1
|
Hartinger JM, Dvořáčková E, Krátký V, Hrušková Z, Mysliveček M, Bobek D, Benáková H, Závora J, Kroneislová G, Halouzková BA, Brejníková M, Martínková V, Tesař V, Slanař O. Elimination and penetration of amikacin into urine in patients with decreased glomerular filtration rate. Clin Kidney J 2024; 17:sfae002. [PMID: 38260825 PMCID: PMC10802929 DOI: 10.1093/ckj/sfae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Indexed: 01/24/2024] Open
Abstract
Background Amikacin monotherapy is recommended for urinary tract infection (UTI) treatment with multi-resistant pathogens. Even though amikacin efficacy in the treatment of UTIs is dependent on its urinary concentration, there are no robust data proving that sufficiently high urinary concentration is reached in patients with reduced glomerular filtration rate (GFR). Methods A prospective study to monitor amikacin penetration into urine of 70 patients [40 males, median (interquartile range) age 70 (65-79) years] with different levels of glomerular filtration decline, including patients treated by dialysis, was conducted. The bactericidal efficacy of amikacin in urine samples has been evaluated. Results Patients with estimated GFR (eGFR) <30 mL/min had significantly lower median amikacin urinary concentration than patients with eGFR >30 mL/min (89.75 vs 186.0 mg/L, P < .0001; 200.5 vs 830.0 mg/L, P < .0001; and 126.0 vs 408.0 mg/L, P < .0001 for minimal, maximal and minimal together with maximal concentrations, respectively). The amount of amikacin eliminated in the first 10-13 h after dose administration was dependent on eGFR (r2 = 0.6144, P < .0001). The urinary concentration of amikacin in patients treated by dialysis was indirectly proportional to pH of urine. The plasma concentrations of amikacin did not correlate with urinary levels in patients in either of the GFR categories. Microbiological evaluation showed that the critical urinary concentration for efficacy of amikacin during UTI monotherapy in patients treated by dialysis is 100 mg/L. We found that 4 out of 11 patients treated by dialysis did not reach this level during the treatment. Conclusion Systemic administration of amikacin monotherapy in patients treated by dialysis is questionable as the concentrations of amikacin in their urine are often below the threshold of effectivity. Amikacin plasma concentrations are not a major determinant of amikacin concentration in urine, therefore pulse dosing is neither necessary nor safe in patients treated by dialysis, and may cause undesirable toxicity.
Collapse
Affiliation(s)
- Jan Miroslav Hartinger
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Eliška Dvořáčková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Vojtěch Krátký
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Zdenka Hrušková
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Marek Mysliveček
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Daniel Bobek
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Hana Benáková
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Jan Závora
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Gabriela Kroneislová
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Barbora Agatha Halouzková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Martina Brejníková
- 3rd Department of Surgery, First Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Vendula Martínková
- 3rd Department of Surgery, First Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Vladimír Tesař
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Ondřej Slanař
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| |
Collapse
|
2
|
Le TA, Hiba T, Chaudhari D, Preston AN, Palowsky ZR, Ahmadzadeh S, Shekoohi S, Cornett EM, Kaye AD. Aminoglycoside-Related Nephrotoxicity and Ototoxicity in Clinical Practice: A Review of Pathophysiological Mechanism and Treatment Options. Adv Ther 2023; 40:1357-1365. [PMID: 36738370 DOI: 10.1007/s12325-023-02436-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023]
Abstract
Aminoglycosides are a class of medications used to treat certain bacterial infections, specifically gram-negative aerobes. These drugs can be used alone as first-line treatments or in combination with other medications. There can be many different formulations of aminoglycosides including oral, inhalants, intravascular, intramuscular, or intraventricular. There are many distinctive types of aminoglycosides, and although they provide excellent coverage, they can have a wide variety of side effects. The most prevalent side effects of aminoglycosides are nephrotoxicity and ototoxicity. Aminoglycoside-induced nephrotoxicity is concerning because of the effects that abnormal creatinine levels can have on other drugs and the potential for neurotoxicity. Fortunately, changes in renal function are typically reversible. The kidney is affected by the drug's ability to enter the proximal tubule and cause a buildup of phospholipids in the lysosomes, inhibiting their function. Exposure to aminoglycosides in utero can result in permanent ototoxicity. The mechanism of ototoxicity is through the drug's ability to freely pass into hair cells and cause reactive oxygen species to damage the mitochondria, resulting in cell death. There is not a substantial amount of research regarding the prevention and treatment of adverse effects of aminoglycosides. Future research on the mediation or modulation of these pathophysiological processes would expand their usage in modern medicine.
Collapse
Affiliation(s)
- Tyler A Le
- American University of the Caribbean, 1 University Drive at, Jordan Dr, Cupecoy, Sint Maarten
| | - Tasneem Hiba
- American University of the Caribbean, 1 University Drive at, Jordan Dr, Cupecoy, Sint Maarten
| | - Disha Chaudhari
- American University of the Caribbean, 1 University Drive at, Jordan Dr, Cupecoy, Sint Maarten
| | - Arielle N Preston
- American University of the Caribbean, 1 University Drive at, Jordan Dr, Cupecoy, Sint Maarten
| | - Zachary R Palowsky
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Alan D Kaye
- Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| |
Collapse
|
3
|
Yan K, Liang B, Zhang G, Wang J, Zhu M, Cai Y. Efficacy and safety of plazomicin in the treatment of Enterobacterales infections: A meta-analysis of randomized controlled trials. Open Forum Infect Dis 2022; 9:ofac429. [PMID: 36092826 PMCID: PMC9454024 DOI: 10.1093/ofid/ofac429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background In the present study, we aimed to compare the efficacy and safety of plazomicin with comparators for the treatment of Enterobacterales infections. Methods Randomized controlled trials (RCTs) assessing plazomicin for Enterobacterales infections were searched on the PubMed, Embase, and Cochrane Library databases. Meta-analyses were used to evaluate the efficacy and safety in RCTs. Results A total of 3 RCTs consisting of 761 patients were included in the present analysis. The study population included complex urinary tract infections (cUTIs), bloodstream infections (BSIs), and hospital-acquired pneumonia (HAP). Plazomicin had a clinical remission rate in the modified intention-to-treat (MITT) population that was similar to that of comparators (odds ratio [OR], 1.02; 95% CI, 0.60–1.73; I2 = 45%) in the pooled analysis of the 3 studies. The overall microbiologic eradication rate in the microbiological MITT (mMITT) population was similar to that of the comparators group (OR, 1.46; 95% CI, 0.72–2.95; I2 = 0%). However, the microbiologic recurrence rate of plazomicin for Enterobacterales was lower than that in the comparators group (OR, 0.38; 95% CI, 0.17–0.86; P = .02; I2 = 0%). No significant differences were found between plazomicin and comparators for the risk of any adverse events (OR, 0.78; 95% CI, 0.55–1.11; I2 = 0%). Conclusions Plazomicin is as good as comparators in terms of efficacy and tolerance in the treatment of Enterobacterales infections. Therefore, plazomicin is a suitable choice for antibiotic treatment in adult patients with cUTIs, BSIs, or HAP.
Collapse
Affiliation(s)
- Kaicheng Yan
- Medical School of Chinese PLA , Beijing 100853 , China
- Department of Pharmacy, Medical Supplies Center of Chinese PLA General Hospital , Beijing 100853 , China
| | - Beibei Liang
- Department of Pharmacy, Medical Supplies Center of Chinese PLA General Hospital , Beijing 100853 , China
| | - Guanxuanzi Zhang
- Department of Pharmacy, Medical Supplies Center of Chinese PLA General Hospital , Beijing 100853 , China
| | - Jin Wang
- Department of Pharmacy, Medical Supplies Center of Chinese PLA General Hospital , Beijing 100853 , China
| | - Man Zhu
- Department of Pharmacy, Medical Supplies Center of Chinese PLA General Hospital , Beijing 100853 , China
| | - Yun Cai
- Department of Pharmacy, Medical Supplies Center of Chinese PLA General Hospital , Beijing 100853 , China
| |
Collapse
|
4
|
Duong A, Simard C, Williamson D, Marsot A. Model Re-Estimation: An Alternative for Poor Predictive Performance during External Evaluations? Example of Gentamicin in Critically Ill Patients. Pharmaceutics 2022; 14:pharmaceutics14071426. [PMID: 35890322 PMCID: PMC9315759 DOI: 10.3390/pharmaceutics14071426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/03/2022] [Accepted: 07/06/2022] [Indexed: 12/01/2022] Open
Abstract
Background: An external evaluation is crucial before clinical applications; however, only a few gentamicin population pharmacokinetic (PopPK) models for critically ill patients included it in the model development. In this study, we aimed to evaluate gentamicin PopPK models developed for critically ill patients. Methods: The evaluated models were selected following a literature review on aminoglycoside PopPK models for critically ill patients. The data of patients were retrospectively collected from two Quebec hospitals, the external evaluation and model re-estimation were performed with NONMEM® (v7.5) and the population bias and imprecisions were estimated. Dosing regimens were simulated using the best performing model. Results: From the datasets of 39 and 48 patients from the two Quebec hospitals, none of the evaluated models presented acceptable values for bias and imprecision. Following model re-estimations, all models showed an acceptable predictive performance. An a priori dosing nomogram was developed with the best performing re-estimated model and was consistent based on recommended dosing regimens. Conclusion: Due to the poor predictive performance during the external evaluations, the latter must be prioritized during model development. Model re-estimation may be an alternative to developing a new model, especially when most known models display similar covariates.
