1
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Jaiswal S, Agarwal A, Singh S, Mohan P. Therapeutic drug monitoring of Amikacin in hospitalized patients: A pilot study. Med J Armed Forces India 2023; 79:S119-S124. [PMID: 38144659 PMCID: PMC10746789 DOI: 10.1016/j.mjafi.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 02/20/2022] [Indexed: 10/18/2022] Open
Abstract
Background Amikacin, an aminoglycoside, is a widely used parenteral antibiotic. Therapeutic drug monitoring (TDM) is recommended for aminoglycosides to avoid toxicity. However, the lack of infrastructure at most places precludes it. This pilot and novel study attempt to estimate the real-world serum levels of Amikacin in hospitalised patients. Methods Thirty admitted patients, given Amikacin injections, were included in the study. In addition, 15 clinical specimens isolated with gram-negative bacteria were tested for minimum inhibitory concentration (MIC) value of Amikacin. Trough and peak serum levels of Amikacin were estimated by high-pressure liquid chromatography (HPLC). Results The average MIC value of Amikacin estimated in our laboratory was 3.92 mcg/mL. Peak and trough serum levels of Amikacin ranged from 12.1 to 66.4 mcg/ml and 1.1 to 20.7 mcg/ml, respectively. More than 83% of our patients achieved peak Amikacin levels of 15 mcg/mL, and 37% had trough levels above 5 mcg/mL. These levels are desirable watersheds as per available literature. Conclusion Trough levels of Amikacin in all cases and a review of dosing according to MIC values are recommended to achieve drug safety and therapeutic efficacy.
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Affiliation(s)
- Sanjay Jaiswal
- Professor, Department of Pharmacology, Armed Forces Medical College, Pune, India
| | - Amit Agarwal
- Senior Advisor (Surgery) & Urologist, Command Hospital (Western Command), Chandimandir Cantt, Panchkula, India
| | - S.P. Singh
- Professor & Head, Department of Microbiology, Armed Forces Medical College, Pune, India
| | - Prafull Mohan
- Professor, Department of Pharmacology, Armed Forces Medical College, Pune, India
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2
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Frost KJ, Hamilton RA, Hughes S, Jamieson C, Rafferty P, Troise O, Jenkins A. Systematic review of high-dose amikacin regimens for the treatment of Gram-negative infections based on EUCAST dosing recommendations. Eur J Hosp Pharm 2023; 30:189-195. [PMID: 36344247 PMCID: PMC10359793 DOI: 10.1136/ejhpharm-2022-003421] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Updated European Committee on Antimicrobial Susceptibility Testing (EUCAST) amikacin breakpoints for Enterobacterales and Pseudomonas aeruginosa included revised dosing recommendations of 25-30 mg/kg to achieve key pharmacokinetic/pharmacodynamic parameters, higher than recommended in the British National Formulary. The objectives of this review were to identify clinical evidence for high-dose amikacin regimens and to determine drug exposures that are related to adverse events and toxicity. METHODS The literature search was conducted in October 2021 and updated in May 2022 using electronic databases for any study reporting adult participants treated with amikacin at doses ≥20 mg/kg/day. Reference lists of included papers were also screened for potential papers. Data were extracted for pharmacokinetic parameters and clinical outcomes, presented in a summary table and consolidated narratively. Meta-analysis was not possible. Each study was assessed for bias before, during and after the intervention using the ROBINS-I tool. RESULTS Nine studies (total 501 participants in 10 reports) were identified and included, eight of which were observational studies. Assessment of bias showed substantial flaws. Dosing regimens ranged from 25 to 30 mg/kg/day. Six studies adjusted the dose in obesity when participants had a body mass index of ≥30 kg/m2. Target peak serum concentrations ranged from 60 mg/L to 80 mg/L and 59.6-81.8% of patients achieved these targets, but there was no information on clinical outcomes. Two studies reported the impact of high-dose amikacin on renal function. No studies reporting auditory or vestibular toxicity were identified. CONCLUSION All included papers were limited by a significant risk of bias, while methodological and reporting heterogeneity made drawing conclusions challenging. Lack of information on the impact on renal function or ototoxicity means high-dose regimens should be used cautiously in older people. There is a need for a consensus guideline for high-dose amikacin to be written. TRIAL REGISTRATION NUMBER PROSPERO (CRD42021250022).
