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Zhou W, Deng Y, Liu X, Liu Z, Huang C, Miao L, Zhang C. Therapeutic drug monitoring status of four common antibiotics: vancomycin, meropenem, linezolid and teicoplanin. Scand J Clin Lab Invest 2022; 82:556-562. [PMID: 36300737 DOI: 10.1080/00365513.2022.2137689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Accurate therapeutic drug monitoring (TDM) of vancomycin, meropenem, linezolid and teicoplanin are conducive to developing optimal therapeutic regimes for patients. However, the measurement status of those drugs in different laboratories has not been reported. In this study, four samples including two frozen plasma samples and two lyophilized plasma samples were measured by over 35 laboratories across China. The inter- and intra-laboratory %CV, biases (%) of laboratories and intra- and inter-measurement-system %CV were calculated and analyzed. The short-term stability and homogeneity of those drugs in samples were studied. The results of frozen and lyophilized samples were also compared to determine whether there were significant differences in their matrix effects on various measurement systems. Results showed most laboratories' intra-laboratory %CVs were less than 9% for all drugs, and the mean inter-laboratory %CVs were 18.4%, 86.4%, 19.1% and 37.1% for vancomycin, meropenem, linezolid and teicoplanin measurements, respectively. For vancomycin, the intra-measurement %CV of commercial measurement systems was found to be smaller than that of other measurement systems. For meropenem, linezolid and teicoplanin, the agreement among laboratories using self-developed methods (Liquid chromatography-mass spectrometry [LC-MS] or high-performance liquid chromatography [HPLC]) was not satisfactory as most intra-measurement system CVs% were over 20%. Drugs in lyophilized samples were found to be more stable than in frozen samples, and no obvious differences in matrix effects were found for those two kinds of processed samples on most measurement systems. In conclusion, this study depicted the measurement status of those drugs in clinical laboratories, and found the lyophilized samples were more suitable EQA material for those drugs.
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Affiliation(s)
- Weiyan Zhou
- National Center for Clinical Laboratories, Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Yuhang Deng
- National Center for Clinical Laboratories, Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Xiaoxue Liu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, PR China
| | - Zhenni Liu
- National Center for Clinical Laboratories, Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Chenrong Huang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, PR China
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, PR China
| | - Chuanbao Zhang
- National Center for Clinical Laboratories, Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
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2
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Zhou P, Cheng Y, Cao G, Xing Y, Zhai S, Tong X, Yang K. The OBTAINS study: A nationwide cross-sectional survey on the implementation of extended or continuous infusion of β-lactams and vancomycin among neonatal sepsis patients in China. Front Pharmacol 2022; 13:1001924. [PMID: 36299905 PMCID: PMC9589050 DOI: 10.3389/fphar.2022.1001924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/23/2022] [Indexed: 01/03/2023] Open
Abstract
Background: Dosing strategies of β-lactams and vancomycin should be optimized according to pharmacokinetic/pharmacodynamic principles. However, there is no available data indicating the implementation of extended infusion (EI) or continuous infusion (CI) administration in the management of neonatal sepsis. Methods: A nationwide cross-sectional survey was conducted and the pediatricians from 31 provinces in China were enrolled. A multidisciplinary team created the questionnaire, which had three sections and a total of 21 questions with open- and closed-ended responses. The survey was then conducted using an internet platform in an anonymous way. The data was eventually gathered, compiled, and examined. To identify the risk factors associated with the implementation of EI/CI, logistic regression was carried out. Results: A total of 1501 respondents answered the questionnaires. The implementation of EI/CI of β-lactams and vancomycin were only available to one-third of the respondents, and the prolonged strategy was primarily supported by guidelines (71.25%) and advice from medical specialists (55.18%). A significant fraction (72.94%-94.71%) lacked a strong understanding of the infusions' stability. Additionally, it was discovered that more frequent MDT discussions about antibiotic use and the appropriate time pediatricians worked in the neonatal ward were associated with an increase in the use of the EI/CI strategy. Conclusion: The EI/CI strategy in neonatal sepsis was not well recognized in China, and it is necessary to establish a solid MDT team with regularly collaborates. In the near future, guidelines regarding prolonged infusion management in neonatal sepsis should be developed.