Collapse
Affiliation(s)
- Alexandre Duong
- Faculté de Pharmacie, Université de Montréal, Montreal, QC H3T 1J4, Canada; (D.W.); (A.M.)
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montreal, QC H3T 1J4, Canada
- Correspondence:
| | - Chantale Simard
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Quebec, QC G1V 4G5, Canada;
- Faculté de Pharmacie, Université Laval, Quebec, QC G1V 0A6, Canada
| | - David Williamson
- Faculté de Pharmacie, Université de Montréal, Montreal, QC H3T 1J4, Canada; (D.W.); (A.M.)
- Hôpital Sacré-Cœur de Montréal, Université de Montréal, Montreal, QC H4J 1C5, Canada
| | - Amélie Marsot
- Faculté de Pharmacie, Université de Montréal, Montreal, QC H3T 1J4, Canada; (D.W.); (A.M.)
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montreal, QC H3T 1J4, Canada
- Centre de Recherche, CHU Sainte Justine, Montreal, QC H3T 1C5, Canada
| |
Collapse
|
5
|
Halouzková BA, Hartinger JM, Krátký V, Tesař V, Slanař O. Dosing of Aminoglycosides in Chronic Kidney Disease and End-Stage Renal Disease Patients Treated with Intermittent Hemodialysis. Kidney Blood Press Res 2022; 47:448-458. [PMID: 35443243 DOI: 10.1159/000523892] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/25/2022] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> The dosing of aminoglycosides (AGs) in patients with kidney disease is challenging due to their markedly prolonged half-life, which renders pulse dosing schedules unsuitable. We performed a review of the literature that describes the pharmacokinetics of, and dosing recommendations for, AG for patients with abnormal renal functions and various renal replacement therapy modalities, focusing on patients treated with intermittent hemodialysis (iHD). <b><i>Summary:</i></b> During one iHD session, dialysis removes a remarkable amount of the drug regardless of the dialyzer type. In patients with severely reduced kidney functions, the distribution phase is prolonged, which needs to be taken into account when drawing samples shortly after drug administration or following an iHD session. <b><i>Key Messages:</i></b> The doses recommended for the pulse dosing of patients without kidney disease leads to unacceptably high overall systemic exposure for patients with severely reduced kidney functions even with dosing intervals extended up to 48 h. Therefore, lower doses accompanied by extended dosing intervals must be applied for this patient group. The clinical evidence and current recommendations support the dosing of AG following, rather than before, HD sessions. In patients with end-stage kidney disease, the samples for TDM of AGs should not be drawn earlier than 2 h after end of the infusion and 4 h after the end of iHD session to allow full (re)distribution of the drug.
Collapse
Affiliation(s)
- Barbora Agatha Halouzková
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Jan Miroslav Hartinger
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Vojtěch Krátký
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Vladimír Tesař
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Ondřej Slanař
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| |
Collapse
|
6
|
Duong A, Thirion DJG, Williamson D, Simard C, Marsot A. Aminoglycosides' dosing and monitoring practices in critically ill patients in Quebec hospitals. J Chemother 2022; 34:341-344. [PMID: 35238282 DOI: 10.1080/1120009x.2022.2040771] [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: 10/18/2022]
Abstract
Considering the aminoglycosides' characteristics in terms of efficacy and toxicity, multiple dosing recommendations and nomograms have been suggested over several decades. The objective is to describe the dosing and monitoring practices of amikacin, gentamicin, and tobramycin in critically ill patients across health care institutions in the province of Quebec.This survey was developed with multiple-choices and short answers and targeted the lead pharmacist responsible of antimicrobial stewardship in each health care institution.Gentamicin and tobramycin dosing regimens were in-line with guidelines from different countries. Amikacin was not commonly used in Quebec. Therapeutic targets were generally consistent with the literature.Dosing adaptation were mostly done based on clinician judgment or with homemade software. Given the variability seen across practices in Quebec institutions, standardization and optimization of aminoglycosides therapeutic drug monitoring may be considered.
Collapse
Affiliation(s)
- Alexandre Duong
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montréal, Canada
| | - Daniel J G Thirion
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Centre Universitaire de Santé McGill, Université McGill, Montréal, Canada
| | - David Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Hôpital Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - Chantale Simard
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec, Canada.,Faculté de Pharmacie, Université de Laval, Québec, Canada
| | - Amélie Marsot
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Centre de Recherche, CHU Sainte Justine, Montréal, Canada
| |
Collapse
|
7
|
Shipkova M, Jamoussi H. Therapeutic Drug Monitoring of Antibiotic Drugs: The Role of the Clinical Laboratory. Ther Drug Monit 2022; 44:32-49. [PMID: 34726200 DOI: 10.1097/ftd.0000000000000934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/08/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of anti-infective drugs is an increasingly complex field, given that in addition to the patient and drug as 2 usual determinants, its success is driven by the pathogen. Pharmacodynamics is related both to the patient (toxicity) and bacterium (efficacy or antibiotic susceptibility). The specifics of TDM of antimicrobial drugs stress the need for multidisciplinary knowledge and expertise, as in any other field. The role and the responsibility of the laboratory in this interplay are both central and multifaceted. This narrative review highlights the role of the clinical laboratory in the TDM process. METHODS A literature search was conducted in PubMed and Google Scholar, focusing on the past 5 years (studies published since 2016) to limit redundancy with previously published review articles. Furthermore, the references cited in identified publications of interest were screened for additional relevant studies and articles. RESULTS The authors addressed microbiological methods to determine antibiotic susceptibility, immunochemical and chromatographic methods to measure drug concentrations (primarily in blood samples), and endogenous clinical laboratory biomarkers to monitor treatment efficacy and toxicity. The advantages and disadvantages of these methods are critically discussed, along with existing gaps and future perspectives on strategies to provide clinicians with as reliable and useful results as possible. CONCLUSIONS Although interest in the field has been the driver for certain progress in analytical technology and quality in recent years, laboratory professionals and commercial providers persistently encounter numerous unresolved challenges. The main tasks that need tackling include broadly and continuously available, easily operated, and cost-effective tests that offer short turnaround times, combined with reliable and easy-to-interpret results. Various fields of research are currently addressing these features.
Collapse
Affiliation(s)
- Maria Shipkova
- Competence Center for Therapeutic Drug Monitoring, SYNLAB Holding Germany GmbH, SYNLAB MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
| | | |
Collapse
|
8
|
Risk Factors Associated with Suboptimal Tobramycin Levels in the Medical Intensive Care Unit. Eur J Drug Metab Pharmacokinet 2022; 47:271-278. [PMID: 35029839 DOI: 10.1007/s13318-021-00749-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Optimal aminoglycoside dosing in critically ill patients represents a challenge for practitioners, especially in the medical intensive care unit (MICU). MICU patients exhibit altered pharmacokinetics due to pathophysiological changes the body undergoes in critical illness, leading to possible treatment failure. The literature surrounding optimal dosing and therapeutic drug monitoring strategies of aminoglycosides in MICU patients is scarce and conflicting. Additionally, only a few studies have investigated risk factors for suboptimal pharmacokinetic target obtainment. Currently, no definitive risk factors have been identified to predict suboptimal aminoglycoside target obtainment in MICU patients. OBJECTIVE The objective of this study was to determine risk factors for suboptimal pharmacokinetic target obtainment in patients receiving tobramycin in the MICU. METHODS This single-center, retrospective cohort study included patients 18-89 years old who received at least one 7 mg/kg tobramycin dose in the MICU from January, 1 2015 to September, 30 2020. Patients also had to have at least two detectable drug levels obtained at least one half-life apart following the first tobramycin dose. The primary outcome was to determine the incidence of optimal pharmacokinetic target obtainment, defined as a tobramycin maximum concentration (Cmax) ≥ 10 mcg/ml, and to identify the risk factors for suboptimal (Cmax < 10 mcg/mL) pharmacokinetic target obtainment, in MICU patients. Secondary outcomes were compared between suboptimal and optimal target obtainment in patients with culture confirmed gram-negative infection susceptible to tobramycin. These secondary outcomes included all-cause in-hospital mortality, ICU length of stay (LOS), hospital LOS, and vasopressor duration in those with shock. RESULTS A total of 230 patients were included in this retrospective study. For the primary outcome, 187 (81.3%) patients achieved optimal target obtainment. Through multivariate logistic regression, female sex and serum albumin < 2.5 g/dL were identified as independent risk factors for suboptimal target obtainment; [OR = 2.14; 95% CI (1.05-4.37), p = 0.037], [OR = 2.50; 95% CI (1.21-5.19), p = 0.014], respectively. Fifty-four (23%) patients had culture-confirmed gram-negative infections susceptible to tobramycin and were included in the subgroup analysis. Of these 54 patients, 11 (20.4%) did not achieve optimal target concentrations. In patients with culture-confirmed gram-negative infection, there was no difference between patients with optimal target obtainment and suboptimal target obtainment in ICU LOS, hospital LOS, all-cause mortality, or vasopressor duration in those with shock. CONCLUSIONS Among patients receiving their first dose of tobramycin in the MICU, 81.3% obtained an optimal serum concentration. Female sex and serum albumin < 2.5 g/dL were identified as risk factors for suboptimal target obtainment; however, further research is warranted to assess the utility of using these two covariates as risk factors for more aggressive dosing in critically ill MICU patients.
