections (LRTIs) in infants and children >3 months, (2) neonates with suspected or proven sepsis, and (3) neonates with suspected central nervous system (CNS) infections. We compared our findings to dosing guidance for these specific indications. DESIGN Retrospective cohort study. SETTING The study included data from 32 children's hospitals in the United States. METHODS We reviewed prescriptions from the SHARPS study of antimicrobials, a survey of antibiotic prescribing from July 2016 to December 2017. Prescriptions were analyzed for indication, total daily dose per kilogram, and presence of antimicrobial stewardship program (ASP) review. LRTI prescriptions were compared to IDSA recommendations for community-acquired pneumonia. Neonatal prescriptions were compared to recommendations from the American Academy of Pediatrics (AAP). Prescriptions were categorized as "optimal" (80%-120% of recommended dosing), "suboptimal" (<80% of recommended dosing), or "excessive" (>120% of recommended dosing). RESULTS Among 1,038 ampicillin prescriptions, we analyzed 88 prescriptions for LRTI, 499 prescriptions for neonatal sepsis, and 27 prescriptions for neonatal CNS infection. Of the LRTI prescriptions, 77.3%were optimal. Of prescriptions for neonatal sepsis, 81.6% were excessive compared to AAP bacteremia recommendations but 78.8% were suboptimal compared to AAP meningitis guidelines. Also, 48.1% of prescriptions for neonatal CNS infection were suboptimal, and 50.6% of prescriptions were not reviewed by the ASP. CONCLUSIONS LRTI dosing is generally within the IDSA-recommended range. However, dosing for neonatal sepsis often exceeds the recommendation for bacteremia but is below the recommendation for meningitis. This variability points to an important opportunity for future antimicrobial stewardship efforts.
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Affiliation(s)
- Elizabeth A. Daniels
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | | | - Jason G. Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Brian R. Lee
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
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Nephrotoxic medications and associated acute kidney injury in hospitalized neonates. J Nephrol 2022; 35:1679-1687. [PMID: 35167057 DOI: 10.1007/s40620-022-01264-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Hospitalized neonates are often treated with nephrotoxic medications, a known risk factor for acute kidney injury (AKI). Nephrotoxic medications and AKI, especially in periviable neonates, could be detrimental to nephrogenesis. Our objectives were to evaluate the prevalence of neonatal treatment with nephrotoxic medications and its relationship with AKI in in the first 28 days of life, and to delineate the associated demographics and diagnoses. STUDY DESIGN Multicenter retrospective analysis using the national Pediatric Hospital Information System database, including 49 pediatric hospitals. Neonates admitted within the first two postnatal days were included. Treatment with 37 nephrotoxic medications across demographics and clinical variables, and relationship with AKI were evaluated. AKI was determined by using the International Classification of Diseases codes. RESULTS Of 192,229 neonates, 74% were treated with at least one nephrotoxic medication. Incidence of AKI was significantly higher in the treated group (aRR 3.68 [95% CI: 2.85, 4.75]). The aRRs of treatment were increased in infants born < 32-week, and < 2000 g. Nephrotoxic medications were prescribed to 90-95% of neonates born ≤ 28-week gestational age. Most treatments (95-98%) occurred in the first 3 days. Intravascular aminoglycosides were the most frequent type; 28% of neonates were treated for ≥ 4 calendar days. Most common diagnoses were infections (25%) and patent ductus arteriosus (20%). CONCLUSIONS Neonatal treatment with nephrotoxic medications is common, especially among the smallest, most immature preterm neonates and demonstrates a need for initiatives to reduce neonatal exposure to these agents, when feasible. Across all gestational age categories, the prevalence of AKI is higher in the neonates treated with nephrotoxic drugs. The long-term effects of treatment with nephrotoxic medications and subsequent AKI on nephrogenesis and nephron endowment will need to be evaluated.
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Hill LF, Clements MN, Turner MA, Donà D, Lutsar I, Jacqz-Aigrain E, Heath PT, Roilides E, Rawcliffe L, Alonso-Diaz C, Baraldi E, Dotta A, Ilmoja ML, Mahaveer A, Metsvaht T, Mitsiakos G, Papaevangelou V, Sarafidis K, Walker AS, Sharland M, Clements M, Turner MA, Donà D, Lutsar I, Jacqz-Aigrain E, Heath PT, Roilides E, Rawcliffe L, Bafadal B, Alarcon Allen A, Alonso-Diaz C, Anatolitou F, Baraldi E, Del Vecchio A, Dotta A, Giuffrè M, Ilmoja ML, Karachristou K, Mahaveer A, Manzoni P, Martinelli S, Metsvaht T, Mitsiakos G, Moriarty P, Nika A, Papaevangelou V, Roehr C, Sanchez Alcobendas L, Sarafidis K, Siahanidou T, Tzialla C, Bonadies L, Booth N, Catalina Morales-Betancourt P, Cordeiro M, de Alba Romero C, de la Cruz J, De Luca M, Farina D, Franco C, Gialamprinou D, Hallik M, Ilardi L, Insinga V, Iosifidis E, Kalamees R, Kontou A, Molnar Z, Nikaina E, Petropoulou C, Reyné M, Tataropoulou K, Triantafyllidou P, Vontzalidis A, Walker AS, Sharland M. Optimised versus standard dosing of vancomycin in infants with Gram-positive sepsis (NeoVanc): a multicentre, randomised, open-label, phase 2b, non-inferiority trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:49-59. [PMID: 34843669 DOI: 10.1016/s2352-4642(21)00305-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Vancomycin is the most widely used antibiotic for neonatal Gram-positive sepsis, but clinical outcome data of dosing strategies are scarce. The NeoVanc programme comprised extensive preclinical studies to inform a randomised controlled trial to assess optimised vancomycin dosing. We compared the efficacy of an optimised regimen to a standard regimen in infants with late onset sepsis that was known or suspected to be caused by Gram-positive microorganisms. METHODS NeoVanc was an open-label, multicentre, phase 2b, parallel-group, randomised, non-inferiority trial comparing the efficacy and toxicity of an optimised regimen of vancomycin to a standard regimen in infants aged 90 days or younger. Infants with at least three clinical or laboratory sepsis criteria or confirmed Gram-positive sepsis with at least one clinical or laboratory criterion were enrolled from 22 neonatal intensive care units in Greece, Italy, Estonia, Spain, and the UK. Infants were randomly assigned (1:1) to either the optimised regimen (25 mg/kg loading dose, followed by 15 mg/kg every 12 h or 8 h dependent on postmenstrual age, for 5 ± 1 days) or the standard regimen (no loading dose; 15 mg/kg every 24 h, 12 h, or 8 h dependent on postmenstrual age for 10 ± 2 days). Vancomycin was administered intravenously via 60 min infusion. Group allocation was not masked to local investigators or parents. The primary endpoint was success at the test of cure visit (10 ± 1 days after the end of actual vancomycin therapy) in the per-protocol population, where success was defined as the participant being alive at the test of cure visit, having a successful outcome at the end of actual vancomycin therapy, and not having a clinically or microbiologically significant relapse or new infection requiring antistaphylococcal antibiotics for more than 24 h within 10 days of the end of actual vancomycin therapy. The non-inferiority margin was -10%. Safety was assessed in the intention-to-treat population. This trial is registered at ClinicalTrials.gov (NCT02790996). FINDINGS Between March 3, 2017, and July 29, 2019, 242 infants were randomly assigned to the standard regimen group (n=122) or the optimised regimen group (n=120). Primary outcome data in the per-protocol population were available for 90 infants in the optimised group and 92 in the standard group. 64 (71%) of 90 infants in the optimised group and 73 (79%) of 92 in the standard group had success at test of cure visit; non-inferiority was not confirmed (adjusted risk difference -7% [95% CI -15 to 2]). Incomplete resolution of clinical or laboratory signs after 5 ± 1 days of vancomycin therapy was the main factor contributing to clinical failure in the optimised group. Abnormal hearing test results were recorded in 25 (30%) of 84 infants in the optimised group and 12 (15%) of 79 in the standard group (adjusted risk ratio 1·96 [95% CI 1·07 to 3·59], p=0·030). There were six vancomycin-related adverse events in the optimised group (one serious adverse event) and four in the standard group (two serious adverse events). 11 infants in the intention-to-treat population died (six [6%] of 102 infants in the optimised group and five [5%] of 98 in the standard group). INTERPRETATION In the largest neonatal vancomycin efficacy trial yet conducted, no clear clinical impact of a shorter duration of treatment with a loading dose was demonstrated. The use of the optimised regimen cannot be recommended because a potential hearing safety signal was identified; long-term follow-up is being done. These results emphasise the importance of robust clinical safety assessments of novel antibiotic dosing regimens in infants. FUNDING EU Seventh Framework Programme for research, technological development and demonstration.
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Affiliation(s)
- Louise F Hill
- Institute for Infection and Immunity, St George's, University of London, London, UK.
| | - Michelle N Clements
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy; Fondazione Penta, Padua, Italy
| | | | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, Paris, France
| | - Paul T Heath
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Emmanuel Roilides
- 3rd Department of Pediatrics, Aristotle University, Thessaloniki, Greece
| | | | | | - Eugenio Baraldi
- Azienda Ospedale-Universita' di Padova, Fondazione Istituto di Ricerca Pediatrica, Padova, Italy
| | | | | | | | | | | | | | | | - A Sarah Walker
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Michael Sharland
- Institute for Infection and Immunity, St George's, University of London, London, UK
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Prescription of Aminoglycosides in 23 French Neonatal Intensive Care Units. Antibiotics (Basel) 2021; 10:antibiotics10111422. [PMID: 34827360 PMCID: PMC8614949 DOI: 10.3390/antibiotics10111422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Aminoglycosides are the most prescribed antibiotics in neonatal intensive care units (NICU). Reducing exposure to antibiotics in the NICU is highly desirable, particularly through benchmarking methods. Methods: Description of aminoglycosides prescriptions in 23 French NICU using the same computerized system over a 4-year period (2017–2020). A benchmarking program of antibiotics prescription was associated. Results: The population included 53,818 patients. Exposition rates to gentamicin and amikacin were 31.7% (n = 17,049) and 9.1% (n = 4894), respectively. Among neonates exposed to gentamicin, 90.4% of gentamicin and 77.6% of amikacin treatments were started within the 1st week of life. Among neonates exposed to amikacin, 77.6% started amikacin within the 1st week. The average daily dose of gentamicin at first prescription increased over the study period from 3.9 in 2017 to 4.4 mg/kg/d in 2020 (p < 0.0001). Conversely, the corresponding amikacin daily doses decreased from 13.0 in 2017 to 12.3 mg/kg/d in 2020 (p = 0.001). The time interval between the first 2 doses of gentamicin was mainly distributed in 3 values during the first week of life: 49.4% at 24 h, 26.4% at 36 h, and 22.9% at 48 h. At first amikacin prescription, the time interval was distributed in 4 categories: 48% at 24 h, 4.1% at 30 h, 8.5% at 36 h, and 37.1% at 48 h. As compared to literature guidelines, the rates of overdose and underdose in gentamicin (1.5% and 2.7%) and amikacin (0.3% and 1.0%). They significantly decreased for gentamicin over the study period. In multivariate analysis, the factors significantly associated with GENT overdose were the year of admission, prematurity, length of stay, and duration of the treatment. Conclusion: This prescription strategy ensured a low rate of overdose and underdose, and some benefits of the benchmarking program is suggested.