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Affiliation(s)
| | - Ryan A Hamilton
- Pharmacy, De Montfort University, Leicester, UK
- Pharmacy, Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Stephen Hughes
- Pharmacy, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Conor Jamieson
- NHS England and NHS Improvement Midlands, Birmingham, UK
| | - Paul Rafferty
- Pharmacy, Southern Health and Social Care Trust, Portadown, UK
| | - Oliver Troise
- Pharmacy, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Abi Jenkins
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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3
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Vairo C, Villar Vidal M, Maria Hernandez R, Igartua M, Villullas S. Colistin- and amikacin-loaded lipid-based drug delivery systems for resistant gram-negative lung and wound bacterial infections. Int J Pharm 2023; 635:122739. [PMID: 36801363 DOI: 10.1016/j.ijpharm.2023.122739] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
Antimicrobial resistance (AMR) is a global health issue, which needs to be tackled without further delay. The World Health Organization(WHO) has classified three gram-negative bacteria, Pseudomonas aeruginosa, Klebsiella pneumonia and Acinetobacter baumannii, as the principal responsible for AMR, mainly causing difficult to treat nosocomial lung and wound infections. In this regard, the need for colistin and amikacin, the re-emerged antibiotics of choice for resistant gram-negative infections, will be examined as well as their associated toxicity. Thus, current but ineffective clinical strategies designed to prevent toxicity related to colistin and amikacin will be reported, highlighting the importance of lipid-based drug delivery systems (LBDDSs), such as liposomes, solid lipid nanoparticles (SLNs) and nanostructured lipid carriers (NLCs), as efficient delivery strategies for reducing antibiotic toxicity. This review reveals that colistin- and amikacin-NLCs are promising carriers with greater potential than liposomes and SLNs to safely tackle AMR, especially for lung and wound infections.
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Affiliation(s)
- Claudia Vairo
- BioKeralty Research Institute AIE, Albert Einstein, 25-E3, 01510 Miñano, Spain; NanoBioCel Group, Laboratory of Pharmaceutics, University of the Basque Country (UPV/EHU), School of Pharmacy, Paseo de la Universidad 7, 01006 Vitoria-Gasteiz, Spain
| | | | - Rosa Maria Hernandez
- NanoBioCel Group, Laboratory of Pharmaceutics, University of the Basque Country (UPV/EHU), School of Pharmacy, Paseo de la Universidad 7, 01006 Vitoria-Gasteiz, Spain; Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Vitoria-Gasteiz, Spain; Bioaraba Health Research Institute, Vitoria-Gasteiz, Spain
| | - Manoli Igartua
- NanoBioCel Group, Laboratory of Pharmaceutics, University of the Basque Country (UPV/EHU), School of Pharmacy, Paseo de la Universidad 7, 01006 Vitoria-Gasteiz, Spain; Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Vitoria-Gasteiz, Spain; Bioaraba Health Research Institute, Vitoria-Gasteiz, Spain
| | - Silvia Villullas
- BioKeralty Research Institute AIE, Albert Einstein, 25-E3, 01510 Miñano, Spain.
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4
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Aquino M, Tinoco M, Bicker J, Falcão A, Rocha M, Fortuna A. Therapeutic Drug Monitoring of Amikacin in Neutropenic Oncology Patients. Antibiotics (Basel) 2023; 12:antibiotics12020373. [PMID: 36830283 PMCID: PMC9952017 DOI: 10.3390/antibiotics12020373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
Amikacin is the antibiotic of choice for the treatment of Gram-negative infections, namely, those in neutropenic oncology patients. No populational pharmacokinetic studies are currently available reporting amikacin pharmacokinetics in neutropenic oncology patients despite their specific pathophysiological features and treatments. A large-scale retrospective study was herein conducted to specifically investigate the effects that tumor diseases have on the pharmacokinetic parameters of amikacin and identify whether chemotherapy, the lag time between administration of chemotherapy and amikacin, age and renal function contribute to amikacin pharmacokinetics in neutropenic cancer patients. A total of 1180 pharmacokinetic analysis from 629 neutropenic patients were enrolled. The daily dose administered to oncology patients was higher than that administered to non-oncology patients (p < 0.0001). No statistical differences were found in amikacin concentrations, probably because drug clearance was increased in cancer patients (p < 0.0001). Chemotherapy influenced amikacin pharmacokinetics and drug clearance decreased as the lag time enhanced. The elderly group revealed no statistical differences between the doses administered to both the oncology groups, suggesting that the impact of ageing is stronger than chemotherapy. Our research suggests that cancer patients require higher initial doses of amikacin, as well as when chemotherapy is received less than 30 days before amikacin treatment has started.