Collapse
|
9
|
Tait JR, Bilal H, Rogers KE, Lang Y, Kim TH, Zhou J, Wallis SC, Bulitta JB, Kirkpatrick CMJ, Paterson DL, Lipman J, Bergen PJ, Roberts JA, Nation RL, Landersdorfer CB. Effect of Different Piperacillin-Tazobactam Dosage Regimens on Synergy of the Combination with Tobramycin against Pseudomonas aeruginosa for the Pharmacokinetics of Critically Ill Patients in a Dynamic Infection Model. Antibiotics (Basel) 2022; 11:antibiotics11010101. [PMID: 35052977 PMCID: PMC8772788 DOI: 10.3390/antibiotics11010101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/11/2022] [Indexed: 12/10/2022] Open
Abstract
We evaluated piperacillin-tazobactam and tobramycin regimens against Pseudomonas aeruginosa isolates from critically ill patients. Static-concentration time-kill studies (SCTK) assessed piperacillin-tazobactam and tobramycin monotherapies and combinations against four isolates over 72 h. A 120 h-dynamic in vitro infection model (IVM) investigated isolates Pa1281 (MICpiperacillin 4 mg/L, MICtobramycin 0.5 mg/L) and CR380 (MICpiperacillin 32 mg/L, MICtobramycin 1 mg/L), simulating the pharmacokinetics of: (A) tobramycin 7 mg/kg q24 h (0.5 h-infusions, t1/2 = 3.1 h); (B) piperacillin 4 g q4 h (0.5 h-infusions, t1/2 = 1.5 h); (C) piperacillin 24 g/day, continuous infusion; A + B; A + C. Total and less-susceptible bacteria were determined. SCTK demonstrated synergy of the combination for all isolates. In the IVM, regimens A and B provided initial killing, followed by extensive regrowth by 72 h for both isolates. C provided >4 log10 CFU/mL killing, followed by regrowth close to initial inoculum by 96 h for Pa1281, and suppressed growth to <4 log10 CFU/mL for CR380. A and A + B initially suppressed counts of both isolates to <1 log10 CFU/mL, before regrowth to control or starting inoculum and resistance emergence by 72 h. Overall, the combination including intermittent piperacillin-tazobactam did not provide a benefit over tobramycin monotherapy. A + C, the combination regimen with continuous infusion of piperacillin-tazobactam, provided synergistic killing (counts <1 log10 CFU/mL) of Pa1281 and CR380, and suppressed regrowth to <2 and <4 log10 CFU/mL, respectively, and resistance emergence over 120 h. The shape of the concentration–time curve was important for synergy of the combination.
Collapse
Affiliation(s)
- Jessica R. Tait
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
| | - Hajira Bilal
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (H.B.); (C.M.J.K.); (P.J.B.)
| | - Kate E. Rogers
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
| | - Yinzhi Lang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (Y.L.); (J.Z.); (J.B.B.)
| | - Tae-Hwan Kim
- College of Pharmacy, Daegu Catholic University, Gyeongsan 38430, Korea;
| | - Jieqiang Zhou
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (Y.L.); (J.Z.); (J.B.B.)
| | - Steven C. Wallis
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
| | - Jürgen B. Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (Y.L.); (J.Z.); (J.B.B.)
| | - Carl M. J. Kirkpatrick
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (H.B.); (C.M.J.K.); (P.J.B.)
| | - David L. Paterson
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
| | - Jeffrey Lipman
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
- Intensive Care Unit, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30900 Nîmes, France
- Jamieson Trauma Institute, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
| | - Phillip J. Bergen
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (H.B.); (C.M.J.K.); (P.J.B.)
| | - Jason A. Roberts
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
- Intensive Care Unit, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30900 Nîmes, France
| | - Roger L. Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
| | - Cornelia B. Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
- Correspondence: ; Tel.: +61-3-990-39011
| |
Collapse
|
10
|
Wang Y, Hanrahan G, Azar FA, Mittermaier A. Binding interactions in a kinase active site modulate background ATP hydrolysis. BIOCHIMICA ET BIOPHYSICA ACTA. PROTEINS AND PROTEOMICS 2022; 1870:140720. [PMID: 34597835 DOI: 10.1016/j.bbapap.2021.140720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/31/2021] [Accepted: 09/26/2021] [Indexed: 06/13/2023]
Abstract
Kinases play central roles in many cellular processes, transferring the terminal phosphate groups of nucleoside triphosphates (NTPs) onto substrates. In the absence of substrates, kinases can also hydrolyse NTPs producing NDPs and inorganic phosphate. Hydrolysis is usually much less efficient than the native phosphoryl transfer reaction. This may be related to the fact that NTP hydrolysis is metabolically unfavorable as it unproductively consumes the cell's energy stores. It has been suggested that substrate interactions could drive changes in NTP binding pocket, activating catalysis only when substrates are present. Structural data show substrate-induced conformational rearrangements, however there is a lack of corresponding functional information. To better understand this phenomenon, we developed a suite of isothermal titration calorimetry (ITC) kinetics methods to characterize ATP hydrolysis by the antibiotic resistance enzyme aminoglycoside-3'-phosphotransferase-IIIa (APH(3')-IIIa). We measured Km, kcat, and product inhibition constants and single-turnover kinetics in the presence and absence of non-substrate aminoglycosides (nsAmgs) that are structurally similar to the native substrates. We found that the presence of an nsAmg increased the chemical step of cleaving the ATP γ-phosphate by at least 10- to 20-fold under single-turnover conditions, supporting the existence of interactions that link substrate binding to substantially enhanced catalytic rates. Our detailed kinetic data on the association and dissociation rates of nsAmgs and ADP shed light on the biophysical processes underlying the enzyme's Theorell-Chance reaction mechanism. Furthermore, they provide clues on how to design small-molecule effectors that could trigger efficient ATP hydrolysis and generate selective pressure against bacteria harboring the APH(3')-IIIa.
Collapse
Affiliation(s)
- Yun Wang
- Department of Chemistry, McGill University, 801 Sherbrooke St. W., Montreal, Quebec H3A 0B8, Canada
| | - Grace Hanrahan
- Department of Chemistry, McGill University, 801 Sherbrooke St. W., Montreal, Quebec H3A 0B8, Canada
| | - Frederic Abou Azar
- Department of Chemistry, McGill University, 801 Sherbrooke St. W., Montreal, Quebec H3A 0B8, Canada
| | - Anthony Mittermaier
- Department of Chemistry, McGill University, 801 Sherbrooke St. W., Montreal, Quebec H3A 0B8, Canada.
| |
Collapse
|
11
|
Pérez-Blanco JS, Sáez Fernández EM, Calvo MV, Lanao JM, Martín-Suárez A. Evaluation of Current Amikacin Dosing Recommendations and Development of an Interactive Nomogram: The Role of Albumin. Pharmaceutics 2021; 13:pharmaceutics13020264. [PMID: 33672057 PMCID: PMC7919491 DOI: 10.3390/pharmaceutics13020264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 11/16/2022] Open
Abstract
This study aimed to evaluate the potential efficacy and safety of the amikacin dosage proposed by the main guidelines and to develop an interactive nomogram, especially focused on the potential impact of albumin on initial dosage recommendation. The probability of target attainment (PTA) for each of the different dosing recommendations was calculated through stochastic simulations based on pharmacokinetic/pharmacodynamic (PKPD) criteria. Large efficacy and safety differences were observed for the evaluated amikacin dosing guidelines together with a significant impact of albumin concentrations on efficacy and safety. For all recommended dosages evaluated, efficacy and safety criteria of amikacin dosage proposed were not achieved simultaneously in most of the clinical scenarios evaluated. Furthermore, a significant impact of albumin was identified: The higher is the albumin, (i) the higher will be the PTA for maximum concentration/minimum inhibitory concentration (Cmax/MIC), (ii) the lower will be the PTA for the time period with drug concentration exceeding MIC (T>MIC) and (iii) the lower will be the PTA for toxicity (minimum concentration). Thus, accounting for albumin effect might be of interest for future amikacin dosing guidelines updates. In addition, AMKnom, an amikacin nomogram builder based on PKPD criteria, has been developed and is freely available to help evaluating dosing recommendations.
Collapse
Affiliation(s)
- Jonás Samuel Pérez-Blanco
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, 37007 Salamanca, Spain; (J.S.P.-B.); (E.M.S.F.); (M.V.C.); (A.M.-S.)
- Institute for Biomedical Research of Salamanca (IBSAL), Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Eva María Sáez Fernández
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, 37007 Salamanca, Spain; (J.S.P.-B.); (E.M.S.F.); (M.V.C.); (A.M.-S.)