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14
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van der Veen A, Somers A, Vanhaesebrouck S, Ter Heine R, Brüggemann R, Allegaert K, De Cock P. Variation in vancomycin dosing and therapeutic drug monitoring practices in neonatal intensive care units. Int J Clin Pharm 2021; 44:564-569. [PMID: 34727280 DOI: 10.1007/s11096-021-01345-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 10/19/2021] [Indexed: 11/29/2022]
Abstract
Background Vancomycin is a frequently used antibiotic in neonates. However, there is no consensus guideline on the optimal dosing regimen and therapeutic drug monitoring (TDM) practices in this patient population. Objective To document the variability in the current dosing and TDM practices in neonatal intensive care units (NICU). Setting Belgian and Dutch NICUs. Method An online questionnaire was disseminated by e-mail to potential respondents. Main outcome measure Differences in vancomycin dosing and TDM practices in comparison with a reference source, the Dutch Paediatric Formulary. Results Eighteen NICUs (response rate 62%) participated. Eleven different dosing regimens are applied, with 83% using intermittent dosing regimens. Stratifying covariates used to determine the (initial) dosage include gestational age, postnatal age, serum creatinine, concurrent use of non-steroidal anti-inflammatory drugs, birth weight and current weight. Large variability is observed with regard to TDM practice as well, both for the concentration target range and the times of (re)sampling. Dosing calculators are more commonly used in the Netherlands than Belgium. Conclusion Significant inter-centre variability in dosing and TDM practices was found. The development of international consensus guidelines is required to optimize therapy. Dosing calculators to guide dosing are not yet considered as part of standard-of-care.
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Affiliation(s)
- Anouk van der Veen
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan, 10, 9000, Ghent, Belgium
| | - Annemie Somers
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan, 10, 9000, Ghent, Belgium.,Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | | | - Rob Ter Heine
- Department of Pharmacy and Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger Brüggemann
- Department of Pharmacy and Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karel Allegaert
- Department of Development and Regeneration, and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pieter De Cock
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan, 10, 9000, Ghent, Belgium. .,Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium. .,Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium.
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15
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Garrido F, Allegaert K, Arribas C, Villamor E, Raffaeli G, Paniagua M, Cavallaro G. Variations in Antibiotic Use and Sepsis Management in Neonatal Intensive Care Units: A European Survey. Antibiotics (Basel) 2021; 10:1046. [PMID: 34572631 PMCID: PMC8469483 DOI: 10.3390/antibiotics10091046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 12/18/2022] Open
Abstract
Management of neonatal sepsis and the use of antimicrobials have an important impact on morbidity and mortality. However, there is no recent background on which antibiotic regimens are used in different European neonatal intensive care units (NICUs). Our study aimed to describe the use of antibiotics and other aspects of early- and late-onset sepsis (EOS and LOS, respectively) management by European NICUs. We conducted an online survey among NICUs throughout Europe to collect information about antibiotic stewardship, antibiotic regimens, and general aspects of managing neonatal infections. NICUs from up to 38 European countries responded, with 271 valid responses. Most units had written clinical guidelines for EOS (92.2%) and LOS (81.1%) management. For EOS, ampicillin, penicillin, gentamicin, and amikacin were the most commonly used antibiotics. Analysis of the combinations of EOS regimens showed that the most frequently used was ampicillin plus gentamicin (54.6%). For LOS, the most frequently used antibiotics were vancomycin (52.4%), gentamicin (33.9%), cefotaxime (28%), and meropenem (15.5%). Other aspects of the general management of sepsis have also been analyzed. The management of neonatal sepsis in European NICUs is diverse. There was high self-reported adherence to the local clinical guidelines. There was homogeneity in the combination of antibiotics in EOS but less in LOS.
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Affiliation(s)
- Felipe Garrido
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Cristina Arribas
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), 6229 Maastricht, The Netherlands;
| | - Genny Raffaeli
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, NICU, 20122 Milan, Italy; (G.R.); (G.C.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Miren Paniagua
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
| | - Giacomo Cavallaro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, NICU, 20122 Milan, Italy; (G.R.); (G.C.)
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Panditrao AM, Shafiq N, Chatterjee S, Pathak A, Trivedi N, Sadasivam B, Kshirsagar N, Kaul R, Biswal M, Kakkar A, Malhotra S, Arora P, Talati S, Dhaliwal N, Hazra A, Jhaj R, Najmi A, Pandey N, Chakraverty R, Pathan S, Chauhan J, Mathur A. A multicentre point prevalence survey (PPS) of antimicrobial use amongst admitted patients in tertiary care centres in India. J Antimicrob Chemother 2021; 76:1094-1101. [PMID: 34244744 DOI: 10.1093/jac/dkaa533] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 11/23/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Data from point prevalence surveys (PPSs) in India are scarce. Conducting PPSs is especially challenging in the absence of electronic medical records, a lack of dedicated resources and a high patient load in resource-poor settings. This multicentre survey was conducted to provide background data for planning and strengthening antimicrobial stewardship programmes across the country. METHODS This inpatient PPS was conducted over 2 weeks in May 2019 simultaneously across five study centres in India. Data about patient characteristics, indications for antimicrobials use and details of each antimicrobial prescribed including supportive investigation reports were collected in predesigned forms. RESULTS A total of 3473 admitted patients in wards and ICUs were covered across five study centres. Of these, 1747 (50.3%) patients were on antimicrobials, with 46.9% patients being on two or more antimicrobials. Out of the total antimicrobials prescribed, 40.2% of the antimicrobials were prescribed for community-acquired infection requiring hospitalization followed by surgical prophylaxis (32.6%). Third-generation cephalosporins and drugs from the 'Watch' category were prescribed most commonly. Only 22.8% of the antimicrobials were based on microbiology reports. CONCLUSIONS The survey demonstrated a high use of antimicrobials in admitted patients with a considerable proportion of drugs from the 'Watch' category. The targets for interventions that emerged from the survey were: improving surgical prophylaxis, decreasing double anaerobic cover, initiating culture of sending cultures and de-escalation with targeted therapy.
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Affiliation(s)
- Aditi M Panditrao
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nusrat Shafiq
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Suparna Chatterjee
- Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India
| | - Ashish Pathak
- Ruxmaniben Deepchand Gardi Medical College (RDGMC), Ujjain, Madhya Pradesh, India
| | - Niyati Trivedi
- Government Medical College and Hospital (GMC), Vadodara, Gujarat, India
| | | | | | - Rajni Kaul
- Indian Council of Medical Research, New Delhi, India
| | - Manisha Biswal
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashish Kakkar
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Samir Malhotra
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pankaj Arora
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shweta Talati
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Navneet Dhaliwal
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Avijit Hazra
- Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India
| | - Ratinder Jhaj
- All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Ahmad Najmi
- Government Medical College and Hospital (GMC), Vadodara, Gujarat, India
| | - Navin Pandey
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Raja Chakraverty
- Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India
| | - Saman Pathan
- All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Janki Chauhan
- Government Medical College and Hospital (GMC), Vadodara, Gujarat, India
| | - Aditya Mathur
- Ruxmaniben Deepchand Gardi Medical College (RDGMC), Ujjain, Madhya Pradesh, India
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Tu Q, Cotta M, Raman S, Graham N, Schlapbach L, Roberts JA. Individualized precision dosing approaches to optimize antimicrobial therapy in pediatric populations. Expert Rev Clin Pharmacol 2021; 14:1383-1399. [PMID: 34313180 DOI: 10.1080/17512433.2021.1961578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction:Severe infections continue to impose a major burden on critically ill children and mortality rates remain stagnant. Outcomes rely on accurate and timely delivery of antimicrobials achieving target concentrations in infected tissue. Yet, developmental aspects, disease-related variables, and host factors may severely alter antimicrobial pharmacokinetics in pediatrics. The emergence of antimicrobial resistance increases the need for improved treatment approaches.Areas covered:This narrative review explores why optimization of antimicrobial therapy in neonates, infants, children, and adolescents is crucial and summarizes the possible dosing approaches to achieve antimicrobial individualization. Finally, we outline a roadmap toward scientific evidence informing the development and implementation of precision antimicrobial dosing in critically ill children.The literature search was conducted on PubMed using the following keywords: neonate, infant, child, adolescent, pediatrics, antimicrobial, pharmacokinetic, pharmacodynamic target, Bayes dosing software, optimizing, individualizing, personalizing, precision dosing, drug monitoring, validation, attainment, and software implementation. Further articles were sought from the references of the above searched articles.Expert opinion:Recently, technological innovations have emerged that enabled the development of individualized antimicrobial dosing approaches in adults. More work is required in pediatrics to make individualized antimicrobial dosing approaches widely operationalized in this population.
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Affiliation(s)
- Quyen Tu
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Menino Cotta
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Sainath Raman
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Centre for Children's Health Research (CCHR), The University of Queensland, Brisbane, QLD, Australia
| | - Nicolette Graham
- Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Luregn Schlapbach
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Department of Intensive Care and Neonatology, The University Children's Hospital Zurich, Switzerland
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Abstract
Antibiotics are extensively and inconsistently prescribed in neonatal ICUs, and usage does not correlate with rates of culture positive sepsis. There is mounting data describing the short and long-term adverse effects associated with antibiotic overuse in neonates, including the increased burden of multi-drug resistant organisms. Currently there is considerable variation in antibiotic prescribing practice among neonatologists. Applying the practice of antibiotic stewardship in the NICU is crucial for standardizing antibiotic use and improving outcomes in this population. Several approaches have been proposed to identify neonatal sepsis, with the hope of reducing antibiotic utilization. These strategies all have their limitations, and often include laboratory testing and treatment of well-appearing, non-septic, infants. A conservative "watch and wait" algorithm is suggested as an alternative method for when to initiate antibiotics. This observational approach relies on availability of trained personnel able to examine infants at specified intervals, without delaying antibiotics, should signs of sepsis arise.
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Affiliation(s)
- Noa Fleiss
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas A Hooven
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Richard A Polin
- Department of Pediatrics, Columbia University School of Medicine, New York City, NY, USA.