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Affiliation(s)
- Pengxiang Zhou
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China,Department of Pharmacy, Peking University Third Hospital, Beijing, China,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Yinchu Cheng
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Guangna Cao
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Yan Xing
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Xiaomei Tong
- Department of Pediatrics, Peking University Third Hospital, Beijing, China,*Correspondence: Kehu Yang, ; Xiaomei Tong,
| | - Kehu Yang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China,*Correspondence: Kehu Yang, ; Xiaomei Tong,
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3
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Chen Q, Wan J, Shen W, Lin W, Lin X, Huang Z, Lin M, Chen Y. Optimal exposure targets for vancomycin in the treatment of neonatal coagulase-negative Staphylococcus infection: A retrospective study based on electronic medical records. Pediatr Neonatol 2022; 63:247-254. [PMID: 35190273 DOI: 10.1016/j.pedneo.2021.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/12/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND The currently advocated ratio of area under the curve (AUC) over 24 h to minimum inhibitory concentration (AUC/MIC) > 400 and AUC < 600 mg h/L as the therapeutic drug monitoring (TDM) target of vancomycin is based on data from multiple observational studies in adult patients with methicillin-resistant Staphylococcus aureus (MRSA) infection. It may not be applicable to newborns with coagulase-negative Staphylococcus (CoNS) infection. We conducted a retrospective study to identify the optimal exposure targets for vancomycin in the treatment of neonatal CoNS infection. METHODS Based on the inclusion and exclusion criteria, serum vancomycin concentration, demographics, clinical data, and related laboratory data of newborns who received vancomycin intravenous infusion from June 1, 2016 to February 1, 2021 were collected retrospectively. The AUC was calculated using the maximum a posteriori Bayesian (MAPB) method. The vancomycin exposure threshold of AUC/MIC for efficacy and AUC for toxicity (acute kidney injury, AKI) were determined based on receiver operating characteristic (ROC) curve analysis. The correlation between vancomycin exposure and both clinical effect and nephrotoxicity was analyzed using logistic multivariate regression. RESULTS In total, 153 patients and 245 vancomycin concentrations (160 trough and 85 peak concentrations) were included. The ROC curve analysis showed that the exposure thresholds of AUC/MIC for clinical efficacy and AUC for nephrotoxicity were 281 and 602 mg h/L, respectively. The multivariate regression analysis showed that AUC/MIC > 280 was a predictor of efficacy (OR: 13.960, 95% CI: 1.891-103.078, P < 0.05) and AUC > 600 mg h/L was associated with AKI (OR: 9.008, 95% CI: 2.706-29.983, P < 0.05). The vancomycin AUC/MIC threshold for treating neonatal CoNS infection with vancomycin is lower than the currently advocated AUC/MIC >400. CONCLUSION The optimal exposure targets for vancomycin in neonatal CoNS infection were AUC/MIC > 280 and AUC < 600 mg h/L.
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Affiliation(s)
- Quanyao Chen
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Jun Wan
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Wei Shen
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Wanlong Lin
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Xiuxian Lin
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Zhiyi Huang
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Min Lin
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China.
| | - Yao Chen
- Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China.
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Xu J, Zhu Y, Niu P, Liu Y, Li D, Jiang L, Shi D. Establishment and application of population pharmacokinetics model of vancomycin in infants with meningitis. Pediatr Neonatol 2022; 63:57-65. [PMID: 34544677 DOI: 10.1016/j.pedneo.2021.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To establish a population pharmacokinetics (PPK) model of vancomycin (VCM) for dose individualization in Chinese infants with meningitis. METHODS We collected the data of 82 children with meningitis in hospital from July 2014 to June 2016. The initial vancomycin dosage regimen for children was 10 or 15 mg/kg for q12 h, q8 h or q6 h. Serum concentrations were determined by Viva-E Analyzer before and after the fifth administration. The PPK model was developed by nonlinear mixed-effect model software, assessed by the bootstrap method and then tested in 20 infant patients. RESULTS The VCM clearance (CL) was increased by body weight (WT) and decreased by blood urea nitrogen (BUN). Pharmacokinetic parameters of VCM were not influenced by co-administered drugs. The trough concentrations of VCM were accurately predicted by the PPK model, with the prediction errors less than 32%. CONCLUSION A new individual strategy for VCM regimens was proposed and validated by the PPK model.
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Affiliation(s)
- Jianwen Xu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China; Department of Pharmacy, Affiliated First Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Yanting Zhu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Peiguang Niu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Ying Liu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Danyun Li
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Li Jiang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Daohua Shi
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China.
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5
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Liu XT, Zhao YX, Jia GW, Yang F, Zhang CZ, Han B, Dai JH, Han YQ, Tang BH, Yang XM, Shi HY, Zhou Y, Sui ZG, Chen JZ, van den Anker JN, Zhao W. Pharmacokinetics and safety of pegylated recombinant human granulocyte colony-stimulating factor in children with acute leukaemia. Br J Clin Pharmacol 2021; 87:3292-3300. [PMID: 33506975 DOI: 10.1111/bcp.14750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/04/2021] [Accepted: 01/21/2021] [Indexed: 12/24/2022] Open
Abstract
AIMS This open-label, phase I study evaluated the pharmacokinetics and safety of pegylated recombinant human granulocyte colony-stimulating factor (PEG-rhG-CSF) for the treatment of chemotherapy-induced neutropenia in children with acute leukaemia. METHODS PEG-rhG-CSF was administered as a single 100 mcg/kg (3 mg maximum dose) subcutaneous injection at the end of each chemotherapy period when neutropenia occurred. Blood samples were obtained from patients treated with PEG-rhG-CSF. PEG-rhG-CSF serum concentrations were determined by an enzyme-linked immunosorbent assay. Population pharmacokinetic (PPK) analysis was implemented using the nonlinear mixed-effects model. Short-term safety was evaluated through adverse events collection (registered at clinicaltrials.gov identifier: 03844360). RESULTS A total of 16 acute leukaemia patients (1.8-13.6 years) were included, of whom two (12.5%) had grade 3 neutropenia, six (37.5%) had grade 4 neutropenia, and eight (50.0%) had severe neutropenia. For PPK modelling, 64 PEG-rhG-CSF serum concentrations were obtainable. A one-compartment model with first-order elimination was used for pharmacokinetic data modelling. The current weight was a significant covariate. The median (range) of clearance (CL) and area under the serum concentration-time curve (AUC) were 5.65 (1.49-14.45) mL/h/kg and 16514.75 (6632.45-54423.30) ng·h/mL, respectively. Bone pain, pyrexia, anaphylaxis and nephrotoxicity were not observed. One patient died 13 days after administration, and the objective assessment of causality was that an association with PEG-rhG-CSF was "possible". CONCLUSIONS The AUC of PEG-rhG-CSF (100 mcg/kg, 3 mg maximum dose) in paediatric patients with acute leukaemia were similar to those of PEG-rhG-CSF (100 mcg/kg) in children with sarcoma. PEG-rhG-CSF is safe, representing an important therapeutic option for chemotherapy-induced neutropenia in paediatric patients with acute leukaemia.