- Institute for Biomedical Research of Salamanca (IBSAL), Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
- Pharmacy Service, University Hospital of Salamanca, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - María Victoria Calvo
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, 37007 Salamanca, Spain; (J.S.P.-B.); (E.M.S.F.); (M.V.C.); (A.M.-S.)
- Institute for Biomedical Research of Salamanca (IBSAL), Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - José M. Lanao
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, 37007 Salamanca, Spain; (J.S.P.-B.); (E.M.S.F.); (M.V.C.); (A.M.-S.)
- Institute for Biomedical Research of Salamanca (IBSAL), Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
- Correspondence: ; Tel.: +34-923294518
| | - Ana Martín-Suárez
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, 37007 Salamanca, Spain; (J.S.P.-B.); (E.M.S.F.); (M.V.C.); (A.M.-S.)
| |
Collapse
|
12
|
Impact of Therapeutic Drug Monitoring on Once-Daily Regimen of Amikacin in Patients With Urinary Tract Infection: A Prospective Observational Study. Ther Drug Monit 2020; 42:841-847. [PMID: 32947556 DOI: 10.1097/ftd.0000000000000800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Amikacin is a semisynthetic antibiotic used in the treatment of gram-negative bacterial infections and has a narrow therapeutic index. Although therapeutic drug monitoring is recommended for amikacin, it is not routinely performed because of the use of a less toxic once-daily regimen. Only few studies have evaluated the role of therapeutic drug monitoring in patients treated with amikacin. The objective of our study was to find an association between the pharmacokinetic parameters of amikacin and the time required for a clinical cure, creatinine clearance, and frequency of ototoxicity in patients with urinary tract infection treated for 7 or more days. METHODS A prospective study was conducted on patients with urinary tract infections who were administered amikacin for 7 or more days. Blood samples were obtained from the patients to measure the maximum drug concentration (Cmax) and trough concentration (Ctrough). Minimum inhibitory concentration (MIC) values were determined for patients with positive urine cultures. Serum creatinine levels were estimated every 3 days. The auditory assessment was performed using pure tone audiometry at baseline and weekly until the patients were discharged. Levels of amikacin were analyzed using a validated liquid chromatography-tandem mass spectrometry method. RESULTS Of 125 patients analyzed, the median time required for a clinical cure was less in the group of patients who achieved a Cmax/MIC ratio ≥8 than it was in those who did not achieve this level [7 versus 8 days (P = 0.02)]. The Ctrough of amikacin was associated with the change in serum creatinine level (P = 0.01) and the incidence of nephrotoxicity (P = 0.004). CONCLUSIONS In patients receiving short-term amikacin therapy, Cmax/MIC value can be used to predict the time required for a clinical cure. Ctrough can be used to predict the occurrence of nephrotoxicity in patients receiving amikacin therapy.
Collapse
|
13
|
Sou T, Hansen J, Liepinsh E, Backlund M, Ercan O, Grinberga S, Cao S, Giachou P, Petersson A, Tomczak M, Urbas M, Zabicka D, Vingsbo Lundberg C, Hughes D, Hobbie SN, Friberg LE. Model-Informed Drug Development for Antimicrobials: Translational PK and PK/PD Modeling to Predict an Efficacious Human Dose for Apramycin. Clin Pharmacol Ther 2020; 109:1063-1073. [PMID: 33150591 PMCID: PMC8048880 DOI: 10.1002/cpt.2104] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/18/2020] [Indexed: 12/12/2022]
Abstract
Apramycin represents a subclass of aminoglycoside antibiotics that has been shown to evade almost all mechanisms of clinically relevant aminoglycoside resistance. Model-informed drug development may facilitate its transition from preclinical to clinical phase. This study explored the potential of pharmacokinetic/pharmacodynamic (PK/PD) modeling to maximize the use of in vitro time-kill and in vivo preclinical data for prediction of a human efficacious dose (HED) for apramycin. PK model parameters of apramycin from four different species (mouse, rat, guinea pig, and dog) were allometrically scaled to humans. A semimechanistic PK/PD model was developed from the rich in vitro data on four Escherichia coli strains and subsequently the sparse in vivo efficacy data on the same strains were integrated. An efficacious human dose was predicted from the PK/PD model and compared with the classical PK/PD index methodology and the aminoglycoside dose similarity. One-compartment models described the PK data and human values for clearance and volume of distribution were predicted to 7.07 L/hour and 26.8 L, respectively. The required fAUC/MIC (area under the unbound drug concentration-time curve over MIC ratio) targets for stasis and 1-log kill in the thigh model were 34.5 and 76.2, respectively. The developed PK/PD model predicted the efficacy data well with strain-specific differences in susceptibility, maximum bacterial load, and resistance development. All three dose prediction approaches supported an apramycin daily dose of 30 mg/kg for a typical adult patient. The results indicate that the mechanistic PK/PD modeling approach can be suitable for HED prediction and serves to efficiently integrate all available efficacy data with potential to improve predictive capacity.
Collapse
Affiliation(s)
- Tomás Sou
- Pharmacometrics, Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Jon Hansen
- Department of Bacteria, Parasites and Fungi, Statens Serum Institute, Copenhagen, Denmark
| | | | - Maria Backlund
- Department of Pharmacy, Uppsala University Drug Optimization and Pharmaceutical Profiling, Uppsala University, Uppsala, Sweden
| | - Onur Ercan
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | | | - Sha Cao
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Paraskevi Giachou
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Anna Petersson
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Magdalena Tomczak
- Department of Epidemiology and Clinical Microbiology, National Medicines Institute, Warsaw, Poland
| | - Malgorzata Urbas
- Department of Epidemiology and Clinical Microbiology, National Medicines Institute, Warsaw, Poland
| | - Dorota Zabicka
- Department of Epidemiology and Clinical Microbiology, National Medicines Institute, Warsaw, Poland
| | | | - Diarmaid Hughes
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Sven N Hobbie
- Institute of Medical Microbiology, University of Zurich, Zurich, Switzerland
| | - Lena E Friberg
- Pharmacometrics, Department of Pharmacy, Uppsala University, Uppsala, Sweden
| |
Collapse
|
14
|
Simulated Comparison of a Bayesian Clinical Decision Support System Versus Standard of Care For Achieving Gentamicin Pharmacokinetic Targets in Neonates. Pediatr Infect Dis J 2020; 39:313-317. [PMID: 32032171 PMCID: PMC7182238 DOI: 10.1097/inf.0000000000002592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Gentamicin therapy in neonates is optimized through achieving specific peak and trough concentrations. The objective of this study was to compare the ability a Bayesian clinical decision support system (CDSS) with standard of care (SOC) in determining personalized gentamicin therapies for neonates, at regimen initiation and in response to measured drug concentrations. METHODS This retrospective review and simulation compared target attainment among 4 arms: historical dosing according to SOC, via nomogram for initial dosing (SOC-initial) and via clinician judgment in response to measured concentrations (SOC-adjusted), and simulated dosing using the CDSS, incorporating a neonatal pharmacokinetic model for initial dosing (CDSS-initial) and incorporating maximum a posteriori-Bayesian analysis in response to measured concentrations (CDSS-adjusted). "True" patient pharmacokinetic parameters and peak and trough concentration predictions were calculated via the CDSS using the entirety of the patient dosing and concentration history. The primary outcome was pharmacokinetic target attainment of desired gentamicin peak and trough concentrations. RESULTS The study included 564 gentamicin concentrations among 339 patients. Mean demographics were 35 weeks gestational age (52% premature births) and 2.44 kg dosing weight. Mean PK parameters were 0.0533 L/h/kg clearance, 0.458 L/kg volume of distribution, and 8.66 hours half-life. Peak concentrations in the desired range were achieved in 96% of significantly more often in the CDSS-initial regimens and 94% of CDSS-adjusted regimens versus 86% of SOC-initial regimens and 66% of SOC-adjusted regimens. No difference was found in trough target attainment among study groups. CONCLUSIONS In simulation, a Bayesian CDSS showed superiority to SOC in achieving gentamicin pharmacokinetic exposure targets in neonates. Use of a CDSS may improve the safety and efficacy of gentamicin therapy for neonates.