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Li X, Qi H, Jin F, Yao BF, Wu YE, Qi YJ, Kou C, Wu XR, Luo XJ, Shen YH, Zheng X, Wang YH, Xu F, Jiao WW, Li JQ, Xiao J, Dong YN, Du B, Shi HY, Xu BP, Shen AD, Zhao W. Population pharmacokinetics-pharmacodynamics of ceftazidime in neonates and young infants: Dosing optimization for neonatal sepsis. Eur J Pharm Sci 2021; 163:105868. [PMID: 33951483 DOI: 10.1016/j.ejps.2021.105868] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 03/01/2021] [Accepted: 04/25/2021] [Indexed: 01/22/2023]
Abstract
Ceftazidime is a third-generation cephalosporin with high activity against many pathogens. But the ambiguity and diversity of the dosing regimens in neonates and young infants impair access to effective treatment. Thus, we conducted a population pharmacokinetic study of ceftazidime in this vulnerable population and recommended a model-based dosage regimen to optimize sepsis therapy. Totally 146 neonates and young infants (gestational age (GA): 36-43.4 weeks, postnatal age (PNA): 1-81 days, current weight (CW): 900-4500 g) were enrolled based on inclusion and exclusion criteria. Ceftazidime bloods samples (203) were obtained using the opportunistic sampling strategy and determined by the high-performance liquid chromatography. The population pharmacokinetic-pharmacodynamic analysis was conducted by nonlinear mixed effects model (NONMEM). A one-compartment model with first-order elimination best described the pharmacokinetic data. Covariate analysis showed the significance of GA, PNA, and CW on developmental pharmacokinetics. Monte Carlo simulation was performed based on above covariates and minimum inhibitory concentration (MIC). In the newborns with PNA ≤ 3 days (MIC=8 mg/L), the dose regimen was 25 mg/kg twice daily (BID). For the newborns with PNA > 3 days (MIC=16 mg/L), the optimal dose was 30 mg/kg three times daily (TID) for those with GA ≤ 37 weeks and 40 mg/kg TID for those with GA > 37 weeks. Overall, on the basis of the developmental population pharmacokinetic-pharmacodynamic analysis covering the whole range of neonates and young infants, the evidence-based ceftazidime dosage regimens were proposed to optimize neonatal early-onset and late-onset sepsis therapy.
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Affiliation(s)
- Xue Li
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Hui Qi
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Fei Jin
- Neonatal intensive care unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Yue-E Wu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Yu-Jie Qi
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Chen Kou
- Department of Neonatology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100045, China
| | - Xi-Rong Wu
- Department of Respiratory Diseases, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Xiao-Jing Luo
- Neonatal intensive care unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Yan-Hua Shen
- Neonatal intensive care unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Xu Zheng
- Neonatal intensive care unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Yong-Hong Wang
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Fang Xu
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Wei-Wei Jiao
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Jie-Qiong Li
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Jing Xiao
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Yi-Ning Dong
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Bin Du
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Hai-Yan Shi
- Department of Clinical Pharmacy, Clinical Trial Center, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan 250014, China
| | - Bao-Ping Xu
- Department of Respiratory Diseases, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - A-Dong Shen
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China.
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China; Department of Clinical Pharmacy, Clinical Trial Center, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan 250014, China.
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20
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Abstract
BACKGROUND AND AIMS Ampicillin is 1 of the most commonly used antibiotics for treatment of early onset sepsis, but its pharmacokinetics (PK) is poorly characterized. We aimed to define the dose of ampicillin for late preterm and term neonates by evaluating its PK in serum, cerebrospinal (CSF), and epithelial lining fluid. METHODS A prospective study included neonates receiving ampicillin for suspected or proven early onset sepsis and pneumonia. PK samples were collected at steady state, at predose and 5 minutes, 1 hour, 3 hours, 8 hours, and 12 hours after ampicillin 3-minute infusion. Ampicillin concentrations were measured by ultra-high-performance liquid chromatography. Noncompartmental anaysis (NCA) and population pharmacokinetic (pop-PK) modeling were performed and probability of therapeutic target attainment was simulated. RESULTS In 14 neonates (GA of 32-42 wks; mean BW 2873 g), PK parameters (mean ± SD) in NCA were the following: half-life 7.21 ± 7.97 hours; volume of distribution (Vd) 1.07 ± 0.51 L; clearance (CL) 0.20 ± 0.13 L/h; 24-hour area under the concentration-time curve 348.92 ± 114.86 mg*h/L. In pop-PK analysis, a 2-compartmental model described the data most adequately with the final parameter estimates of CL 15.15 (CV 40.47%) L/h/70kg; central Vd 24.87 (CV 37.91%) L/70kg; intercompartmental CL 0.39 (CV 868.56) L/h and peripheral Vd 1.039 (CV 69.32%) L. Peutic target attainment simulations demonstrated that a dosage of 50 mg/kg q 12 hours attained 100% fT > MIC 0.25 mg/L, group B streptococcal breakpoint. CONCLUSIONS We recommend ampicillin dosage 50 mg/kg q 12 hours for neonates with gestational age ≥32 weeks during the first week of life.
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21
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Zahn J, Wimmer S, Rödle W, Toni I, Sedlmayr B, Prokosch HU, Rascher W, Neubert A. Development and Evaluation of a Web-Based Paediatric Drug Information System for Germany. PHARMACY 2021; 9:pharmacy9010008. [PMID: 33466548 PMCID: PMC7838899 DOI: 10.3390/pharmacy9010008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/20/2020] [Accepted: 12/29/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Off-label use is frequent in paediatrics but that does not necessarily mean that the risk-benefit ratio is negative. Nevertheless, evidence-based data is essential for safe drug therapy. In Germany, there is no publicly available compendium providing transparent, evidence-based information for paediatric pharmacotherapy to date. This work describes the development of a web-based paediatric drug information system (PDIS) for Germany and its evaluation by health care professionals (HCP). Methods: Since 2012, a PDIS is being developed by the authors and is supported by the Federal Ministry of Health since 2016. Dosing recommendations were established based on systematic literature reviews and subsequent evaluation by clinical experts. The prototype was evaluated by HCP. Based on the results, the further development was concluded. Results: 92% of HCP believed that the PDIS could improve the quality of prescribing, as currently available information is deficient. Besides the license and formulations, dosing recommendations were the most relevant modules. A dosage calculator was the most wanted improvement. To facilitate sustainability of future development, a collaboration with the Dutch Kinderformularium was established. As of 2021, the database will be available to German HCP. Conclusion: The fundamentals for a German PDIS were established, and vital steps were taken towards successful continuation.
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Affiliation(s)
- Julia Zahn
- Department of Paediatrics and Adolescent Medicine, Faculty of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (S.W.); (I.T.); (W.R.)
- Correspondence: (J.Z.); (A.N.); Tel.: +49-91318541723 (J.Z.); +49-91318536874 (A.N.)
| | - Stefan Wimmer
- Department of Paediatrics and Adolescent Medicine, Faculty of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (S.W.); (I.T.); (W.R.)
- Department of Pharmacy, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
| | - Wolfgang Rödle
- Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91058 Erlangen, Germany; (W.R.); (B.S.); (H.-U.P.)
| | - Irmgard Toni
- Department of Paediatrics and Adolescent Medicine, Faculty of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (S.W.); (I.T.); (W.R.)
| | - Brita Sedlmayr
- Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91058 Erlangen, Germany; (W.R.); (B.S.); (H.-U.P.)
- Institute for Medical Informatics and Biometry, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, 01069 Dresden, Germany
| | - Hans-Ulrich Prokosch
- Chair of Medical Informatics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91058 Erlangen, Germany; (W.R.); (B.S.); (H.-U.P.)
| | - Wolfgang Rascher
- Department of Paediatrics and Adolescent Medicine, Faculty of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (S.W.); (I.T.); (W.R.)
| | - Antje Neubert
- Department of Paediatrics and Adolescent Medicine, Faculty of Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (S.W.); (I.T.); (W.R.)
- Correspondence: (J.Z.); (A.N.); Tel.: +49-91318541723 (J.Z.); +49-91318536874 (A.N.)
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Aleem S, Wohlfarth M, Cotten CM, Greenberg RG. Infection control and other stewardship strategies in late onset sepsis, necrotizing enterocolitis, and localized infection in the neonatal intensive care unit. Semin Perinatol 2020; 44:151326. [PMID: 33158599 PMCID: PMC7550069 DOI: 10.1016/j.semperi.2020.151326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Suspected or proven late onset sepsis, necrotizing enterocolitis, urinary tract infections, and ventilator associated pneumonia occurring after the first postnatal days contribute significantly to the total antibiotic exposures in neonatal intensive care units. The variability in definitions and diagnostic criteria in these conditions lead to unnecessary antibiotic use. The length of treatment and choice of antimicrobial agents for presumed and proven episodes also vary among centers due to a lack of supportive evidence and guidelines. Implementation of robust antibiotic stewardship programs can encourage compliance with appropriate dosages and narrow-spectrum regimens.
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Affiliation(s)
- Samia Aleem
- Department of Pediatrics, Duke University, Durham, NC, USA
| | | | | | - Rachel G. Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA,Corresponding author at: Department of Pediatrics, Duke University, Durham, NC, USA
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23
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Jacqz-Aigrain E, Leroux S, Thomson AH, Allegaert K, Capparelli EV, Biran V, Simon N, Meibohm B, Lo YL, Marques R, Peris JE, Lutsar I, Saito J, Nakamura H, van den Anker JN, Sharland M, Zhao W. Population pharmacokinetic meta-analysis of individual data to design the first randomized efficacy trial of vancomycin in neonates and young infants. J Antimicrob Chemother 2020; 74:2128-2138. [PMID: 31049551 DOI: 10.1093/jac/dkz158] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/26/2019] [Accepted: 03/16/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES In the absence of consensus, the present meta-analysis was performed to determine an optimal dosing regimen of vancomycin for neonates. METHODS A 'meta-model' with 4894 concentrations from 1631 neonates was built using NONMEM, and Monte Carlo simulations were performed to design an optimal intermittent infusion, aiming to reach a target AUC0-24 of 400 mg·h/L at steady-state in at least 80% of neonates. RESULTS A two-compartment model best fitted the data. Current weight, postmenstrual age (PMA) and serum creatinine were the significant covariates for CL. After model validation, simulations showed that a loading dose (25 mg/kg) and a maintenance dose (15 mg/kg q12h if <35 weeks PMA and 15 mg/kg q8h if ≥35 weeks PMA) achieved the AUC0-24 target earlier than a standard 'Blue Book' dosage regimen in >89% of the treated patients. CONCLUSIONS The results of a population meta-analysis of vancomycin data have been used to develop a new dosing regimen for neonatal use and to assist in the design of the model-based, multinational European trial, NeoVanc.