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Affiliation(s)
- Maria Aquino
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Maria Tinoco
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Joana Bicker
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- CIBIT—Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Amílcar Falcão
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- CIBIT—Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Marília Rocha
- Centro Hospitalar e Universitário de Coimbra (CHUC, EPE), 3000-548 Coimbra, Portugal
| | - Ana Fortuna
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- CIBIT—Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, 3000-548 Coimbra, Portugal
- Correspondence:
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A simple and rapid HPLC-MS/MS method for therapeutic drug monitoring of amikacin in dried matrix spots. J Chromatogr B Analyt Technol Biomed Life Sci 2023; 1220:123592. [PMID: 36890098 DOI: 10.1016/j.jchromb.2023.123592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/22/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023]
Abstract
Individualized treatment of amikacin under the guidance of therapeutic drug monitoring (TDM) is important to reduce the occurrence of toxicity and improve clinical efficacy. In the present study, we developed and validated a simple and high-throughput liquid chromatography-tandem mass spectrometry (LC-MS/MS) method to determine the concentration of amikacin in dried matrix spots (DMS) which the matrix is serum. DMS samples were obtained by spotting volumetric blood onto Whatman 903® cards. Samples were punched into 3 mm diameter discs and extracted with 0.2 % formic acid in water. The HILIC column (2.1 mm × 100 mm, 3.0 µm) under gradient elution was applied, and the analysis time was 3 min per injection. The mass spectrometry transitions were m/z 586.3 → 163.0 for amikacin and m/z 591.4 → 163.1 for D5-amikacin. Full validation was conducted for DMS method, and the method was applied for the amikacin TDM and compared with serum method. The linearity was ranged from 0.5 to 100 mg/L. Both within-run and between-run accuracy and precision of DMS ranged from 91.8 % to 109.6 % and 3.6 % to 14.2 %, respectively. The matrix effect was 100.5 %-106.5 % of DMS method. Amikacin remained stable in DMS for at least 6 days at room temperature, 16 days at 4 °C, 86 days at -20 °C and -70 °C. A good agreement between the DMS method and serum method has been shown in Bland-Altman plots and Passing-Bablok regression. All of the results demonstrated that the DMS methods can be a favorable replacement for amikacin TDM.
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6
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Medellín-Garibay SE, Romano-Aguilar M, Parada A, Suárez D, Romano-Moreno S, Barcia E, Cervero M, García B. Amikacin pharmacokinetics in elderly patients with severe infections. Eur J Pharm Sci 2022; 175:106219. [PMID: 35618200 DOI: 10.1016/j.ejps.2022.106219] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 05/02/2022] [Accepted: 05/22/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim of this study was to characterize the population pharmacokinetics of amikacin in elderly patients by means of nonlinear mixed effects modelling and to propose initial dosing schemes to optimize therapy based on PK/PD targets. METHOD A total of 137 elderly patients from 65 to 94 years receiving intravenous amikacin and routine therapeutic drug monitoring at Hospital Universitario Severo Ochoa were included. Concentration-time data and clinical information were retrospectively collected; initial doses of amikacin ranged from 5.7 to 22.5 mg/kg/day and each patient provided between 1 and 10 samples. RESULTS Amikacin pharmacokinetics were best described by a two-compartment open model; creatinine clearance (CrCL) was related to drug clearance (2.75 L/h/80 mL/min) and it was augmented 28% when non-steroidal anti-inflammatory drugs were concomitantly administered. Body mass index (BMI) influenced the central volume of distribution (17.4 L/25 kg/m2). Relative absolute prediction error was reduced from 33.2% (base model) to 17.9% (final model) when predictive performance was evaluated with a different group of elderly patients. A nomogram for initial amikacin dosage was developed and evaluated based on stochastic simulations considering final model to achieve PK/PD targets (Cmax/MIC>10 and AUC/MIC>75) and to avoid toxic threshold (Cmin<2.5 mg/L). CONCLUSION Initial dosing approach for amikacin was designed for elderly patients based on nonlinear mixed effects modeling to maximize the probability to attain efficacy and safety targets considering individual BMI and CrCL.