Collapse
|
15
|
du Toit M, Burger JR, Rakumakoe DM, Rheeders M. Standards of aminoglycoside therapeutic drug monitoring in a South African private hospital: perspectives and implications. Ghana Med J 2019; 53:8-12. [PMID: 31138938 PMCID: PMC6527830 DOI: 10.4314/gmj.v53i1.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Therapeutic drug monitoring (TDM) is essential to ensure that aminoglycoside peak concentrations are high enough for effective antimicrobial treatment and trough levels are low enough to minimise toxicity. Inappropriate utilisation of TDM may lead to suboptimal therapy, toxicity and waste of resources. This study aimed to investigate the standard of aminoglycoside TDM performed in adult hospitalised patients. Design An observational, descriptive, cross-sectional study. Setting A 221-bed private hospital. Participants All patients, older than 18 years, on intravenous aminoglycosides for more than 48 hours were included. Interventions None, was observational. A computerised database and patient files were used to obtain the information required for this study. Descriptive statistical analysis was used. Main outcomes measures Aminoglycoside blood levels and estimated glomerular filtration rate (eGFR) in the patients. Results One hundred and three (103) patients were included: 65 on gentamicin and 38 on amikacin. Blood levels were performed in only 19 gentamicin (29.23%) and 22 amikacin (57.89%) patients. Trough levels were taken more than 2 hours before the next dose in 12 gentamicin (63.16%) and 12 amikacin (54.54%) patients. The majority of patients (96.92% on gentamicin and 84.21% on amikacin) received once daily doses. TDM was performed in all patients with an estimated glomerular filtration rate (eGFR) lower than 60 mL/min/1.73m2 and in 23.31% of gentamicin patients and 56.76% of amikacin patients with an eGFR higher than 60 mg/min/1.73m2. Conclusions Incorrect sampling times and unnecessary levels taken in patients with normal renal function indicate a need for aminoglycoside treatment guidelines in the private hospital. Funding None
Collapse
Affiliation(s)
- Mariette du Toit
- Medicine Usage in South Africa (MUSA), Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Johanita R Burger
- Medicine Usage in South Africa (MUSA), Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Dorcas M Rakumakoe
- Medicine Usage in South Africa (MUSA), Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Malie Rheeders
- Centre of Excellence for Pharmaceutical Science, North-West University, Potchefstroom, South Africa
| |
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW In the absence of randomized clinical trial data, questions remain regarding the optimal treatment of carbapenem-resistant Enterobacteriaceae (CRE) infections. CRE have historically been susceptible to polymyxins, tigecycline or aminoglycosides (mostly gentamicin), and these antibiotics have long been considered the drugs of choice for CRE infections, although varying rates of resistance to all have been reported. This review looks at data from clinical studies assessing the outcomes of CRE infections treated with different antibiotic regimens. RECENT FINDINGS The recently approved fixed-dose combination agent, ceftazidime-avibactam (CAZ-AVI), is active against KPC and OXA-48-producing Enterobacteriaceae. The limited clinical data available on CAZ-AVI indicate that it is associated with survival benefits relative to other commonly used regimens, although development of resistance is a concern. New drugs active against CRE isolates (including the recently approved meropenem-vaborbactam) are in different stages of development. SUMMARY CAZ-AVI and meropenem-vaborbactam seem destined to become the backbone of target therapy for high-risk patients with severe infections caused by susceptible CRE strains. However, empirical therapy should be based on risk factors to be defined in the near future, whereas the necessity of combinations with CAZ-AVI requires further studies. Polymyxins are still important options for low-risk patients with susceptible CRE infections, but also for high-risk patients in regions where metallo-β-lactamase-producing CRE predominate because CAZ-AVI and meropenem-vaborbactam are both ineffective against these strains.
Collapse
|
17
|
Application of the Hartford Hospital Nomogram for Plazomicin Dosing Interval Selection in Patients with Complicated Urinary Tract Infection. Antimicrob Agents Chemother 2019; 63:AAC.00148-19. [PMID: 31358580 DOI: 10.1128/aac.00148-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 07/19/2019] [Indexed: 11/20/2022] Open
Abstract
Plazomicin is a new FDA-approved aminoglycoside antibiotic for complicated urinary tract infections (cUTI). In the product labeling, trough-based therapeutic drug management (TDM) is recommended for cUTI patients with renal impairment to prevent elevated trough concentrations associated with serum creatinine increases of ≥0.5 mg/dl above baseline. Herein, the utility of the Hartford nomogram to prevent plazomicin trough concentrations exceeding the TDM trough of 3 μg/ml and optimize the area under the curve (AUC) was assessed. The AUC reference range was defined as the 5th to 95th percentile AUC observed in the phase 3 cUTI trial (EPIC) (121 to 368 μg · h/ml). Observed 10-h plazomicin concentrations from patients in EPIC (n = 281) were plotted on the nomogram to determine an eligible dosing interval (every 24 h [q24h], q36h, q48h). Based on creatinine clearance (CLcr), a 15- or 10-mg/kg of body weight dose was simulated with the nomogram-derived interval. The nomogram recommended an extended interval (q36h and q48h) in 31% of patients. Compared with the 15 mg/kg q24h regimen received by patients with CLcr of ≥60 ml/min in EPIC, the nomogram-derived interval reduced the proportion of patients with troughs of ≥3 μg/ml (q36h, 27% versus 0%, P = 0.021; q48h, 57% versus 0%, P = 0.002) while significantly increasing the number of patients within the AUC range. Compared with the 8 to 12 mg/kg q24h regimen (received by patients with CLcr of >30 to 59 ml/min in EPIC), the nomogram-derived interval significantly reduced the proportion of troughs of ≥3μg/ml in the q48h cohort (72% versus 0%, P < 0.001) while maintaining a similar proportion of patients in the AUC range. Simulated application of the Hartford nomogram optimized plazomicin exposures in patients with cUTI while reducing troughs to <3 μg/ml.
Collapse
|
18
|
Lim WXS, Chua WBB, Chua JM, Lee Q, Chan JW, Sultana R, Poh BH. A Retrospective Review of the Efficiency of First‐Dose Therapeutic Drug Monitoring of Gentamicin, Amikacin, and Vancomycin in the Pediatric Population. J Clin Pharmacol 2019; 60:7-15. [DOI: 10.1002/jcph.1509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/28/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Wan Xuan Selina Lim
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | | | - Jie Min Chua
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | - Qianyu Lee
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | - Jer Wei Chan
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | - Rehena Sultana
- Centre for Quantitative MedicineDuke‐National University of Singapore Singapore
| | - Bao Hui Poh
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| |
Collapse
|
19
|
Asempa TE, Kuti JL, Seroogy JD, Komirenko AS, Nicolau DP. A Simulated Application of the Hartford Hospital Aminoglycoside Dosing Nomogram for Plazomicin Dosing Interval Selection in Patients With Serious Infections Caused by Carbapenem-Resistant Enterobacterales. Clin Ther 2019; 41:1453-1462. [PMID: 31248681 DOI: 10.1016/j.clinthera.2019.04.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/02/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE In the Phase III Study of Plazomicin Compared With Colistin in Patients With Infection Due to Carbapenem-Resistant Enterobacteriaceae (CARE), plazomicin was studied for the treatment of critically ill patients with infections caused by carbapenem-resistant Enterobacterales. Initial plazomicin dosing was guided by creatinine clearance (CrCl) and subsequent doses adjusted by therapeutic drug monitoring to achieve AUC0-24 exposures within a target range (210-315 mg∙h/L). We applied the Hartford nomogram to evaluate whether this clinical tool could reduce plazomicin troughs levels and increase the proportion of patients within the target AUC range. METHODS Thirty-seven patients enrolled in cohorts 1 or 2 of CARE were eligible for analyses. Observed 10-hour concentrations after the initial dose were plotted on the Hartford nomogram to determine an eligible dosing interval group (q24h, q36h or q48h). On the basis of baseline CrCl, a 15- or 10-mg/kg dose was simulated with the nomogram-recommended dosing interval. The proportion of patients in each dosing interval group with a trough ≥3 mg/L (trough threshold associated with serum creatinine increases ≥0.5 mg/dL in product label) was quantified. Simulated interval-normalized AUC0-24 was compared with the target AUC range. FINDINGS Among the 28 patients with a CrCl ≥60 mL/min, the nomogram recommended every-24-hour dosing in 61% and an extended-interval (q36h or q48h) in 39% of patients. For patients with a CrCl ≥30-59 mL/min (n = 9), the nomogram recommended every-24-hour dosing and an extended-interval in 22% and 78% of patients, respectively. Among both renal function cohorts, exposure simulation with the nomogram significantly reduced the proportion of patients with trough concentrations ≥3 mg/L (CrCl ≥60 mL/min cohort: 91% vs 9%, P < 0.001; CrCl ≥30-59 mL/min cohort, 100% vs 0%, P < 0.001). Relative to the observed mean (SD) AUC0-24 of 309 mg∙h/mL (96 mg∙h/mL), simulation of extended intervals resulted in a mean interval-normalized AUC0-24 of 210 mg∙h/mL (40 mg∙h/mL) in all patients eligible for an extended interval, resulting in a similar proportion (49% vs 54%) of patients within the target AUC0-24 range after the first dose. IMPLICATIONS Application of the Hartford nomogram successfully reduced the likelihood of elevated plazomicin trough concentrations while improving AUC exposures in these patients with carbapenem-resistant Enterobacterales infections.