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Affiliation(s)
- Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France.,Clinical Investigation Center CIC1426, Hôpital Robert Debré, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Stéphanie Leroux
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France.,Clinical Investigation Center CIC1426, Hôpital Robert Debré, Paris, France.,Division of Neonatology, Department of Child and Adolescent Medicine, CHU de Rennes, Rennes, France
| | - Alison H Thomson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Pharmacy Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Edmund V Capparelli
- Pediatric Pharmacology and Drug Discovery, University of California, San Diego, CA, USA
| | - Valérie Biran
- Neonatal Intensive Care Unit, Hôpital Robert Debré, Paris, France
| | - Nicolas Simon
- Department of Pharmacology, Hôpital de la Timone, APHM, Université de la Méditerranée, Marseille, France.,Service de Pharmacologie Clinique, Hôpital Sainte marguerite, CAP-TV, 13274 Marseille, France.,Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
| | - Bernd Meibohm
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yoke-Lin Lo
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,School of Pharmacy, International Medical University, Kuala Lumpur, Malaysia
| | - Remedios Marques
- Department of Pharmacy Services, La Fe Hospital, Valencia, Spain
| | - José-Esteban Peris
- Department of Pharmacy and Pharmaceutical Technology, University of Valencia, Valencia, Spain
| | - Irja Lutsar
- Institute of Medical Microbiology, University of Tartu, Tartu, Estonia
| | - Jumpei Saito
- Department of Pharmacy, National Children's Hospital National Center for Child Health and Development, Tokyo, Japan
| | - Hidefumi Nakamura
- Department of Development Strategy, Center for Clinical Research and Development, National Center for Child Health and Development, Tokyo, Japan
| | - Johannes N van den Anker
- Pharmacy Department, Glasgow Royal Infirmary, Glasgow, UK.,Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA.,Departments of Pediatrics, Pharmacology & Physiology, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.,Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland
| | - Mike Sharland
- Paediatric Infectious Disease Unit, St George's Hospital, London, UK
| | - Wei Zhao
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France.,Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
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Dosing of Antimicrobials in the Neonatal Intensive Care Unit: Does Clinical Practice Reflect Pharmacokinetics-based Recommendations? Pediatr Infect Dis J 2020; 39:713-717. [PMID: 32677811 DOI: 10.1097/inf.0000000000002657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We sought to compare meropenem and fluconazole dosing in the neonatal intensive care unit with recommendations based on published pharmacokinetic (PK) studies in infants. METHODS We performed an observational cohort study of infants <90 days postnatal age who received a course of meropenem or fluconazole who were treated in neonatal intensive care units managed by the Pediatrix Medical Group (1997-2016). We defined any dose amount from 80% to 120% of the published recommendation to constitute an appropriate dose of either antimicrobial. We calculated the percentage of appropriately dosed courses overall and by discharge year. We then evaluated the change in appropriate dosing over time using a nonparametric test of trend to evaluate the proportion of appropriately dosed courses of each antimicrobial by discharge year. RESULTS A total of 3608 infants were administered 2025 courses of meropenem and 1201 courses of fluconazole. Of all meropenem courses, 32% were dosed appropriately (increased significantly over time; P = 0.01), while 17% of fluconazole courses were dosed appropriately (increased significantly over time; P = 0.01). Median dosing for both meropenem and fluconazole was at or below recommendations; therefore, under-dosing was more common. CONCLUSIONS There was marked discordance between actual fluconazole and meropenem dosing and dosing recommendation in PK publications, yet adherence to PK-based doses showed improvement over time.
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Approaches to Dose Finding in Neonates, Illustrating the Variability between Neonatal Drug Development Programs. Pharmaceutics 2020; 12:pharmaceutics12070685. [PMID: 32698409 PMCID: PMC7408157 DOI: 10.3390/pharmaceutics12070685] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/10/2020] [Accepted: 07/18/2020] [Indexed: 12/14/2022] Open
Abstract
Drug dosing in neonates should be based on integrated knowledge concerning the disease to be treated, the physiological characteristics of the neonate, and the pharmacokinetics (PK) and pharmacodynamics (PD) of a given drug. It is critically important that all sources of information be leveraged to optimize dose selection for neonates. Sources may include data from adult studies, pediatric studies, non-clinical (juvenile) animal models, in vitro studies, and in silico models. Depending on the drug development program, each of these modalities could be used to varying degrees and with varying levels of confidence to guide dosing. This paper aims to illustrate the variability between neonatal drug development programs for neonatal diseases that are similar to those seen in other populations (meropenem), neonatal diseases related but not similar to pediatric or adult populations (clopidogrel, thyroid hormone), and diseases unique to neonates (caffeine, surfactant). Extrapolation of efficacy from older children or adults to neonates is infrequently used. Even if a disease process is similar between neonates and children or adults, such as with anti-infectives, additional dosing and safety information will be necessary for labeling, recognizing that dosing in neonates is confounded by maturational PK in addition to body size.
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26
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Sridharan K, Al Daylami A. Clinical audit of gentamicin use by Bayesian pharmacokinetic approach in critically ill children. J Infect Chemother 2020; 26:540-548. [DOI: 10.1016/j.jiac.2020.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 02/09/2023]
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27
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Hill LF, Turner MA, Lutsar I, Heath PT, Hardy P, Linsell L, Jacqz-Aigrain E, Roilides E, Sharland M. An optimised dosing regimen versus a standard dosing regimen of vancomycin for the treatment of late onset sepsis due to Gram-positive microorganisms in neonates and infants aged less than 90 days (NeoVanc): study protocol for a randomised controlled trial. Trials 2020; 21:329. [PMID: 32293527 PMCID: PMC7158076 DOI: 10.1186/s13063-020-4184-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 02/19/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Vancomycin has been used in clinical practice for over 50 years; however, validated, pharmacokinetic (PK) data relating clinical outcomes to different dosing regimens in neonates are lacking. Coagulase negative staphylococci (CoNS) are the most commonly isolated organisms in neonatal, late-onset sepsis (LOS). Optimised use to maximise efficacy while minimising toxicity and resistance selection is imperative to ensure vancomycin's continued efficacy. METHODS NeoVanc is a European, open-label, Phase IIb, randomised, controlled, non-inferiority trial comparing an optimised vancomycin regimen to a standard vancomycin regimen when treating LOS known/suspected to be caused by Gram-positive organisms (excluding Staphylococcus aureus) in infants aged ≤ 90 days. Three hundred infants will be recruited and randomised in a 1:1 ratio. Infants can be recruited if they have culture confirmed (a positive culture from a normally sterile site and at least one clinical/laboratory criterion) or clinical sepsis (presence of any ≥ 3 clinical/laboratory criteria) in the 24 h before randomisation. The optimised regimen consists of a vancomycin loading dose (25 mg/kg) followed by 5 ± 1 days of 15 mg/kg q12h or q8h, dependent on postmenstrual age (PMA). The standard regimen is a 10 ± 2 day vancomycin course at 15 mg/kg q24h, q12h or q8h, dependent on PMA. The primary endpoint is a successful outcome at the test of cure visit (10 ± 1 days after the end of vancomycin therapy). A successful outcome consists of the patient being alive, having successfully completed study vancomycin therapy and having not had a clinical/microbiological relapse/new infection requiring treatment with vancomycin or other anti-staphylococcal antibiotic for > 24 h. Secondary endpoints include clinical/microbiological relapse/new infection at the short-term follow-up visit (30 ± 5 days after the initiation of vancomycin), evaluation of safety (renal/hearing), vancomycin PK and assessment of a host biomarker panel over the course of vancomycin therapy. DISCUSSION Based on previous pre-clinical data and a large meta-analysis of neonatal, PK/pharmacodynamic data, NeoVanc was set up to provide evidence on whether a loading dose followed by a short vancomycin course is non-inferior, regarding efficacy, when compared to a standard, longer course. If non-inferiority is demonstrated, this would support adoption of the optimised regimen as a way of safely reducing vancomycin exposure when treating neonatal, Gram-positive LOS. TRIAL REGISTRATION ClinicalTrials.gov, NCT02790996. Registered on 7 April 2016. EudraCT, 2015-000203-89. Entered on 18 July 2016.
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Affiliation(s)
- Louise F Hill
- Paediatric Infectious Diseases Research Group, Institute for Infection & Immunity, St George's, University of London, London, UK. .,UCL Great Ormond Street Institute of Child Health, London, UK.
| | - Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Paul T Heath
- Paediatric Infectious Diseases Research Group, Institute for Infection & Immunity, St George's, University of London, London, UK
| | - Pollyanna Hardy
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, Paris, France
| | - Emmanuel Roilides
- 3rd Department of Pediatrics, Aristotle University, Thessaloniki, Greece
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection & Immunity, St George's, University of London, London, UK
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Population Pharmacokinetics of Teicoplanin in Preterm and Term Neonates: Is It Time for a New Dosing Regimen? Antimicrob Agents Chemother 2020; 64:AAC.01971-19. [PMID: 31932366 DOI: 10.1128/aac.01971-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023] Open
Abstract
Our objective was to develop a population pharmacokinetic (PK) model in order to evaluate the currently recommended dosing regimen in term and preterm neonates. By using an optimal design approach, a prospective PK study was designed and implemented in 60 neonates with postmenstrual ages (PMA) of 26 to 43 weeks. A loading dose of 16 mg/kg was administered at day 1, followed by a maintenance dose of 8 mg/kg daily. Plasma concentrations were quantified by high-pressure liquid chromatography-mass spectrometry. Population PK (popPK) analysis was performed using NONMEM software. Monte-Carlo (MC) simulations were performed to evaluate currently recommended dosing based on a pharmacodynamic index of area under the concentration-time curve (AUC)/MIC ratio of ≥400. A two-compartment model with linear elimination best described the data by the following equations: clearance (CL) = 0.0227 × (weight [wt]/1,765)0.75 × (estimated creatinine clearance [eCRCL]/22)0.672, central compartment volume of distribution (V1) = 0.283 (wt/1,765), intercompartmental clearance (Q) = 0.151 (wt/1,765)0.75, and peripheral compartment volume (V2) = 0.541 (wt/1,765). The interindividual variability estimates for CL, V1, and V2 were 36.5%, 45.7%, and 51.4%, respectively. Current weight (wt) and estimated creatinine clearance (eCRCL) significantly explained the observed variability. MC simulation demonstrated that, with the current dosing regimen, an AUC/MIC ratio of ≥400 was reached by only 68.5% of neonates with wt of <1 kg when the MIC was equal to 1 mg/kg, versus 82.2%, 89.7%, and 92.7% of neonates with wt of 1 to <2, 2 to <3, or ≥3 kg, respectively. Augmentation of a maintenance dose up to 10 or 11 mg/kg for preterm neonates with wt of 1 to <2 or <1 kg, respectively, increases the probability of reaching the therapeutic target; the recommended doses seem to be adequate for neonates with wt of ≥2 kg. Teicoplanin PK are variable in neonates, with wt and eCRCL having the most significant impact. Neonates with wt of <2 kg need higher doses, especially for Staphylococcus spp. with an MIC value of ≥1 mg/liter.