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Affiliation(s)
- Xi-Ting Liu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yan-Xia Zhao
- Department of Pediatric Hematology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guang-Wei Jia
- Key Laboratory of Clinical Pharmacology, Liaocheng People's Hospital, Liaocheng, China
| | - Fan Yang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chuan-Zhou Zhang
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bing Han
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jian-Hua Dai
- Department of Pediatrics, Liaocheng People's Hospital, Liaocheng, China
| | - Yue-Qin Han
- Department of Pediatrics, Liaocheng People's Hospital, Liaocheng, China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xin-Mei Yang
- Department of Pharmacy, Clinical Trial Center, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Hai-Yan Shi
- Department of Pharmacy, Clinical Trial Center, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yue Zhou
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zhong-Guo Sui
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jian-Zhong Chen
- Key Laboratory of Clinical Pharmacology, Liaocheng People's Hospital, Liaocheng, China
| | - Johannes N van den Anker
- Division of Clinical Pharmacology, Children's National Medical Center, Washington, District of Columbia, USA.,Departments of Pediatrics, Pharmacology & Physiology, Genomics & Precision Medicine, the George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA.,Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - 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, China.,Department of Pharmacy, Clinical Trial Center, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
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Tang Z, Guan J, Li J, Yu Y, Qian M, Cao J, Shuai W, Jiao Z. Determination of vancomycin exposure target and individualised dosing recommendations for neonates: model-informed precision dosing. Int J Antimicrob Agents 2021; 57:106300. [PMID: 33567334 DOI: 10.1016/j.ijantimicag.2021.106300] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/18/2021] [Accepted: 01/30/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Few studies incorporating population pharmacokinetic/pharmacodynamic (Pop-PK/PD) modelling have been conducted to quantify the exposure target of vancomycin in neonates. A retrospective observational cohort study was undertaken in neonates to determine this target and dosing recommendations (chictr.org.cn, ChiCTR1900027919). METHODS A Pop-PK model was developed to estimate PK parameters. Causalities between acute kidney injury (AKI) occurrence and vancomycin use were verified using Naranjo criteria. Thresholds of vancomycin exposure in predicting AKI or efficacy were identified via classification and regression tree analysis. Associations between exposure thresholds and clinical outcomes, including AKI and efficacy, were analysed by logistic regression. Dosing recommendations were designed using Monte Carlo simulations based on the optimised exposure target. RESULTS Pop-PK modelling included 182 neonates with 411 observations. On covariate analysis, neonatal physiological maturation, renal function and concomitant use of vasoactive agents (VAS) significantly affected vancomycin PK. Seven cases of vancomycin-induced AKI were detected. Area under the concentration-time curve from 0-24 hours (AUC0-24) ≥ 485 mg•h/L was an independent risk factor for AKI after adjusting for VAS co-administration. The clinical efficacy of vancomycin was analysed in 42 patients with blood culture-proven staphylococcal sepsis. AUC0-24 to minimum inhibitory concentration (AUC0-24/MIC) ≥ 234 was the only significant predictor of clinical effectiveness. Monte Carlo simulations indicated that regimens in Neonatal Formulary 7 and Red Book (2018) were unsuitable for all neonates. CONCLUSION An AUC0-24 of 240-480 (assuming MIC = 1 mg/L) is a recommended exposure target of vancomycin in neonates. Model-informed dosing regimens are valuable in clinical practice.
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Affiliation(s)
- Zhe Tang
- Department of Pharmacy, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Jing Guan
- Department of Pharmacy, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Jingjing Li
- Department of Pharmacy, Suzhou Municipal Hospital, Suzhou, China
| | - Yanxia Yu
- Department of Pharmacy, Suzhou Municipal Hospital, Suzhou, China
| | - Miao Qian
- Department of Neonatology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Jing Cao
- Department of Pharmacy, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Weiwei Shuai
- Department of Pharmacy, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.