Collapse
Affiliation(s)
- Tomefa E Asempa
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | | | | | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA.
| |
Collapse
|
20
|
Karaiskos I, Lagou S, Pontikis K, Rapti V, Poulakou G. The "Old" and the "New" Antibiotics for MDR Gram-Negative Pathogens: For Whom, When, and How. Front Public Health 2019; 7:151. [PMID: 31245348 PMCID: PMC6581067 DOI: 10.3389/fpubh.2019.00151] [Citation(s) in RCA: 169] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/23/2019] [Indexed: 12/15/2022] Open
Abstract
The recent expansion of multidrug resistant and pan-drug-resistant pathogens poses significant challenges in the treatment of healthcare associated infections. An important advancement, is a handful of recently launched new antibiotics targeting some of the current most problematic Gram-negative pathogens, namely carbapenem-producing Enterobacteriaceae (CRE) and carbapenem-resistant P. aeruginosa (CRPA). Less options are available against carbapenem-resistant Acinetobacter baumannii (CRAB) and strains producing metallo-beta lactamases (MBL). Ceftazidime-avibactam signaled a turning point in the treatment of KPC and partly OXA- type carbapenemases, whereas meropenem-vaborbactam was added as a potent combination against KPC-producers. Ceftolozane-tazobactam could be seen as an ideal beta-lactam backbone for the treatment of CRPA. Plazomicin, an aminoglycoside with better pharmacokinetics and less toxicity compared to other class members, will cover important proportions of multi-drug resistant pathogens. Eravacycline holds promise in the treatment of infections by CRAB, with a broad spectrum of activity similar to tigecycline, and improved pharmacokinetics. Novel drugs and combinations are not to be considered "panacea" for the ongoing crisis in the therapy of XDR Gram-negative bacteria and colistin will continue to be considered as a fundamental companion drug for the treatment of carbapenem-resistant Enterobacteriaceae (particularly in areas where MBL predominate), for the treatment of CRPA (in many cases being the only in vitro active drug) as well as CRAB. Aminoglycosides are still important companion antibiotics. Finally, fosfomycin as part of combination treatment for CRE infections and P. aeruginosa, deserves a greater attention. Optimal conditions for monotherapy and the "when and how" of combination treatments integrating the novel agents will be discussed.
Collapse
Affiliation(s)
- Ilias Karaiskos
- First Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Styliani Lagou
- Third Department of Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Pontikis
- ICU First Department of Respiratory Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasiliki Rapti
- Third Department of Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Garyphallia Poulakou
- Third Department of Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
21
|
Muller AE, Huttner B, Huttner A. Therapeutic Drug Monitoring of Beta-Lactams and Other Antibiotics in the Intensive Care Unit: Which Agents, Which Patients and Which Infections? Drugs 2019; 78:439-451. [PMID: 29476349 DOI: 10.1007/s40265-018-0880-z] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antibiotics are among the medications most frequently administered to the critically ill, a population with high levels of intra- and inter-individual pharmacokinetic variability. Our knowledge of the relationships among antibiotic dosing, exposure and clinical effect in this population has increased in recent decades. Therapeutic drug monitoring (TDM) of serum antibiotic concentrations is the most practical means of assessing adequate antibiotic exposure, though until recently, it has been underutilised for this end. Now TDM is becoming more widespread, particularly for the beta-lactam antibiotics, a class historically thought to have a wide therapeutic range. We review the basic requirements, indications, and targets for effective TDM of the glycopeptides, aminoglycosides, quinolones and beta-lactam antibiotics in the adult intensive-care setting, with a special focus on TDM of the beta-lactam antibiotics, the most widely used antibiotic class.
Collapse
Affiliation(s)
- Anouk E Muller
- Department of Medical Microbiology, Haaglanden Medisch Centrum, The Hague, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Benedikt Huttner
- Division of Infectious Diseases, University Hospitals of Geneva, Rue Gabrielle-Gentil-Perret 4, 1205, Geneva, Switzerland
| | - Angela Huttner
- Division of Infectious Diseases, University Hospitals of Geneva, Rue Gabrielle-Gentil-Perret 4, 1205, Geneva, Switzerland.
| |
Collapse
|
22
|
Aminoglycoside Revival: Review of a Historically Important Class of Antimicrobials Undergoing Rejuvenation. EcoSal Plus 2019; 8. [PMID: 30447062 DOI: 10.1128/ecosalplus.esp-0002-2018] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Aminoglycosides are cidal inhibitors of bacterial protein synthesis that have been utilized for the treatment of serious bacterial infections for almost 80 years. There have been approximately 15 members of this class approved worldwide for the treatment of a variety of infections, many serious and life threatening. While aminoglycoside use declined due to the introduction of other antibiotic classes such as cephalosporins, fluoroquinolones, and carbapenems, there has been a resurgence of interest in the class as multidrug-resistant pathogens have spread globally. Furthermore, aminoglycosides are recommended as part of combination therapy for empiric treatment of certain difficult-to-treat infections. The development of semisynthetic aminoglycosides designed to overcome common aminoglycoside resistance mechanisms, and the shift to once-daily dosing, has spurred renewed interest in the class. Plazomicin is the first new aminoglycoside to be approved by the FDA in nearly 40 years, marking the successful start of a new campaign to rejuvenate the class.
Collapse
|
23
|
The role of carbapenem-resistant pathogens in cSSTI and how to manage them. Curr Opin Infect Dis 2019; 32:113-122. [DOI: 10.1097/qco.0000000000000528] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Ben Romdhane H, Ben Fredj N, Chaabane A, Ben Aicha S, Chadly Z, Ben Fadhel N, Boughattas N, Aouam K. Interest of therapeutic drug monitoring of aminoglycosides administered by a monodose regimen. Nephrol Ther 2019; 15:110-114. [PMID: 30660586 DOI: 10.1016/j.nephro.2018.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/24/2018] [Accepted: 08/28/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although the once-daily regimen of aminoglycosides (AG) is considered as predominantly used by many centers, the level of evidence of Therapeutic Drug Monitoring (TDM) of AG in cases of once-daily has not been clearly defined. The objective of this study is to evaluate the impact of TDM in achievement or maintaining target serum concentrations in patients receiving once-daily administration of AG. METHODS We performed a retrospective analysis of data from patients having received a once daily amikacin or gentamicin and underwent routine TDM. A longitudinal follow up was performed. Data were analyzed according to the adhesion or not to recommendations. A logistic regression was performed in order to evaluate the effect of covariates (age, gender, weight, creatinine clearance [CLcr], TDM-based dose adjustment, weighted dose of AG) on the achievement of non-toxic Cmin. RESULTS A total 437 blood samples issued from 324 patients were analyzed. The cut-off value of Clcr associated with a risk of toxic Cmin was≤41.66mL/min (OR: 11.29; 95%CI: 7.21-17.61; P<0.0001). Eighty-eight patients (27.1%) have at least two sampling points. The univariate analysis showed that the age, weight, CLcr and TDM-based dose adjustment were found to be significant factors in the achievement of non-toxic Cmin. In multivariate analysis, only TDM-based dose adjustment remains a significant factor in the achievement of non-toxic Cmin (OR: 6.66; 95%CI: 2.26-19.63; P=0.0006). CONCLUSION Our study demonstrates the usefulness of TDM-based dosing adjustment of AG antibiotics in achieving nontoxic trough concentrations, particularly in critically ill patients, as they are prone to a renal impairment.
Collapse
Affiliation(s)
- Haifa Ben Romdhane
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Nadia Ben Fredj
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia.
| | - Amel Chaabane
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Sana Ben Aicha
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Zohra Chadly
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Najeh Ben Fadhel
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Naceur Boughattas
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Karim Aouam
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| |
Collapse
|
25
|
Vilay AM. Antibiotic Dosing in Chronic Kidney Disease and End-Stage Renal Disease: A Focus on Contemporary Challenges. Adv Chronic Kidney Dis 2019; 26:61-71. [PMID: 30876619 DOI: 10.1053/j.ackd.2018.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/10/2018] [Indexed: 02/08/2023]
Abstract
Infections are an important cause of morbidity and mortality among patients with chronic kidney disease. Therefore, appropriate antibiotic dosing is imperative to achieve positive patient outcomes while minimizing antibiotic dose-related toxicity. Accurately assessing renal function and determining the influence of renal replacement therapy on antibiotic clearance makes drug dosing in this patient population challenging. Furthermore, as technological advances in hemodialysis and peritoneal dialysis occur, research incorporating newer dialysis parameters to guide drug dosing may not be readily available. Currently, there are limited data to guide drug dosing in the setting of automated peritoneal dialysis, short daily hemodialysis, and nocturnal hemodialysis. Antibiotic-dosing recommendations should be carefully evaluated considering the accuracy of the renal function assessment, the similarity of the operating characteristics of the renal replacement therapy studied compared with those being used, and whether the dosing strategy takes advantage of the pharmacodynamic profile of the antibiotic under consideration. After implementing the antibiotic-dosing regimen, therapeutic drug monitoring should occur when possible along with careful monitoring for antibiotic efficacy and safety.
Collapse
|
26
|
Abstract
Ototoxicity diagnosis and management has historically been approached using a variety of methods. However, in recent years a consensus on useful and practical approaches has been developed through clinical guidelines of the American Speech Language Hearing Association, the American Academy of Audiology, and multiple clinical trials published in peer-reviewed literature. Some of the guidelines and approaches are used to detect and monitor ototoxicity, while others are used to grade adverse events. Some of the audiologic measures are primary, while others are adjunct measures and may be tailored to the specific needs of the patient or clinical trial. For some types of monitoring, such as drug-induced tinnitus or dizziness, validated paper survey instruments can be both sensitive and easy for fragile patients. This review addresses the characteristics of some of the most common clinical ototoxins and the most common methods for detecting and monitoring ototoxicity in clinical practice and clinical trials.