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Lutsar I, Chazallon C, Trafojer U, de Cabre VM, Auriti C, Bertaina C, Calo Carducci FI, Canpolat FE, Esposito S, Fournier I, Hallik M, Heath PT, Ilmoja ML, Iosifidis E, Kuznetsova J, Meyer L, Metsvaht T, Mitsiakos G, Pana ZD, Mosca F, Pugni L, Roilides E, Rossi P, Sarafidis K, Sanchez L, Sharland M, Usonis V, Warris A, Aboulker JP, Giaquinto C. Meropenem vs standard of care for treatment of neonatal late onset sepsis (NeoMero1): A randomised controlled trial. PLoS One 2020; 15:e0229380. [PMID: 32130261 PMCID: PMC7055900 DOI: 10.1371/journal.pone.0229380] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/03/2020] [Indexed: 11/22/2022] Open
Abstract
Background The early use of broad-spectrum antibiotics remains the cornerstone for the treatment of neonatal late onset sepsis (LOS). However, which antibiotics should be used is still debatable, as relevant studies were conducted more than 20 years ago, recruited in single centres or countries, evaluated antibiotics not in clinical use anymore and had variable inclusion/exclusion criteria and outcome measures. Moreover, antibiotic-resistant bacteria have become a major problem in many countries worldwide. We hypothesized that efficacy of meropenem as a broad-spectrum antibiotic is superior to standard of care regimens (SOC) in empiric treatment of LOS and aimed to compare meropenem to SOC in infants aged <90 days with LOS. Methods and findings NeoMero-1 was a randomized, open-label, phase III superiority trial conducted in 18 neonatal units in 6 countries. Infants with post-menstrual age (PMA) of ≤44 weeks with positive blood culture and one, or those with negative culture and at least with two predefined clinical and laboratory signs suggestive of LOS, or those with PMA >44 weeks meeting the Goldstein criteria of sepsis, were randomized in a 1:1 ratio to receive meropenem or one of the two SOC regimens (ampicillin+gentamicin or cefotaxime+gentamicin) chosen by each site prior to the start of the study for 8–14 days. The primary outcome was treatment success (survival, no modification of allocated therapy, resolution/improvement of clinical and laboratory markers, no need of additional antibiotics and presumed/confirmed eradication of pathogens) at test-of-cure visit (TOC) in full analysis set. Stool samples were tested at baseline and Day 28 for meropenem-resistant Gram-negative organisms (CRGNO). The primary analysis was performed in all randomised patients and in patients with culture confirmed LOS. Proportions of participants with successful outcome were compared by using a logistic regression model adjusted for the stratification factors. From September 3, 2012 to November 30th 2014, total of 136 patients (instead of planned 275) in each arm were randomized; 140 (52%) were culture positive. Successful outcome at TOC was achieved in 44/136 (32%) in the meropenem arm vs. 31/135 (23%) in the SOC arm (p = 0.087). The respective numbers in patients with positive cultures were 17/63 (27%) vs. 10/77 (13%) (p = 0.022). The main reason of failure was modification of allocated therapy. Treatment emergent adverse events occurred in 72% and serious adverse events in 17% of patients, the Day 28 mortality was 6%. Cumulative acquisition of CRGNO by Day 28 occurred in 4% of patients in the meropenem and 12% in the SOC arm (p = 0.052). Conclusions Within this study population, we found no evidence that meropenem was superior to SOC in terms of success at TOC, short term hearing disturbances, safety or mortality were similar in both treatment arms but the study was underpowered to detect the planned effect. Meropenem treatment did not select for colonization with CRGNOs. We suggest that meropenem as broad-spectrum antibiotic should be reserved for neonates who are more likely to have Gram-negative LOS, especially in NICUs where microorganisms producing extended spectrum- and AmpC type beta-lactamases are circulating.
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Affiliation(s)
- Irja Lutsar
- Institute of Translational Medicine, University of Tartu, Tartu, Estonia
- * E-mail:
| | | | - Ursula Trafojer
- Women's and Children's Health Department, Neonatal Intensive Care Unit, Azienda Ospedaliera-University of Padua, Padua, Italy
| | | | - Cinzia Auriti
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Chiara Bertaina
- University Department of Paediatrics, Immunological and Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Francesca Ippolita Calo Carducci
- University Department of Paediatrics, Immunological and Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Fuat Emre Canpolat
- Sağlık Bilimleri Üniversitesi, Zekai Tahir Burak Kadın Sağlığı Eğitim ve Araştırma Hastanesi, Neonatoloji Kliniği, Ankara, Turkey
| | - Susanna Esposito
- Pediatric Highly Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | | | - Maarja Hallik
- Department of Intensive Care, Tallinn Children’s Hospital, Tallinn, Estonia
| | - Paul T. Heath
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, United Kingdom
| | - Mari-Liis Ilmoja
- Institute of Translational Medicine, University of Tartu, Tartu, Estonia
- Department of Intensive Care, Tallinn Children’s Hospital, Tallinn, Estonia
| | - Elias Iosifidis
- 3 Department of Pediatrics, Faculty of Medicine, Infectious Diseases Unit, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - Jelena Kuznetsova
- Tartu University Hospital, Clinic of Anaesthesiology and Intensive Care, Tartu, Estonia
| | | | - Tuuli Metsvaht
- Institute of Translational Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Clinic of Anaesthesiology and Intensive Care, Tartu, Estonia
| | - George Mitsiakos
- 2 Department of Neonatology, Faculty of Medicine, Aristotle University School of Health Sciences, Papageorgiou Hospital, Thessaloniki, Greece
| | - Zoi Dorothea Pana
- 3 Department of Pediatrics, Faculty of Medicine, Infectious Diseases Unit, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Lorenza Pugni
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Emmanuel Roilides
- 3 Department of Pediatrics, Faculty of Medicine, Infectious Diseases Unit, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - Paolo Rossi
- University Department of Paediatrics, Immunological and Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Kosmas Sarafidis
- 1st Department of Neonatology, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - Laura Sanchez
- Hospital Universitario Infantil LA PAZ- H. Carlos III, Madrid, Spain
| | - Michael Sharland
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, United Kingdom
| | | | - Adilia Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padova, Padova, Italy
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McMullan B, Cooper C, Spotswood N, James R, Jones C, Konecny P, Blyth C, Karen T. Antibiotic prescribing in neonatal sepsis: an Australian nationwide survey. BMJ Paediatr Open 2020; 4:e000643. [PMID: 32232180 PMCID: PMC7101048 DOI: 10.1136/bmjpo-2020-000643] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/24/2020] [Accepted: 02/27/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate quality and variation in antibiotic prescribing for neonatal sepsis. DESIGN We analysed prescribing in hospitalised neonates using the National Antimicrobial Prescribing Survey in Australian neonates from 1 January 2014 to 31 December 2018. SETTING Data from antibiotic point prevalence surveys performed in hospitals, ranging from rural hospitals to tertiary paediatric and maternity hospitals within Australia. PATIENTS Admitted neonates <28 days of age from participating hospitals. MAIN OUTCOME MEASURES Variation and appropriateness in prescribing for neonatal sepsis and variation in dosing for gentamicin and benzylpenicillin across hospitals. RESULTS A total of 415 prescriptions among 214 neonates from 39 different hospitals were included. The majority of prescriptions (342, 82.4%) were for neonates <7 days of age. The most commonly prescribed antibiotics were gentamicin and benzylpenicillin, with 323 (77.8%) prescriptions. Dosing variability was substantial, with doses ranging from 2 to 8 mg/kg for gentamicin (median 5 mg/kg, IQR 4-5) and from 45 to 72 mg/kg for benzylpenicillin (median 60 mg/kg, IQR 50-60), although only 13 (3.2%) and 19 (4.6%) prescriptions were locally assessed as inappropriate or non-compliant with guidelines, respectively. At time of audit, 22% of antibiotics had been given for more than 48 hours and 9% more than 72 hours, although microbiologically confirmed infection was documented in only nine (4.2%) neonates. CONCLUSIONS Prescribing for neonatal sepsis was dominated by use of benzylpenicillin and gentamicin with substantial variation in dosing. A small minority had culture-confirmed infection. Efforts to standardise antibiotic dosing and duration for suspected neonatal sepsis are recommended.
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Affiliation(s)
- Brendan McMullan
- Immunology and Infectious Diseases, Sydney Children's Hospital Randwick, Sydney, New South Wales, Australia.,National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Celia Cooper
- Department of Infectious Diseases, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Naomi Spotswood
- Burnet Institute, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Rodney James
- National Centre for Antimicrobial Stewardship, Melbourne, Victoria, Australia
| | - Cheryl Jones
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Pamela Konecny
- Infectious Diseases, Immunology and Sexual Health, St George Hospital, Kogarah, Sydney, New South Wales, Australia.,St George and Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher Blyth
- School of Paediatrics and Child Health, University of Western Australia, Subiaco, Western Australia, Australia.,Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia.,Department of Paediatric Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Perth, Western Australia, Australia
| | - Thursky Karen
- National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases Service and Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Gastine S, Rashed AN, Hsia Y, Jackson C, Barker CIS, Mathur S, Tomlin S, Lutsar I, Bielicki J, Standing JF, Sharland M. GAPPS (Grading and Assessment of Pharmacokinetic-Pharmacodynamic Studies) a critical appraisal system for antimicrobial PKPD studies - development and application in pediatric antibiotic studies. Expert Rev Clin Pharmacol 2019; 12:1091-1098. [PMID: 31747323 DOI: 10.1080/17512433.2019.1695600] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: There are limited data on optimal dosing of antibiotics in different age groups for neonates and children. Clinicians usually consult pediatric formularies or online databases for dose selection, but these have variable recommendations, are usually based on expert opinion and are not graded based on the existing pharmacokinetic-pharmacodynamic (PKPD) studies. We describe here a potential new tool that could be used to grade the strength of evidence emanating from PKPD studies.Areas covered: A scoring system was developed (GAPPS tool) to quantify the strength of each PK assessment and rate the studies quality in already published articles. GAPPS was evaluated by applying it to pediatric PKPD studies of antibiotics from the 2019 Essential Medicines List for children (EMLC), identified through a search of PubMed.Expert opinion: Evidence for most antibiotic dose selection decisions was generally weak, coming from individual PK studies and lacked PKPD modeling and simulations. However, the quality of evidence appears to have improved over the last two decades.Incorporating a formal grading system, such as GAPPS, into formulary development will provide a transparent tool to support decision-making in clinical practice and guideline development, and guide PKPD authors on study designs most likely to influence guidelines.