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Li DY, Li L, Li GZ, Hu YH, Guo HL, Jing X, Chen F, Ji X, Xu J, Dai HR. Population Pharmacokinetics Modeling of Vancomycin Among Chinese Infants With Normal and Augmented Renal Function. Front Pediatr 2021; 9:713588. [PMID: 34616698 PMCID: PMC8489377 DOI: 10.3389/fped.2021.713588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/06/2021] [Indexed: 11/29/2022] Open
Abstract
There have been good amounts of population pharmacokinetics (PPK) models of vancomycin for Chinese pediatric patients, but none of them had a special focus on modeling infant population with different levels of renal function. Since renal function variability is prominent among infant population and the clearance (CL) of vancomycin is heavily related to renal excretion, it is important to establish precise PPK models based on individual renal function levels. We employed a PPK approach to develop three models of vancomycin in parallel for Chinese pediatric patients with normal renal function [estimated glomerular filtration rate (eGFR) between 30 and 86 ml/min/1.73 m2, Model 1], with augmented renal function (eGFR ≥ 86 ml/min/1.73 m2, Model 2), or with all levels of renal function (Model 3). Three one-compartment models with first-order elimination kinetics were established. The predictive ability of Model 1 and Model 2 among each certain population is comparable with that of Model 3 with no statistical difference. Our study revealed that among the infant population with augmented renal function, only body weight was included as a covariate, which indicated that for an infant whose eGFR ≥ 86 ml/min/1.73 m2, taking blood sample is not compulsory for predicting vancomycin blood concentration, which avoids unnecessary injury to vulnerable infants.
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Affiliation(s)
- De-Yi Li
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ling Li
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Gui-Zhou Li
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Ya-Hui Hu
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hong-Li Guo
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xia Jing
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Chen
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xing Ji
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Xu
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hao-Ran Dai
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
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8
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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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9
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Germovsek E, Osborne L, Gunaratnam F, Lounis SA, Busquets FB, Standing JF, Sinha AK. Development and external evaluation of a population pharmacokinetic model for continuous and intermittent administration of vancomycin in neonates and infants using prospectively collected data. J Antimicrob Chemother 2020; 74:1003-1011. [PMID: 30668696 DOI: 10.1093/jac/dky525] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/05/2018] [Accepted: 11/16/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Vancomycin is commonly used for nosocomial bacterial pathogens causing late-onset septicaemia in preterm infants. We prospectively collected pharmacokinetic data aiming to describe pharmacokinetics and determine covariates contributing to the variability in neonatal vancomycin pharmacokinetics. Further, we aimed to use the model to compare the ratio of AUC24 at steady-state to the MIC (AUC24,ss/MIC) of several intermittent and continuous dosing regimens. METHODS Newborns receiving vancomycin for suspected or confirmed late-onset sepsis were included. Peak and trough concentrations for intermittent vancomycin dosing and steady-state concentrations for continuous vancomycin dosing were measured. NONMEM 7.3 was used for population pharmacokinetic analysis. Monte Carlo simulations were performed to compare dosing schemes. RESULTS Data from 54 infants were used for model development and from 34 infants for the model evaluation {corrected gestational age [median (range)] = 29 (23.7-41.9) weeks and 28 (23.4-41.7) weeks, respectively}. The final model was a one-compartment model. Weight and postmenstrual age were included a priori, and then no additional covariate significantly improved the model fit. Final model parameter estimates [mean (SEM)]: CL = 5.7 (0.3) L/h/70 kg and V = 39.3 (3.7) L/70 kg. Visual predictive check of the evaluation dataset confirmed the model can predict external data. Simulations using MIC of 1 mg/L showed that for neonates with gestational age ≤25 weeks and postnatal age ≤2 weeks AUC24,ss/MIC was lower with the intermittent regimen (median 482 versus 663). CONCLUSIONS A population pharmacokinetic model for continuous and intermittent vancomycin administration in infants was developed. Continuous administration might be favourable for treating infections caused by resistant microorganisms in very young and immature infants.
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Affiliation(s)
- Eva Germovsek
- Inflammation, Infection and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, UK.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Leanne Osborne
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, Whitechapel, London, UK
| | - Flora Gunaratnam
- Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, UK
| | - Shehrazed A Lounis
- Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, UK
| | - Ferran Bossacoma Busquets
- Inflammation, Infection and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, UK.,Hospital Sant Joan de Deu, Passeig Hospital Sant Joan de Deu 2, Barcelona, Spain
| | - Joseph F Standing
- Inflammation, Infection and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, UK
| | - Ajay K Sinha
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, Whitechapel, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, UK
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10
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Costenaro P, Minotti C, Cuppini E, Barbieri E, Giaquinto C, Donà D. Optimizing Antibiotic Treatment Strategies for Neonates and Children: Does Implementing Extended or Prolonged Infusion Provide any Advantage? Antibiotics (Basel) 2020; 9:antibiotics9060329. [PMID: 32560411 PMCID: PMC7344997 DOI: 10.3390/antibiotics9060329] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 12/25/2022] Open
Abstract
Optimizing the use of antibiotics has become mandatory, particularly for the pediatric population where limited options are currently available. Selecting the dosing strategy may improve overall outcomes and limit the further development of antimicrobial resistance. Time-dependent antibiotics optimize their free concentration above the minimal inhibitory concentration (MIC) when administered by continuous infusion, however evidences from literature are still insufficient to recommend its widespread adoption. The aim of this review is to assess the state-of-the-art of intermittent versus prolonged intravenous administration of antibiotics in children and neonates with bacterial infections. We identified and reviewed relevant literature by searching PubMed, from 1 January 1 2000 to 15 April 2020. We included studies comparing intermittent versus prolonged/continuous antibiotic infusion, among the pediatric population. Nine relevant articles were selected, including RCTs, prospective and retrospective studies focusing on different infusion strategies of vancomycin, piperacillin/tazobactam, ceftazidime, cefepime and meropenem in the pediatric population. Prolonged and continuous infusions of antibiotics showed a greater probability of target attainment as compared to intermittent infusion regimens, with generally good clinical outcomes and safety profiles, however its impact in terms on efficacy, feasibility and toxicity is still open, with few studies led on children and adult data not being fully extendable.