Collapse
Affiliation(s)
- Kathleen C M Campbell
- Department of Medical Microbiology, Immunology and Cell Biology, Southern Illinois University School of Medicine, PO Box 9626, Springfield, IL, 62704-9626, USA.
| | - Colleen G Le Prell
- Callier Center for Communication Disorders, University of Texas at Dallas, 1966 Inwood Road, Dallas, TX, 75235, USA
| |
Collapse
|
27
|
Hoo GSR, Liew YX, Kwa ALH. Optimisation of antimicrobial dosing based on pharmacokinetic and pharmacodynamic principles. Indian J Med Microbiol 2018; 35:340-346. [PMID: 29063877 DOI: 10.4103/ijmm.ijmm_17_278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
While suboptimal dosing of antimicrobials has been attributed to poorer clinical outcomes, clinical cure and mortality advantages have been demonstrated when target pharmacokinetic (PK) and pharmacodynamic (PD) indices for various classes of antimicrobials were achieved to maximise antibiotic activity. Dosing optimisation requires a good knowledge of PK/PD principles. This review serves to provide a foundation in PK/PD principles for the commonly prescribed antibiotics (β-lactams, vancomycin, fluoroquinolones and aminoglycosides), as well as dosing considerations in special populations (critically ill and obese patients). PK principles determine whether an appropriate dose of antimicrobial reaches the intended pathogen(s). It involves the fundamental processes of absorption, distribution, metabolism and elimination, and is affected by the antimicrobial's physicochemical properties. Antimicrobial pharmacodynamics define the relationship between the drug concentration and its observed effect on the pathogen. The major indicator of the effect of the antibiotics is the minimum inhibitory concentration. The quantitative relationship between a PK and microbiological parameter is known as a PK/PD index, which describes the relationship between dose administered and the rate and extent of bacterial killing. Improvements in clinical outcomes have been observed when antimicrobial agents are dosed optimally to achieve their respective PK/PD targets. With the rising rates of antimicrobial resistance and a limited drug development pipeline, PK/PD concepts can foster more rational and individualised dosing regimens, improving outcomes while simultaneously limiting the toxicity of antimicrobials.
Collapse
Affiliation(s)
| | - Yi Xin Liew
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Andrea Lay-Hoon Kwa
- Department of Pharmacy, Singapore General Hospital; Emerging Infectious Diseases, Duke-National University of Singapore; Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
| |
Collapse
|
28
|
Šíma M, Hartinger J, Cikánková T, Slanař O. Estimation of once-daily amikacin dose in critically ill adults. J Chemother 2017; 30:37-43. [PMID: 28950787 DOI: 10.1080/1120009x.2017.1376818] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This study aimed at investigating variables affecting amikacin pharmacokinetics in order to propose optimal initial dosing in critically ill adult patients treated with once-daily amikacin regimen. Amikacin pharmacokinetics was calculated based on plasma concentrations using one compartmental analysis. Relationships between pharmacokinetic parameters and demographic/clinical data were explored in linear regression models. Simulated dose and dosing intervals were derived from body size descriptors and estimated creatinine clearances for each patient. Amikacin volume of distribution best correlated with body surface area, while amikacin clearance was best predicted by CKD-EPI creatinine clearance. Our study suggests that dose of 517 mg per m2 of body surface area leads to amikacin levels most approaching target peak concentration. Dosing interval calculated as 228.7 × e-3.08× CKD-EPI creatinine clearance (mL s-1) + 15.84 most closely approximated optimal dosing intervals based on individual pharmacokinetics. The dosing nomogram based on CKD-EPI creatinine clearance was designed.
Collapse
Affiliation(s)
- Martin Šíma
- a First Faculty of Medicine, Department of Pharmacology , Charles University and General University Hospital in Prague , Prague 2 , Czech Republic
| | - Jan Hartinger
- a First Faculty of Medicine, Department of Pharmacology , Charles University and General University Hospital in Prague , Prague 2 , Czech Republic
| | - Tereza Cikánková
- a First Faculty of Medicine, Department of Pharmacology , Charles University and General University Hospital in Prague , Prague 2 , Czech Republic
| | - Ondřej Slanař
- a First Faculty of Medicine, Department of Pharmacology , Charles University and General University Hospital in Prague , Prague 2 , Czech Republic
| |
Collapse
|
29
|
Pitiriga V, Dimitroulia E, Saroglou G, Tsakris A. The challenge of curbing aminoglycoside resistance: can antimicrobial stewardship programs play a critical role? Expert Rev Anti Infect Ther 2017; 15:947-954. [DOI: 10.1080/14787210.2017.1382355] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Vassiliki Pitiriga
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelia Dimitroulia
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Saroglou
- Department of Internal Medicine, Metropolitan General Hospital, Piraeus, Greece
| | - Athanassios Tsakris
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
30
|
Bassetti M, Giacobbe DR, Giamarellou H, Viscoli C, Daikos GL, Dimopoulos G, De Rosa FG, Giamarellos-Bourboulis EJ, Rossolini GM, Righi E, Karaiskos I, Tumbarello M, Nicolau DP, Viale PL, Poulakou G. Management of KPC-producing Klebsiella pneumoniae infections. Clin Microbiol Infect 2017; 24:133-144. [PMID: 28893689 DOI: 10.1016/j.cmi.2017.08.030] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/17/2017] [Accepted: 08/23/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-KP) has become one of the most important contemporary pathogens, especially in endemic areas. AIMS To provide practical suggestion for physicians dealing with the management of KPC-KP infections in critically ill patients, based on expert opinions. SOURCES PubMed search for relevant publications related to the management of KPC-KP infections. CONTENTS A panel of experts developed a list of 12 questions to be addressed. In view of the current lack of high-level evidence, they were asked to provide answers on the bases of their knowledge and experience in the field. The panel identified several key aspects to be addressed when dealing with KPC-KP in critically ill patients (preventing colonization in the patient, preventing infection in the colonized patient and colonization of his or her contacts, reducing mortality in the infected patient by rapidly diagnosing the causative agent and promptly adopting the best therapeutic strategy) and provided related suggestions that were based on the available observational literature and the experience of panel members. IMPLICATIONS Diagnostic technologies could speed up the diagnosis of KPC-KP infections. Combination treatment should be preferred to monotherapy in cases of severe infections. For non-critically ill patients without severe infections, results from randomized clinical trials are needed for ultimately weighing benefits and costs of using combinations rather than monotherapy. Multifaceted infection control interventions are needed to decrease the rates of colonization and cross-transmission of KPC-KP.
Collapse
Affiliation(s)
- M Bassetti
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Udine, Italy.
| | - D R Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa (DISSAL), Genoa, Italy
| | - H Giamarellou
- 6th Department of Internal Medicine, Hygeia General Hospital, 4, Erythrou Stavrou Str & Kifisias, Marousi, Athens, Greece
| | - C Viscoli
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa (DISSAL), Genoa, Italy
| | - G L Daikos
- 1st Department of Propaedeutic Medicine, Laikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - G Dimopoulos
- Department of Critical Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece
| | - F G De Rosa
- Department of Medical Science, University of Turin, Infectious Diseases Amedeo di Savoia Hospital, Turin, Italy
| | - E J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - G M Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - E Righi
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Udine, Italy
| | - I Karaiskos
- 6th Department of Internal Medicine, Hygeia General Hospital, 4, Erythrou Stavrou Str & Kifisias, Marousi, Athens, Greece
| | - M Tumbarello
- Institute of Infectious Diseases Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - D P Nicolau
- Center for Anti-infective Research and Development, Hartford, CT, USA; Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
| | - P L Viale
- Clinic of Infectious Diseases, Department of Internal Medicine, Geriatrics and Nephrologic Diseases, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - G Poulakou
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Udine, Italy
| | | | | |
Collapse
|
31
|
Lee C, Walker SAN, Walker SE, Seto W, Simor A, Jeschke M. A prospective study evaluating tobramycin pharmacokinetics and optimal once daily dosing in burn patients. Burns 2017. [PMID: 28647460 DOI: 10.1016/j.burns.2017.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Once-daily aminoglycoside dosing (ODA) is used in most patient populations to optimize antibacterial activity and reduce toxicity. Unfortunately, burn patients are excluded from ODA due to concerns over altered pharmacokinetics resulting in a shortened half-life and low peak aminoglycoside concentrations. Retrospective studies suggest that ODA may be appropriate if higher milligram/kilogram doses are used. However, no prospective clinical trials in burn patients exist to confirm these findings. OBJECTIVE To determine the adequacy of once daily tobramycin dosed at 10mg/kg in adult burn patients. METHODS This prospective single dose pharmacokinetic clinical trial was conducted at the Ross Tilley Burn Centre. Patients with a total burn surface area (TBSA) of <20% and creatinine clearance ≥50mL/min were eligible. A first-order one compartment model was used to determine the pharmacokinetic profile from 3 or 5 tobramycin levels over a 24h period per patient. Monte Carlo simulation (MCS) was performed to determine the probability of target level attainment. RESULTS The mean percent TBSA, partial, and full thickness burn were 10%, 6%, and 4%, respectively. Nine of the ten patients recruited achieved peak concentrations of ≥20mg/L (mean of 29.4±5.7mg/L) and all patients had a trough level ≤0.5mg/L. The mean half-life, volume of distribution, and clearance were 2.58h, 0.33L/kg, and 7.40L/h, respectively. The MCS determined probability of attaining target peak concentrations with the 10mg/kg dose was 97%, which almost doubled that predicted with the usual 7mg/kg dose. CONCLUSION Burn patients with adequate renal function and <20% TBSA are candidates for ODA. Tobramycin half-life was similar to healthy, non-burn patients. The larger than normal volume of distribution supports the use of the higher empiric dose of 10mg/kg total body or adjusted weight in non-obese and obese patients, respectively, with further dose adjustment based on therapeutic drug monitoring.