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Affiliation(s)
- Silke Gastine
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Asia N Rashed
- Pharmacy Department, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Science, King's College London, London, UK
| | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Charlotte Jackson
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Charlotte I S Barker
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Shrey Mathur
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Stephen Tomlin
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Irja Lutsar
- Department of Microbiology, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Julia Bielicki
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,Paediatric Pharmacology Group, University of Basel Children's Hospital, Basel, Switzerland
| | - Joseph F Standing
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
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Mesek I, Nellis G, Lass J, Metsvaht T, Varendi H, Visk H, Turner MA, Nunn AJ, Duncan J, Lutsar I. Medicines prescription patterns in European neonatal units. Int J Clin Pharm 2019; 41:1578-1591. [PMID: 31625122 DOI: 10.1007/s11096-019-00923-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
Abstract
Background Hospitalized neonates receive the highest number of drugs compared to all other age groups, but consumption rates vary between studies depending on patient characteristics and local practices. There are no large-scale international studies on drug use in neonatal units. Objective We aimed to describe drug use in European neonatal units and characterize its associations with geographic region and gestational age. Setting A one-day point prevalence study was performed as part of the European Study of Neonatal Exposure to Excipients from January to June 2012. Method All neonatal prescriptions and demographic data were registered in a web-based database. The impact of gestational age and region on prescription rate were analysed with logistic regression. Main outcome measure The number and variety of drugs prescribed to hospitalized neonates in different gestational age groups and geographic regions. Results In total, 21 European countries with 89 neonatal units participated. Altogether 2173 prescriptions given to 726 neonates were registered. The 10 drugs with the highest prescription rate were multivitamins, vitamin D, caffeine, gentamicin, amino acids for parenteral nutrition, phytomenadione, ampicillin, benzylpenicillin, fat emulsion for parenteral nutrition and probiotics. The six most commonly prescribed ATC groups (alimentary tract and metabolism, blood and blood-forming organs, systemic anti-infectives, nervous, respiratory and cardiovascular system) covered 98% of prescriptions. Gestational age significantly affected the use of all commonly used drug groups. Geographic region influenced the use of alimentary tract and metabolism, blood and blood-forming organs, systemic anti-infectives, nervous and respiratory system drugs. Conclusion While gestational age-dependent differences in neonatal drug use were expected, regional variations (except for systemic anti-infectives) indicate a need for cooperation in developing harmonized evidence-based guidelines and suggest priorities for collaborative work.
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Affiliation(s)
- Inge Mesek
- Department of Microbiology, University of Tartu, Tartu, Estonia.
| | - Georgi Nellis
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Neonatal Unit, Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Jana Lass
- Department of Microbiology, University of Tartu, Tartu, Estonia.,Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Tuuli Metsvaht
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Clinic of Anaesthesiology and Intensive Care, Paediatric Intensive Care Unit, Tartu University Hospital, Tartu, Estonia
| | - Heili Varendi
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Neonatal Unit, Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Helle Visk
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Anthony J Nunn
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jennifer Duncan
- Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Irja Lutsar
- Department of Microbiology, University of Tartu, Tartu, Estonia
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Adams M, Bassler D. Practice variations and rates of late onset sepsis and necrotizing enterocolitis in very preterm born infants, a review. Transl Pediatr 2019; 8:212-226. [PMID: 31413955 PMCID: PMC6675686 DOI: 10.21037/tp.2019.07.02] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/08/2019] [Indexed: 01/01/2023] Open
Abstract
The burden of late onset sepsis (LOS) and necrotizing enterocolitis (NEC) remains high for newborns in low- and high-income countries. Very preterm born infants born below 32 weeks gestation are at highest risk because their immune system is not yet adapted to ex-utero life, providing intensive care frequently compromises their skin or mucosa and they require a long duration of hospital stay. An epidemiological overview is difficult to provide because there is no mutually accepted definition available for either LOS or NEC. LOS incidence proportions are generally reported based on identified blood culture pathogens. However, discordance in minimum day of onset and whether coagulase negative staphylococci or fungi should be included into the reported proportions lead to variation in reported incidences. Complicating the comparison are the absence of biomarkers, ancillary lab tests or prediction models with sufficiently high positive and/or negative predictive values. The only high negative predictive values result from negative blood culture results with negative lab results allowing to discontinue antibiotic treatment. Similar difficulties exist in reporting and diagnosing NEC. Although most publications base their proportions on a modified version of Bell's stage 2 or 3, comparisons are made difficult by the multifactorial nature of the disease reflecting several pathways to intestinal necrosis, the absence of a reliable biomarker and the unclear differentiation from spontaneous intestinal perforations. Comparable reports in very low birthweight infants range between 5% and 30% for LOS and 1.6% to 7.1% for NEC. Evidence based guidelines to support treatment are missing. Treatment for LOS remains largely empirical and focused mainly on antibiotics. In the absence of a clear diagnosis, even unspecific early warning signals need to be met with antibiotic treatment. Cessation after negative blood culture is difficult unless the child was asymptomatic from the beginning. As a result, antibiotics are the most commonly prescribed medications, but unnecessary exposure may result in increased risk for mortality, NEC, further infections and childhood obesity or asthma. Finding ways to limit antibiotic use are thus important and have shown a large potential for improvement of care and limitation of cost. Over recent decades, none of the attempts to establish novel therapies have succeeded. LOS and NEC proportions remained mostly stable. During the past 10 years however, publications emerged reporting a reduction, sometimes by almost 50%. Most concern units participating in a surveillance system using quality improvement strategies to prevent LOS or NEC (e.g., hand hygiene, evidence based "bundles", feeding onset, providing own mother's milk). We conclude that these approaches display a potential for wider spread reduction of LOS and NEC and for a subsequently more successful development of novel therapies as these often address the same pathways as the prevention strategies.
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Affiliation(s)
- Mark Adams
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Are antibiotics a risk factor for the development of necrotizing enterocolitis-case-control retrospective study. Eur J Pediatr 2019; 178:923-928. [PMID: 30949889 DOI: 10.1007/s00431-019-03373-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 02/24/2019] [Accepted: 03/25/2019] [Indexed: 12/31/2022]
Abstract
Previous studies have identified numerous risk factors associated with necrotizing enterocolitis (NEC) in very low birth weight (VLBW; birth weight less than 1500 g) infants. One of the potential pathophysiological contributors could be antibiotic therapy. Our aim was to explore the association between antibiotic exposure and NEC in VLBW infants. We designed a retrospective 1:2 case-control cohort study in a level III neonatal intensive care unit. Our study group composed of VLBW infants born between January 2012 and December 2014 with a diagnosis of NEC stage IIA or greater (Bell's modified criteria). Our intent was to match every case in the study group to two controls. Our primary outcome was an association between antibiotic exposure and NEC. Twenty-two cases of NEC were matched to 32 controls. The infants who developed NEC were exposed to a statistically significantly more frequent number of antibiotic courses and to more days on any antibiotic prior to the development of NEC. There were significant differences between cases and controls with respect to the duration of exposure to gentamicin and meropenem specifically.Conclusion: The data from our study demonstrate that prolonged exposure to antibiotic therapy is associated with an increased risk of NEC among VLBW infants. Furthermore, gentamicin and meropenem, but not other antibiotics, had a significant association with the incidence of NEC. What is known: • Early antibiotic exposure is a risk factor for the development of necrotising enterocolitis (NEC) in very low birth weight infants • Prolonged initial empirical antibiotic course for ≥ 5 days, despite sterile blood culture, is associated with an increased risk of developing NEC What is new: • The cumulative total number of days of antibiotic exposure is associated with an increased risk of developing NEC • Gentamicin and meropenem, but not other antibiotics, had a significant association with the incidence of NEC in our study.
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Abstract
Antimicrobial medications are the most commonly used medications in the neonatal intensive care unit. Antibiotics are used for infection prophylaxis, empiric treatment, and definitive treatment of confirmed infection. The choice of medication should be informed by the epidemiology and microbiology of infection in specific clinical scenarios and by the clinical condition of the infant. Understanding evolving pathogen susceptibility to antimicrobials and key pharmacotherapy determinants in neonates can inform optimal antibiotic use.
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Affiliation(s)
- Sagori Mukhopadhyay
- Section on Newborn Medicine, Pennsylvania Hospital, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; CHOP Newborn Care, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA
| | - Kelly C Wade
- Section on Newborn Medicine, Pennsylvania Hospital, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; CHOP Newborn Care, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA
| | - Karen M Puopolo
- Section on Newborn Medicine, Pennsylvania Hospital, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; CHOP Newborn Care, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA.
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Allegaert K, van den Anker J. Neonates are not just little children and need more finesse in dosing of antibiotics. Acta Clin Belg 2019; 74:157-163. [PMID: 29745792 DOI: 10.1080/17843286.2018.1473094] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVES Neonates are not just little children. They need more finesse in decisions on when to treat, which antibiotics to use and how to dose these antibiotics. METHODS Representative compounds of three major classes of antibiotics (beta-lactams, aminoglycosides, glycopeptides) are discussed in a narrative review to illustrate the recent progress in the knowledge on PK and its covariates (how to dose). RESULTS This knowledge can subsequently be converted to targeted exposure dosing regimens. This is because it is reasonable to postulate that pharmacodynamics (PD) of antibiotics are similar in neonates to that in other populations if a similar concentration-time profile and targeted exposure are attained. However, this approach has its limitations, since the clinical response may be different in neonates because of maturational differences in innate immunity or toxicity. These dosing regimens should at least be validated. CONCLUSION Relevant information on the PK of antibiotics and its covariates have been generated, but the next steps are to validate the dosing regimens suggested, and consider more sophisticated dosing regimens. This approach should subsequently pave the way to conduct comparative studies to assess the efficacy and safety of these commonly used drugs in neonates.