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Affiliation(s)
- Paola Costenaro
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Chiara Minotti
- Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Elena Cuppini
- Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Elisa Barbieri
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Carlo Giaquinto
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
- Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
- Paediatric Network for Treatment of AIDS (Penta) Foundation, 35128 Padua, Italy
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
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11
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Viel-Thériault I, Martin B, Thompson-Desormeaux F, Blackburn J, Moussa A, Autmizguine J. Vancomycin drug monitoring in infants with CoNS sepsis-target attainment, microbiological response and nephrotoxicity. J Perinatol 2020; 40:97-104. [PMID: 31576000 DOI: 10.1038/s41372-019-0519-2] [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] [Received: 03/15/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To characterize residual vancomycin concentrations (Cmin) and assess the relationships between Cmin, the risk of nephrotoxicity and persistent CoNS sepsis. METHODS In this 5-year retrospective study among infants treated with vancomycin, the primary outcome was the proportion of those with a steady state Cmin between 10 and 20 mg/L. The secondary outcomes were nephrotoxicity and persistent CoNS sepsis. RESULTS Of 120 infants included, the median first steady state Cmin was 12.4 mg/L and 77 (64%) had a Cmin between 10 and 20 mg/L. Six percent developed nephrotoxicity. This risk was not associated with Cmin. Of the 30 infants with CoNS sepsis, 17 (57%) had persistent bacteremia, and this risk did not correlate significantly with Cmin, CoNS minimal inhibitory concentration (MIC) for vancomycin, or Cmin/MIC. CONCLUSIONS The majority of infants achieved targeted levels of vancomycin, but persistent bacteremia was common. We did not identify a Cmin threshold associated with nephrotoxicity, nor with microbiological clearance.
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Affiliation(s)
| | - Brigitte Martin
- Department of Pharmacy, CHU Sainte-Justine, Montreal, QC, Canada
| | | | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montréal, Montreal, QC, Canada
| | - Ahmed Moussa
- Department of Pediatrics, Université de Montréal, Montreal, QC, Canada.,Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Julie Autmizguine
- Department of Pediatrics, Université de Montréal, Montreal, QC, Canada.,Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada.,Clinical Pharmacology Unit, Université de Montréal, Montreal, QC, Canada
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12
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Allegaert K, Flint R, Smits A. Pharmacokinetic modelling and Bayesian estimation-assisted decision tools to optimize vancomycin dosage in neonates: only one piece of the puzzle. Expert Opin Drug Metab Toxicol 2019; 15:735-749. [PMID: 31402708 DOI: 10.1080/17425255.2019.1655540] [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: 12/15/2022]
Abstract
Introduction: Vancomycin is commonly administered to neonates, while observational data on therapeutic drug monitoring (TDM, trough levels) suggest that vancomycin exposure and dosage remain substandard. Area covered: Data on vancomycin pharmacokinetics (PK) and its covariates are abundant. Consequently, modeling is an obvious tool to improve targeted exposure, with a shift from TDM trough levels to area under the curve (AUC24h) targets, as in adults. Continuous administration appeared as a practice to facilitate AUC24h target attainment, while Bayesian model-supported targeting emerged as a novel tool. However, the AUC24h/MIC (minimal inhibitory concentration) target itself should consider neonate-specific aspects (bloodstream infections, coagulase-negative staphylococci, protein binding, underexplored causes of variability, like assays, preparation and administration inaccuracies, or missing covariates). Expert opinion: To improve targeted exposure in neonates, initial vancomycin prescription should be based on 'a priori model-based individual dosing' using validated dosing regimens, followed by further tailoring by dosing optimization applying Bayesian estimation-assisted TDM. Future research should focus on the feasibility to integrate these tools (individualized dosing, Bayesian models) in clinical practice, and to perform PK/PD studies in the relevant animal models and human neonatal setting (coagulase-negative staphylococci, bloodstream infections).