Collapse
Affiliation(s)
- Colin Lee
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada
| | - Sandra A N Walker
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada; SHSC, Division of Infectious Diseases, Canada; SHSC, Sunnybrook Research Institute, Canada.
| | - Scott E Walker
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada
| | - Winnie Seto
- University of Toronto, Leslie Dan Faculty of Pharmacy, Canada; Hospital for Sick Children (HSC), Department of Pharmacy, Canada
| | - Andrew Simor
- SHSC, Division of Infectious Diseases, Canada; SHSC, Sunnybrook Research Institute, Canada; University of Toronto, Faculty of Medicine, Canada
| | - Marc Jeschke
- University of Toronto, Faculty of Medicine, Canada; SHSC, Ross Tilley Burn Centre, Canada
| |
Collapse
|
32
|
Acute Kidney Injury in Hematopoietic Stem Cell Transplantation: A Review. Int J Nephrol 2016; 2016:5163789. [PMID: 27885340 PMCID: PMC5112319 DOI: 10.1155/2016/5163789] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 10/04/2016] [Accepted: 10/11/2016] [Indexed: 01/13/2023] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a highly effective treatment strategy for lymphoproliferative disorders and bone marrow failure states including aplastic anemia and thalassemia. However, its use has been limited by the increased treatment related complications, including acute kidney injury (AKI) with an incidence ranging from 20% to 73%. AKI after HSCT has been associated with an increased risk of mortality. The incidence of AKI reported in recipients of myeloablative allogeneic transplant is considerably higher in comparison to other subclasses mainly due to use of cyclosporine and development of graft-versus-host disease (GVHD) in allogeneic groups. Acute GVHD is by itself a major independent risk factor for the development of AKI in HSCT recipients. The other major risk factors are sepsis, nephrotoxic medications (amphotericin B, acyclovir, aminoglycosides, and cyclosporine), hepatic sinusoidal obstruction syndrome (SOS), thrombotic microangiopathy (TMA), marrow infusion toxicity, and tumor lysis syndrome. The mainstay of management of AKI in these patients is avoidance of risk factors contributing to AKI, including use of reduced intensity-conditioning regimen, close monitoring of nephrotoxic medications, and use of alternative antifungals for prophylaxis against infection. Also, early identification and effective management of sepsis, tumor lysis syndrome, marrow infusion toxicity, and hepatic SOS help in reducing the incidence of AKI in HSCT recipients.
Collapse
|
33
|
Michiels JE, Van den Bergh B, Verstraeten N, Michiels J. Molecular mechanisms and clinical implications of bacterial persistence. Drug Resist Updat 2016; 29:76-89. [PMID: 27912845 DOI: 10.1016/j.drup.2016.10.002] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Any bacterial population harbors a small number of phenotypic variants that survive exposure to high concentrations of antibiotic. Importantly, these so-called 'persister cells' compromise successful antibiotic therapy of bacterial infections and are thought to contribute to the development of antibiotic resistance. Intriguingly, drug-tolerant persisters have also been identified as a factor underlying failure of chemotherapy in tumor cell populations. Recent studies have begun to unravel the complex molecular mechanisms underlying persister formation and revolve around stress responses and toxin-antitoxin modules. Additionally, in vitro evolution experiments are revealing insights into the evolutionary and adaptive aspects of this phenotype. Furthermore, ever-improving experimental techniques are stimulating efforts to investigate persisters in their natural, infection-associated, in vivo environment. This review summarizes recent insights into the molecular mechanisms of persister formation, explains how persisters complicate antibiotic treatment of infections, and outlines emerging strategies to combat these tolerant cells.
Collapse
Affiliation(s)
| | | | | | - Jan Michiels
- Centre of Microbial and Plant Genetics, KU Leuven, Leuven, Belgium.
| |
Collapse
|
34
|
Mega WM, Doyle-Eisele M, Cass RT, Kostrub CF, Sherwood RL, Metz MA, Cirz RT. Plazomicin is effective in a non-human primate pneumonic plague model. Bioorg Med Chem 2016; 24:6429-6439. [PMID: 27614915 DOI: 10.1016/j.bmc.2016.08.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/17/2016] [Accepted: 08/26/2016] [Indexed: 11/16/2022]
Abstract
The efficacy of plazomicin for pneumonic plague was evaluated in a non-human primate model. African Green monkeys challenged with a lethal aerosol of Yersinia pestis [median (range) of 98 (15-331) LD50s] received placebo (n=12) or 'humanized' dose regimens (6.25, 12.5 or 25mg/kg every 24h) of plazomicin (n=52) after the onset of fever for a duration of 5 or 10days. All animals treated with placebo died, while 36 plazomicin-treated animals survived through study end. The majority (33/36) were either in the 10-day (high-/mid-/low-dose) or 5-day high-dose groups. The findings suggest an exposure range of plazomicin for treatment of pneumonic/bacteremic Y. pestis infection in humans.
Collapse
Affiliation(s)
- William M Mega
- Lovelace Respiratory Research Institute, 2425 Ridgecrest Dr. SE, Albuquerque, NM 87108, United States
| | - Melanie Doyle-Eisele
- Lovelace Respiratory Research Institute, 2425 Ridgecrest Dr. SE, Albuquerque, NM 87108, United States
| | - Robert T Cass
- Former or Current Employees of Achaogen Inc., 7000 Shoreline Ct., South San Francisco, CA 94080, United States
| | - Corwin F Kostrub
- Former or Current Employees of Achaogen Inc., 7000 Shoreline Ct., South San Francisco, CA 94080, United States
| | - Robert L Sherwood
- Lovelace Respiratory Research Institute, 2425 Ridgecrest Dr. SE, Albuquerque, NM 87108, United States
| | - Matthew A Metz
- Former or Current Employees of Achaogen Inc., 7000 Shoreline Ct., South San Francisco, CA 94080, United States
| | - Ryan T Cirz
- Former or Current Employees of Achaogen Inc., 7000 Shoreline Ct., South San Francisco, CA 94080, United States.
| |
Collapse
|
35
|
Michiels JE, Van den Bergh B, Verstraeten N, Fauvart M, Michiels J. In Vitro Emergence of High Persistence upon Periodic Aminoglycoside Challenge in the ESKAPE Pathogens. Antimicrob Agents Chemother 2016; 60:4630-7. [PMID: 27185802 PMCID: PMC4958152 DOI: 10.1128/aac.00757-16] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/10/2016] [Indexed: 12/31/2022] Open
Abstract
Health care-associated infections present a major threat to modern medical care. Six worrisome nosocomial pathogens-Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.-are collectively referred to as the "ESKAPE bugs." They are notorious for extensive multidrug resistance, yet persistence, or the phenotypic tolerance displayed by a variant subpopulation, remains underappreciated in these pathogens. Importantly, persistence can prevent eradication of antibiotic-sensitive bacterial populations and is thought to act as a catalyst for the development of genetic resistance. Concentration- and time-dependent aminoglycoside killing experiments were used to investigate persistence in the ESKAPE pathogens. Additionally, a recently developed method for the experimental evolution of persistence was employed to investigate adaptation to high-dose, extended-interval aminoglycoside therapy in vitro We show that ESKAPE pathogens exhibit biphasic killing kinetics, indicative of persister formation. In vitro cycling between aminoglycoside killing and persister cell regrowth, evocative of clinical high-dose extended-interval therapy, caused a 37- to 213-fold increase in persistence without the emergence of resistance. Increased persistence also manifested in biofilms and provided cross-tolerance to different clinically important antibiotics. Together, our results highlight a possible drawback of intermittent, high-dose antibiotic therapy and suggest that clinical diagnostics might benefit from taking into account persistence.
Collapse
Affiliation(s)
| | | | | | - Maarten Fauvart
- Centre of Microbial and Plant Genetics, KU Leuven, Leuven, Belgium Smart Systems and Emerging Technologies Unit, Department of Life Science Technologies, imec, Leuven, Belgium
| | - Jan Michiels
- Centre of Microbial and Plant Genetics, KU Leuven, Leuven, Belgium
| |
Collapse
|
36
|
McGarity GJ, Ariano RE. Once-daily aminoglycosides. Am J Health Syst Pharm 2016; 73:529. [DOI: 10.2146/ajhp150756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Robert E. Ariano
- St. Boniface General Hospital Winnipeg, Canada Faculty of Pharmacy and Faculty of Medicine University of Manitoba Winnipeg, Canada
| |
Collapse
|