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Affiliation(s)
- Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Neonatology, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Development and Regeneration, KU, Leuven, Belgium
| | - John van den Anker
- Intensive Care and Department of Pediatric Surgery, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
- Paediatric Pharmacology and Pharmacometrics, University of Basel Children’s Hospital, Basel, Switzerland
- Division of Clinical Pharmacology, Children’s National Health System, Washington, DC, USA
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Leopoldino RD, Santos MT, Costa TX, Martins RR, Oliveira AG. Drug related problems in the neonatal intensive care unit: incidence, characterization and clinical relevance. BMC Pediatr 2019; 19:134. [PMID: 31027487 PMCID: PMC6485091 DOI: 10.1186/s12887-019-1499-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Any event involving drug therapy that may interfere in a patient's desired clinical outcome is called a drug related problem (DRP). DRP are very common in intensive therapy, however, little is known about DRP in the Neonatal Intensive Care Unit (NICU). The purpose of this study was to determine the incidence of DRPs in NICU patients and to characterize DRPs according to type, cause and corresponding pharmaceutical conducts. METHODS Prospective observational study conducted in the NICU at a teaching hospital in Brazil from January 2014 to November 2016. The data were collected from the records of the clinical pharmacy service, excluding neonates admitted for less than 24 h and those who had no drugs prescribed. DRPs were classified according to the Pharmaceutical Care Network Europe system and evaluated for relevance-safety. RESULTS Six hundred neonates were included in the study, with mean gestational age of 31.9 ± 4.1 weeks and mean birth weight of 1779 ± 885 g. The incidence of DRPs in the NICU was 6.8% patient-days (95%CI 6.2-7.3%) and affected 59.8% of neonates (95% CI 55.8-63.8%). Sub-optimal effect (52.8%) and inappropriate dose selection (39.75%) were the most common problem and cause, respectively. Anti-infectives was the medication class most involved in DRPs. More than one-third of neonates were exposed to DRP of significant or high safety-relevance. Most of the pharmaceutical interventions were related with drug prescription, with over 90% acceptance by attending physicians. CONCLUSION DRP are common in NICU, predominating problems of sub-optimal treatment, mainly due to inappropriate dose selection.
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Affiliation(s)
- Ramon Duarte Leopoldino
- Department of Pharmacy, Universidade Federal do Rio Grande do Norte, Av. General Gustavo Cordeiro de Farias, s/n. Petrópolis, Natal, RN, 59012-570, Brazil.
| | - Marco Tavares Santos
- Maternity School Januário Cicco, Universidade Federal do Rio Grande do Norte, Av. Nilo Peçanha, 259. Petrópolis, Natal, RN, 59012-310, Brazil
| | - Tatiana Xavier Costa
- Maternity School Januário Cicco, Universidade Federal do Rio Grande do Norte, Av. Nilo Peçanha, 259. Petrópolis, Natal, RN, 59012-310, Brazil
| | - Rand Randall Martins
- Department of Pharmacy, Universidade Federal do Rio Grande do Norte, Av. General Gustavo Cordeiro de Farias, s/n. Petrópolis, Natal, RN, 59012-570, Brazil
| | - António Gouveia Oliveira
- Department of Pharmacy, Universidade Federal do Rio Grande do Norte, Av. General Gustavo Cordeiro de Farias, s/n. Petrópolis, Natal, RN, 59012-570, Brazil
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Allegaert K, Simons S, Van Den Anker J. Research on medication use in the neonatal intensive care unit. Expert Rev Clin Pharmacol 2019; 12:343-353. [PMID: 30741041 DOI: 10.1080/17512433.2019.1580569] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Research on medication use aims at assessing how much of current pharmacotherapy is rational. In neonates, this is hampered by extensive off-label drug use and limited knowledge. Areas covered: We report on medication use research and have conducted a systematic review of observational studies on medication use to provide an updated overview on characteristics, objectives, methods, and patterns in hospitalized neonates. Moreover, a review on aspects of medication use for opioids, anti-epileptics, gastric acid-related disorders and respiratory stimulants with emphasis on trends and impact of interventions is presented, illustrating how research on medication use can contribute to improved neonatal pharmacotherapy and more focused research. Medication use reports describe patterns and provide signals on irrational use, benchmarking, or can guide research priorities. Moreover, this may generate information on how neonatal health topics and their pharmacotherapy are handled over time or across regions. Expert opinion: Research on medicine utilization is relevant, since it will inform us on aspects like trends, variability, or about the impact and pattern of implementation of guidelines in neonates. Further progress necessitates to merge datasets on medication use with clinical characteristics, and perinatal drug use remains an area in need of additional research.
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Affiliation(s)
- Karel Allegaert
- a Department of Pediatrics, Division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Sinno Simons
- a Department of Pediatrics, Division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - John Van Den Anker
- c Division of Clinical Pharmacology, Department of Pediatrics , Children's National Health System , Washington , DC , USA.,d Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland.,e Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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Rational Use of Antibiotics in Neonates: Still in Search of Tailored Tools. Healthcare (Basel) 2019; 7:healthcare7010028. [PMID: 30781454 PMCID: PMC6473895 DOI: 10.3390/healthcare7010028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 01/31/2019] [Accepted: 02/14/2019] [Indexed: 12/13/2022] Open
Abstract
Rational medicine use in neonates implies the prescription and administration of age-appropriate drug formulations, selecting the most efficacious and safe dose, all based on accurate information on the drug and its indications in neonates. This review illustrates that important uncertainties still exist concerning the different aspects (when, what, how) of rational antibiotic use in neonates. Decisions when to prescribe antibiotics are still not based on robust decision tools. Choices (what) on empiric antibiotic regimens should depend on the anticipated pathogens, and the available information on the efficacy and safety of these drugs. Major progress has been made on how (beta-lactam antibiotics, aminoglycosides, vancomycin, route and duration) to dose. Progress to improve rational antibiotic use necessitates further understanding of neonatal pharmacology (short- and long-term safety, pharmacokinetics, duration and route) and the use of tailored tools and smarter practices (biomarkers, screening for colonization, and advanced therapeutic drug monitoring techniques). Implementation strategies should not only facilitate access to knowledge and guidelines, but should also consider the most effective strategies (‘skills’) and psychosocial aspects involved in the prescription process: we should be aware that both the decision not to prescribe as well as the decision to prescribe antibiotics is associated with risks and benefits.
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McPherson C, Liviskie C, Zeller B, Nelson MP, Newland JG. Antimicrobial Stewardship in Neonates: Challenges and Opportunities. Neonatal Netw 2018; 37:116-123. [PMID: 29615159 DOI: 10.1891/0730-0832.37.2.116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neonatal infections result in significant morbidity and mortality. Antibiotics are vital for the treatment of infections but disrupt the neonatal microbiome, put the infant at risk for an adverse drug reaction, and may lead to the development of antibiotic resistance. Immediately after birth, clinicians must determine which infants require empiric antibiotics. Online risk stratification tools may provide a superior approach to decision trees. In infants who require empiric therapy for early-onset sepsis, ampicillin and an aminoglycoside with dosing based on recent pharmacokinetic studies represents the most appropriate first-line agents; third-generation cephalosporins should be reserved for patients with a high likelihood of Gram-negative meningitis. An antistaphylococcal penicillin and gentamicin should be utilized for suspected late-onset sepsis. Vancomycin and other broad-spectrum agents are reserved for patients with a history of resistant organisms. Antibiotic duration should be guided by understanding the clinical indications and obtaining the necessary cultures appropriately (i.e., adequate volume blood cultures). In the absence of a positive culture, antibiotic duration should often be limited. Individual institutions should leverage a multidisciplinary, interprofessional team to identify opportunities for antimicrobial stewardship. A collaborative, transparent system is required to change unit culture and generate a sustained impact on antibiotic utilization with optimal patient outcomes.
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Pharmacokinetics of Penicillin G in Preterm and Term Neonates. Antimicrob Agents Chemother 2018; 62:AAC.02238-17. [PMID: 29463540 DOI: 10.1128/aac.02238-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/09/2018] [Indexed: 11/20/2022] Open
Abstract
Group B streptococci are common causative agents of early-onset neonatal sepsis (EOS). Pharmacokinetic (PK) data for penicillin G have been described for extremely preterm neonates but have been poorly described for late-preterm and term neonates. Thus, evidence-based dosing recommendations are lacking. We describe the PK of penicillin G in neonates with a gestational age (GA) of ≥32 weeks and a postnatal age of <72 h. Penicillin G was administered intravenously at a dose of 25,000 or 50,000 IU/kg of body weight every 12 h (q12h). At steady state, PK blood samples were collected prior to and at 5 min, 1 h, 3 h, 8 h, and 12 h after injection. Noncompartmental PK analysis was performed with WinNonlin software. With those data in combination with data from neonates with a GA of ≤28 weeks, we developed a population PK model using NONMEM software and performed probability of target attainment (PTA) simulations. In total, 16 neonates with a GA of ≥32 weeks were included in noncompartmental analysis. The median volume of distribution (V) was 0.50 liters/kg (interquartile range, 0.42 to 0.57 liters/kg), the median clearance (CL) was 0.21 liters/h (interquartile range, 0.16 to 0.29 liters/kg), and the median half-life was 3.6 h (interquartile range, 3.2 to 4.3 h). In the population PK analysis that included 35 neonates, a two-compartment model best described the data. The final parameter estimates were 10.3 liters/70 kg and 29.8 liters/70 kg for V of the central and peripheral compartments, respectively, and 13.2 liters/h/70 kg for CL. Considering the fraction of unbound penicillin G to be 40%, the PTA of an unbound drug concentration that exceeds the MIC for 40% of the dosing interval was >90% for MICs of ≤2 mg/liter with doses of 25,000 IU/kg q12h. In neonates, regardless of GA, the PK parameters of penicillin G were similar. The dose of 25,000 IU/kg q12h is suggested for treatment of group B streptococcal EOS diagnosed within the first 72 h of life. (This study was registered with the EU Clinical Trials Register under EudraCT number 2012-002836-97.).
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van Donge T, Pfister M, Bielicki J, Csajka C, Rodieux F, van den Anker J, Fuchs A. Quantitative Analysis of Gentamicin Exposure in Neonates and Infants Calls into Question Its Current Dosing Recommendations. Antimicrob Agents Chemother 2018; 62:e02004-17. [PMID: 29358294 PMCID: PMC5913996 DOI: 10.1128/aac.02004-17] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/09/2018] [Indexed: 12/20/2022] Open
Abstract
Optimal dosing of gentamicin in neonates is still a matter of debate despite its common use. We identified gentamicin dosing regimens from eight international guidelines and seven Swiss neonatal intensive care units. The dose per administration, the dosing interval, the total daily dose, and the demographic characteristics between guidelines were compared. There was considerable variability with respect to dose (4 to 6 mg/kg), dosing interval (24 h to 48 h), total daily dose (2.5 to 6 mg/kg/day), and patient demographic characteristics that were used to calculate individualized dosing regimens. A model-based simulation study in 1071 neonates was performed to determine the achievement of efficacious peak gentamicin concentrations according to predefined MICs (Cmax/MIC ≥ 10) and safe trough concentrations (Cmin ≤ 2 mg/liter) with recommended dosing regimens. MIC targets of 0.5 and 1 mg/liter were used. Dosing optimization was performed giving priority to the first day of treatment and with the goal of simplifying dosing. Current gentamicin neonatal guidelines allow to achieve effective peak concentrations for MICs ≤ 0.5 mg/liter but not higher. Model-based simulations indicate that to attain peak gentamicin concentrations of ≥10 mg/liter, a dose of 7.5 mg/kg should be administered using an extended dosing interval regimen. Trough concentrations of ≤2 mg/liter can be maintained with a dosing interval of 36 to 48 h in neonates according to gestational and postnatal age. For treatment beyond 3 days, therapeutic drug monitoring is advised to maintain adequate serum concentrations.