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Affiliation(s)
- Karel Allegaert
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam , Rotterdam , the Netherlands.,Department of Development and Regeneration, KU Leuven , Leuven , Belgium
| | - Robert Flint
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam , Rotterdam , the Netherlands.,Department of Pharmacy, Erasmus University Medical Center , Rotterdam , The Netherlands
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven , Leuven , Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven , Leuven , Belgium
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13
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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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14
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Pokorná P, Šíma M, Černá O, Allegaert K, Tibboel D, Slanař O. Actual body weight-based vancomycin dosing in neonates. J Chemother 2019; 31:307-312. [PMID: 30983533 DOI: 10.1080/1120009x.2019.1599574] [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] [Indexed: 01/28/2023]
Abstract
This study aimed to explore vancomycin pharmacokinetics and its covariates in critically ill neonates and to propose an easy applicable dosing nomogram for initial treatment. Individual vancomycin pharmacokinetic parameters were calculated based on therapeutic drug monitoring data using a one-compartmental model. A linear regression model was used for examination of covariates. The mean (SD) volume of distribution (Vd) and clearance (CL) for vancomycin were 0.73 (0.31) L/kg and 0.052 (0.020) L/h/kg, respectively. Vd was related to actual body weight (ABW), gestational and postmenstrual age. CL was also associated with ABW, gestational, postmenstrual age and also creatinine clearance. ABW was the strongest predictor for vancomycin pharmacokinetics and consequently dosing. Loading dose (mg) of 11.81 × ABW (kg) + 7.86 and maintenance dose (mg/day) of 40.92 × ABW (kg) -22.18 most closely approximated pharmacokinetic target. Vancomycin pharmacokinetics was mainly influenced by ABW in neonates and a practical ABW-based dosing algorithm was developed.
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Affiliation(s)
- Pavla Pokorná
- Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Prague , Czech Republic.,Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Czech Republic , Prague , Czech Republic.,Intensive Care and Department of Pediatric Surgery, Erasmus MC and Department of Neonatology- Sophia Childrens Hospital , Rotterdam , The Netherlands
| | - Martin Šíma
- Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Czech Republic , Prague , Czech Republic
| | - Olga Černá
- Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Prague , Czech Republic
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC and Department of Neonatology- Sophia Childrens Hospital , Rotterdam , The Netherlands.,Department of development and regeneration , Katholieke Universiteit Leuven , Leuven , Belgium
| | - Dick Tibboel
- Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Prague , Czech Republic.,Intensive Care and Department of Pediatric Surgery, Erasmus MC and Department of Neonatology- Sophia Childrens Hospital , Rotterdam , The Netherlands
| | - Ondřej Slanař
- Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Czech Republic , Prague , Czech Republic
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15
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Tauzin M, Cohen R, Durrmeyer X, Dassieu G, Barre J, Caeymaex L. Continuous-Infusion Vancomycin in Neonates: Assessment of a Dosing Regimen and Therapeutic Proposal. Front Pediatr 2019; 7:188. [PMID: 31139607 PMCID: PMC6527807 DOI: 10.3389/fped.2019.00188] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/24/2019] [Indexed: 12/12/2022] Open
Abstract
Introduction: Vancomycin remains the reference antibiotic in neonates for care-related infections caused by ß-lactam-resistant Gram-positive bacteria. Achieving the optimal serum vancomycin level is challenging because of high inter-individual variability and the drug's narrow therapeutic window. Continuous infusion might offer pharmacokinetic and practical advantages, but we lack consensus on the dosing regimen. The aim was to determine the proportion of neonates achieving an optimal therapeutic vancomycin level at the first vancomycin concentration assay and which dosing regimen is the most suitable for neonates. Methods: All neonates receiving continuous-infusion vancomycin (loading dose 15 mg/kg and maintenance dose 30 mg/kg/d) in a neonatal intensive care unit were retrospectively analyzed. The proportion of neonates reaching the target serum vancomycin level was calculated. After reviewing the literature to identify all published articles proposing a dosing regimen for continuous-infusion vancomycin for neonates, regimens were theoretically applied to our population by using maintenance doses according to covariate(s) proposed in the original publication. Results: Between January 2013 and December 2014, 75 neonates received 91 vancomycin courses by continuous infusion. Median gestational age, birth weight, and postnatal age were 27 weeks (interquartile range 26-30.5), 815 g (685-1,240), and 15 days (9-33). At the first assay, only 28/91 (30.8%) courses resulted in vancomycin levels between 20 and 30 mg/L (target level), 23/91 (25.3%) >30 mg/L and 40/91 (43.9%) <20 mg/L. We applied six published dosing regimens to our patients. One of these dosing regimens based on corrected gestational age (CGA) and serum creatinine level (SCR) would have allowed us to prescribe lower doses to neonates with high vancomycin levels and higher doses to neonates with low levels. Conclusions: A simplified dosing regimen of continuous-infusion vancomycin did not achieve therapeutic ranges in neonates; a patient-tailored dosing regimen taking into account CGA and SCR level or an individualized pharmacokinetic model can help to anticipate the inter-individual variability in neonates and would have been more suitable.
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Affiliation(s)
- Manon Tauzin
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Robert Cohen
- ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, Saint-Maur des Fossés, France.,Université Paris Est, IMRB- GRC GEMINI, Créteil, France.,Clinical Research Center, Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Groupe de Pathologie Infectieuse Pédiatrique, Paris, France.,Unité Court Séjour, Petits Nourrissons, Service de Néonatologie, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Xavier Durrmeyer
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Université Paris Est, IMRB- GRC GEMINI, Créteil, France.,Inserm, U1153, Obstetrical, Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne, Paris Descartes University, Paris, France
| | - Gilles Dassieu
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Jérôme Barre
- Clinical Research Center, Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Department of Pharmacology, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Laurence Caeymaex
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Clinical Research Center, Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Department of Research in Ethics EA1610 Studies on Science and Technics, Paris Est University, Créteil, France
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16
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Monteiro JF, Hahn SR, Gonçalves J, Fresco P. Vancomycin therapeutic drug monitoring and population pharmacokinetic models in special patient subpopulations. Pharmacol Res Perspect 2018; 6:e00420. [PMID: 30156005 PMCID: PMC6113434 DOI: 10.1002/prp2.420] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 06/20/2018] [Indexed: 01/02/2023] Open
Abstract
Vancomycin is a fundamental antibiotic in the management of severe Gram-positive infections. Inappropriate vancomycin dosing is associated with therapeutic failure, bacterial resistance and toxicity. Therapeutic drug monitoring (TDM) is acknowledged as an important part of the vancomycin therapy management, at least in specific patient subpopulations, but implementation in clinical practice has been difficult because there are no consensus and agglutinator documents. The aims of the present work are to present an overview of the current knowledge on vancomycin TDM and population pharmacokinetic (PPK) models relevant to specific patient subpopulations. Based on three published international guidelines (American, Japanese and Chinese) on vancomycin TDM and a bibliographic review on available PPK models for vancomycin in distinct subpopulations, an analysis of evidence was carried out and the current knowledge on this topic was summarized. The results of this work can be useful to redirect research efforts to address the detected knowledge gaps. Currently, TDM of vancomycin presents a moderate level of evidence and practical recommendations with great robustness in neonates, pediatric and patients with renal impairment. However, it is important to investigate in other subpopulations known to present altered vancomycin pharmacokinetics (eg neurosurgical, oncological and cystic fibrosis patients), where evidence is still unsufficient.
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Affiliation(s)
- Joaquim F. Monteiro
- Faculdade de Medicina da Universidade do Porto (FMUP)PortoPortugal
- Instituto de Investigação e Formação Avançadas em Ciências e Tecnologias da Saúde (IINFACTS)Instituto Universitário de Ciências da Saúde (IUCS)GandraPortugal
| | - Siomara R. Hahn
- Instituto de Ciências BiológicasCurso de FarmáciaUniversidade de Passo Fundo (UPF)Passo FundoBrasil
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
| | - Jorge Gonçalves
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
- I3SInstituto de Investigação e Inovação em SaúdeUniversidade do PortoPortoPortugal
| | - Paula Fresco
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
- I3SInstituto de Investigação e Inovação em SaúdeUniversidade do PortoPortoPortugal
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17
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Li ZL, Liu YX, Jiao Z, Qiu G, Huang JQ, Xiao YB, Wu SJ, Wang CY, Hu WJ, Sun HJ. Population Pharmacokinetics of Vancomycin in Chinese ICU Neonates: Initial Dosage Recommendations. Front Pharmacol 2018; 9:603. [PMID: 29997498 PMCID: PMC6029141 DOI: 10.3389/fphar.2018.00603] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/21/2018] [Indexed: 01/21/2023] Open
Abstract
The main goal of our study was to characterize the population pharmacokinetics of vancomycin in critically ill Chinese neonates to develop a pharmacokinetic model and investigate factors that have significant influences on the pharmacokinetics of vancomycin in this population. The study population consisted of 80 neonates in the neonatal intensive care unit (ICU) from which 165 trough and peak concentrations of vancomycin were obtained. Nonlinear mixed effect modeling was used to develop a population pharmacokinetic model for vancomycin. The stability and predictive ability of the final model were evaluated based on diagnostic plots, normalized prediction distribution errors and the bootstrap method. Serum creatinine (Scr) and body weight were significant covariates on the clearance of vancomycin. The average clearance was 0.309 L/h for a neonate with Scr of 23.3 μmol/L and body weight of 2.9 kg. No obvious ethnic differences in the clearance of vancomycin were found relative to the earlier studies of Caucasian neonates. Moreover, the established model indicated that in patients with a greater renal clearance status, especially Scr < 15 μmol/L, current guideline recommendations would likely not achieve therapeutic area under the concentration-time curve over 24 h/minimum inhibitory concentration (AUC24h/MIC) ≥ 400. The exceptions to this are British National Formulary (2016-2017), Blue Book (2016) and Neofax (2017). Recommended dose regimens for neonates with different Scr levels and postmenstrual ages were estimated based on Monte Carlo simulations and the established model. These findings will be valuable for developing individualized dosage regimens in the neonatal ICU setting.