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Affiliation(s)
- Tamara van Donge
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
| | - Marc Pfister
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Quantitative Solutions, a Certara Company, London, United Kingdom
| | - Julia Bielicki
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
| | - Chantal Csajka
- Service of Clinical Pharmacology, Department of Laboratory, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Frederique Rodieux
- Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - John van den Anker
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Aline Fuchs
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
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Liem TBY, Slob EMA, Termote JUM, Wolfs TFW, Egberts ACG, Rademaker CMA. Comparison of antibiotic dosing recommendations for neonatal sepsis from established reference sources. Int J Clin Pharm 2018; 40:436-443. [PMID: 29340851 PMCID: PMC5918525 DOI: 10.1007/s11096-018-0589-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/04/2018] [Indexed: 11/28/2022]
Abstract
Background Incorrect dosing is the most frequent prescribing error in neonatology, with antibiotics being the most frequently prescribed medicines. Computer physician order entry and clinical decision support systems can create consistency contributing to a reduction of medication errors. Although evidence-based dosing recommendations should be included in such systems, the evidence is not always available and subsequently, dosing recommendations mentioned in guidelines and textbooks are often based on expert opinion. Objective To compare dosage recommendations for antibiotics in neonates with sepsis provided by eight commonly used and well-established international reference sources. Setting An expert team from our Dutch tertiary care neonatal intensive care unit selected eight well-established international reference sources. Method Daily doses of the seven most frequently used antibiotics in the treatment of neonatal sepsis, classified by categories for birth weight and gestational age, were identified from eight well-respected reference sources in neonatology/pediatric infectious diseases. Main outcome measure Standardized average daily dosage. Results A substantial variation in dosage recommendations of antibiotics for neonatal sepsis between the reference sources was shown. Dosage recommendations of ampicillin, ceftazidime, meropenem and vancomycin varied more than recommendations for benzylpenicillin, cefotaxime and gentamicin. One reference source showed a larger variation in dosage recommendations in comparison to the average recommended daily dosage, compared to the other reference sources. Conclusion Antibiotic dosage recommendations for neonates with sepsis can be derived from important reference sources and guidelines. Further exploration to overcome variation in dosage recommendations is necessary to obtain standardized dosage regimens.
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Affiliation(s)
- T B Y Liem
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands.
| | - E M A Slob
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
| | - J U M Termote
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Centre, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
| | - T F W Wolfs
- Department of Pediatrics, Infectious Diseases and Immunology, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
| | - A C G Egberts
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
| | - C M A Rademaker
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
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Antibiotic PK/PD research in critically ill neonates and children: how do we proceed? ACTA ACUST UNITED AC 2018. [DOI: 10.4155/ipk-2017-0019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Cuzzolin L, Agostino R. Antibiotic Use in a Cohort of Extremely Low Birth Weight Neonates: Focus on Off-Label Uses and Prescription Behaviour. ACTA ACUST UNITED AC 2018. [DOI: 10.4236/pp.2018.99029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Development of a Novel Multipenicillin Assay and Assessment of the Impact of Analyte Degradation: Lessons for Scavenged Sampling in Antimicrobial Pharmacokinetic Study Design. Antimicrob Agents Chemother 2017; 62:AAC.01540-17. [PMID: 29084754 DOI: 10.1128/aac.01540-17] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 10/24/2017] [Indexed: 11/20/2022] Open
Abstract
Penicillins are widely used to treat infections in children; however, the evidence is continuing to evolve in defining the optimal dosing. Modern pediatric pharmacokinetic study protocols frequently favor opportunistic, "scavenged" sampling. This study aimed to develop a small-volume single assay for five major penicillins and to assess the influence of sample degradation on inferences made using pharmacokinetic modeling, to investigate the suitability of scavenged sampling strategies. Using a rapid ultrahigh-performance liquid chromatographic-tandem mass spectrometric method, an assay for five penicillins (amoxicillin, ampicillin, benzylpenicillin, piperacillin, and flucloxacillin) in blood plasma was developed and validated. Penicillin stabilities were evaluated under different conditions. Using these data, the impact of drug degradation on inferences made during pharmacokinetic modeling was evaluated. All evaluated penicillins indicated good stability at room temperature (23 ± 2°C) over 1 h, remaining in the range of 98 to 103% of the original concentration. More-rapid analyte degradation had already occurred after 4 h, with stability ranging from 68% to 99%. Stability over longer periods declined: degradation of up to 60% was observed with delayed sample processing of up to 24 h. Modeling showed that analyte degradation can lead to a 30% and 28% bias in clearance and volume of distribution, respectively, and falsely show nonlinearity in clearance. Five common penicillins can now be measured in a single low-volume blood sample. Beta-lactam chemical instability in plasma can cause misleading pharmacokinetic modeling results, which could impact upon model-based dosing recommendations and the forthcoming era of beta-lactam therapeutic drug monitoring.
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DosOpt: A Tool for Personalized Bayesian Dose Adjustment of Vancomycin in Neonates. Ther Drug Monit 2017; 39:604-613. [DOI: 10.1097/ftd.0000000000000456] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The role of breast milk in the colonization of neonatal gut and skin with coagulase-negative staphylococci. Pediatr Res 2017; 82:759-767. [PMID: 28665928 DOI: 10.1038/pr.2017.150] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 06/04/2017] [Indexed: 12/19/2022]
Abstract
BackgroundWe aimed to determine the genetic relatedness between Staphylococcus epidermidis colonizing breast milk (BM) and BM-fed neonates during the first month of life.MethodsS. epidermidis was isolated from the stool and skin swabs of 20 healthy term and 49 preterm neonates hospitalized in the neonatal intensive care unit and from the BM of mothers once a week and typed by multilocus variable-number tandem-repeat analysis. Virulence-related genes were determined by PCR.ResultsThe gut (95%) and skin (100%) of term neonates were colonized with strains genetically similar to those in BM and carrying mecA and IS256 at low rate (both <6.7%). In preterm neonates, colonization with strains genetically similar to those in BM was low on the skin (34.7%) and in the gut in the first week of life (14.3%), but the prevalence of mecA (>90.6%) and IS256 (>61.7%) was high. By the fourth week, in the gut of preterm neonates the prevalence of mecA (73.8%) and IS256 (18.4%) decreased, but colonization with strains genetically similar to those in BM increased (83.7%).ConclusionDuring early life, the skin and gut of preterm neonates is colonized with S. epidermidis that is distinct from strains found in BM, but gradually the gut is enriched with strains genetically similar to those in BM, as in term neonates.
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Saddi V, Preddy J, Dalton S, Connors J, Patterson S. Variation in Gentamicin Dosing and Monitoring in Pediatric Units across New South Wales. Pediatr Qual Saf 2017; 2:e015. [PMID: 30229154 PMCID: PMC6132910 DOI: 10.1097/pq9.0000000000000015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 01/10/2017] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Gentamicin is an aminoglycoside antibiotic with broad-spectrum bactericidal activity and is widely used in pediatric units to treat infection with susceptible organisms. This study aimed to describe the dosage regimen for gentamicin and approach to its therapeutic drug monitoring (TDM) among the pediatric units within the state of New South Wales (NSW). METHODS A questionnaire was sent electronically to representatives of 40 pediatric units in NSW, requesting details of each unit's gentamicin dosing and TDM policy. RESULTS A total of 35 units responded to the survey. The majority (63%) of the units used a dose of 7.5 mg/kg of gentamicin in patients with normal renal function. More than half of the units (54%) did not have a local gentamicin dosing protocol and relied on other sources for dosing regimens. Dosing responses varied from a dose of 6 mg/kg once daily for patients more than 10 years of age to 7 mg/kg once daily on day 1, followed by 5 mg/kg once daily for patients over 10 years of age. For TDM of gentamicin, 63% of units indicated use of trough levels and 23% units used the Hartford Nomogram. CONCLUSIONS A significant variation exists in clinical practice among pediatric units in NSW on gentamicin dosing and TDM guidelines. There is an urgent need for collaboration among nursing, medical, and pharmacy experts to achieve consensus to develop and adopt statewide uniform guidelines on gentamicin dosing and TDM.
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Affiliation(s)
- Vishal Saddi
- From the Department of Paediatrics, Sydney Children’s Hospital, Randwick; Discipline of Paediatrics and Child Health, University of New South Wales, Rural Medical School, Wagga Wagga; and Clinical Excellence Commission, Sydney, New South Wales, Australia
| | - John Preddy
- From the Department of Paediatrics, Sydney Children’s Hospital, Randwick; Discipline of Paediatrics and Child Health, University of New South Wales, Rural Medical School, Wagga Wagga; and Clinical Excellence Commission, Sydney, New South Wales, Australia
| | - Sarah Dalton
- From the Department of Paediatrics, Sydney Children’s Hospital, Randwick; Discipline of Paediatrics and Child Health, University of New South Wales, Rural Medical School, Wagga Wagga; and Clinical Excellence Commission, Sydney, New South Wales, Australia
| | - John Connors
- From the Department of Paediatrics, Sydney Children’s Hospital, Randwick; Discipline of Paediatrics and Child Health, University of New South Wales, Rural Medical School, Wagga Wagga; and Clinical Excellence Commission, Sydney, New South Wales, Australia
| | - Sarah Patterson
- From the Department of Paediatrics, Sydney Children’s Hospital, Randwick; Discipline of Paediatrics and Child Health, University of New South Wales, Rural Medical School, Wagga Wagga; and Clinical Excellence Commission, Sydney, New South Wales, Australia
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Affiliation(s)
- Aggeliki Kontou
- a Infectious Diseases Unit, 3rd Department of Paediatrics , Aristotle University School of Health Sciences , Thessaloniki , Greece.,b 1st Department of Neonatology, Faculty of Medicine , Aristotle University School of Health Sciences , Thessaloniki , Greece
| | - Kosmas Sarafidis
- b 1st Department of Neonatology, Faculty of Medicine , Aristotle University School of Health Sciences , Thessaloniki , Greece
| | - Emmanuel Roilides
- a Infectious Diseases Unit, 3rd Department of Paediatrics , Aristotle University School of Health Sciences , Thessaloniki , Greece
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