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Affiliation(s)
- Zhi-ling Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yi-xi Liu
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Zheng Jiao
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Gang Qiu
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jian-quan Huang
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yu-bo Xiao
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
- Department of Pharmacy, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shu-jin Wu
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
- Department of Pharmacy, Gansu Provincial Hospital, Lanzhou, China
| | - Chen-yu Wang
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Wen-juan Hu
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hua-jun Sun
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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18
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Factors impacting unbound vancomycin concentrations in neonates and young infants. Eur J Clin Microbiol Infect Dis 2018; 37:1503-1510. [DOI: 10.1007/s10096-018-3277-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/09/2018] [Indexed: 01/19/2023]
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19
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Leroux S, Elie V, Zhao W, Magreault S, Jacqz-Aigrain E. Principles and applications of pharmacometrics in drug evaluation in children. Therapie 2018; 73:165-170. [DOI: 10.1016/j.therap.2017.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 11/15/2017] [Indexed: 12/11/2022]
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20
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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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21
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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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22
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Abstract
Therapeutic drug monitoring (TDM) aims to integrate drug measurement results into clinical decision making. The basic rules apply when using TDM in neonates (aminoglycosides, vancomycin, phenobarbital, digoxin), but additional factors should also be taken into account. First, due to both pharmacokinetic variability and non-pharmacokinetic factors, the correlation between dosage and concentration is poor in neonates, but can be overcome with the use of more complex, validated dosing regimens. Second, the time to reach steady state is prolonged, especially when no loading dose is used. Consequently, the timing of TDM sampling is important in this population. Third, the target concentration may be uncertain (vancomycin) or depend on specific factors (phenobarbital during whole body cooling). Finally, because of differences in matrix composition (eg, protein, bilirubin), assay-related inaccuracies may be different in neonates. We anticipate that complex validated dosing regimens, with subsequent TDM sampling and Bayesian forecasting, are the next step in tailoring pharmacotherapy to individual neonates.
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Affiliation(s)
- Steven Pauwels
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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23
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Clinical Utility and Safety of a Model-Based Patient-Tailored Dose of Vancomycin in Neonates. Antimicrob Agents Chemother 2016; 60:2039-42. [PMID: 26787690 DOI: 10.1128/aac.02214-15] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 12/30/2015] [Indexed: 01/07/2023] Open
Abstract
Pharmacokinetic modeling has often been applied to evaluate vancomycin pharmacokinetics in neonates. However, clinical application of the model-based personalized vancomycin therapy is still limited. The objective of the present study was to evaluate the clinical utility and safety of a model-based patient-tailored dose of vancomycin in neonates. A model-based vancomycin dosing calculator, developed from a population pharmacokinetic study, has been integrated into the routine clinical care in 3 neonatal intensive care units (Robert Debré, Cochin Port Royal, and Clocheville hospitals) between 2012 and 2014. The target attainment rate, defined as the percentage of patients with a first therapeutic drug monitoring serum vancomycin concentration achieving the target window of 15 to 25 mg/liter, was selected as an endpoint for evaluating the clinical utility. The safety evaluation was focused on nephrotoxicity. The clinical application of the model-based patient-tailored dose of vancomycin has been demonstrated in 190 neonates. The mean (standard deviation) gestational and postnatal ages of the study population were 31.1 (4.9) weeks and 16.7 (21.7) days, respectively. The target attainment rate increased from 41% to 72% without any case of vancomycin-related nephrotoxicity. This proof-of-concept study provides evidence for integrating model-based antimicrobial therapy in neonatal routine care.
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Samardzic J, Allegaert K, Wilbaux M, Pfister M, van den Anker JN. Quantitative clinical pharmacology practice for optimal use of antibiotics during the neonatal period. Expert Opin Drug Metab Toxicol 2016; 12:367-75. [PMID: 26817821 DOI: 10.1517/17425255.2016.1147559] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION For safe and effective neonatal antibiotic therapy, knowledge of the pharmacokinetic parameters of antibacterial agents in neonates is a prerequisite. Fast maturational changes during the neonatal period influence pharmacokinetic and pharmacodynamic parameters and their variability. Consequently, the need for applying quantitative clinical pharmacology and determining optimal drug dosing regimens in neonates has become increasingly recognized. AREAS COVERED Modern quantitative approaches, such as pharmacometrics, are increasingly utilized to characterize, understand and predict the pharmacokinetics of a drug and its effect, and to quantify the variability in the neonatal population. Individual factors, called covariates in modeling, are integrated in such approaches to explain inter-individual pharmacokinetic variability. Pharmacometrics has been shown to be a relevant tool to evaluate, optimize and individualize drug dosing regimens. EXPERT OPINION Challenges for optimal use of antibiotics in neonates can largely be overcome with quantitative clinical pharmacology practice. Clinicians should be aware that there is a next step to support the clinical decision-making based on clinical characteristics and therapeutic drug monitoring, through Bayesian-based modeling and simulation methods. Pharmacometric modeling and simulation approaches permit us to characterize population average, inter-subject and intra-subject variability of pharmacokinetic parameters such as clearance and volume of distribution, and to identify and quantify key factors that influence the pharmacokinetic behavior of antibiotics during the neonatal period.
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Affiliation(s)
- Janko Samardzic
- a Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical Faculty , University of Belgrade , Belgrade , Serbia.,b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - Karel Allegaert
- c Department of Development and Regeneration , KU Leuven , Leuven , Belgium.,d Intensive Care and Department of Pediatric Surgery , Erasmus MC Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Mélanie Wilbaux
- b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - Marc Pfister
- b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - John N van den Anker
- b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland.,d Intensive Care and Department of Pediatric Surgery , Erasmus MC Sophia Children's Hospital , Rotterdam , the Netherlands.,e Division of Pediatric Clinical Pharmacology , Children's National Medical Center , Washington , DC , USA
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