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Affiliation(s)
- Susanna E Medellín-Garibay
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, Av. Manuel Nava #6, Zona Universitaria, 78210 SLP, México
| | - Melissa Romano-Aguilar
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, Av. Manuel Nava #6, Zona Universitaria, 78210 SLP, México
| | - Alejandro Parada
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, Av. Manuel Nava #6, Zona Universitaria, 78210 SLP, México
| | - David Suárez
- Hospital Universitario Severo Ochoa, Avenida de Orellana, 28911 Leganés, Spain; Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana, Majadahona, Madrid, Spain
| | - Silvia Romano-Moreno
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, Av. Manuel Nava #6, Zona Universitaria, 78210 SLP, México
| | - Emilia Barcia
- Facultad de Farmacia, Universidad Complutense de Madrid, Plaza de Ramón y Cajal s/n, 28040 Madrid, Spain
| | - Miguel Cervero
- Hospital Universitario Severo Ochoa, Avenida de Orellana, 28911 Leganés, Spain; Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana, Majadahona, Madrid, Spain
| | - Benito García
- Hospital Universitario Severo Ochoa, Avenida de Orellana, 28911 Leganés, Spain; Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana, Majadahona, Madrid, Spain.
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7
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Sadeghi K, Shahrami B, Hosseini Fani F, Hamishehkar H, Mojtahedzadeh M. Detection of subclinical nephrotoxicity induced by aminoglycosides in critically ill elderly patients using trough levels and urinary neutrophil gelatinase-associated lipocalin. Eur J Hosp Pharm 2022; 29:e63-e66. [PMID: 34285109 PMCID: PMC8899642 DOI: 10.1136/ejhpharm-2021-002868] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/15/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Early detection of aminoglycoside-induced acute kidney injury (AKI) is crucial in intensive care unit (ICU) patients, but it is not adequately reflected by serum creatinine (SrCr) levels. This study proposed investigating the relationship between amikacin trough levels and the development of nephrotoxicity using both conventional markers and a new biomarker of renal function in critically ill elderly patients. METHODS Thirty-three critically ill patients aged ≥65 years with normal SrCr who received once-daily amikacin were evaluated. Trough levels of amikacin, creatinine clearance (CrCL) and urinary neutrophil gelatinase-associated lipocalin (uNGAL) were measured during the 10-day study period. The patients were divided into three groups and were compared based on the trough levels on both day 3 and day 7: <3 µg/mL (low trough (LT)), 3-6 µg/mL (moderate trough (MT)) and >6 µg/mL (high trough (HT)). RESULTS In the LT group, neither CrCL nor uNGAL levels significantly changed from baseline (p=0.364 and p=0.562, respectively). In the MT group, the CrCL level altered significantly over time from baseline (p=0.007), but the uNGAL level did not change significantly over the study period (p=0.916). In the HT group, both CrCL and uNGAL levels significantly changed from baseline during the study period (p=0.002 and p=0.046, respectively). CONCLUSIONS In critically ill elderly patients with MT, the mean uNGAL level changed at least 4 days earlier than the SrCr level. Instead, the trough level of amikacin demonstrated a potential value for predicting subclinical AKI for implementing necessary interventions. Amikacin trough levels <3 µg/mL in the once-daily dosing regimen appeared safe, even in geriatric patients. Further studies are needed to confirm this finding.
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Affiliation(s)
- Kourosh Sadeghi
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Bita Shahrami
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Faezeh Hosseini Fani
- Department of Pharmaceutical Care, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Hadi Hamishehkar
- Tabriz University of Medical Sciences, Tabriz, East Azerbaijan, Iran (the Islamic Republic of)
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
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8
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Ghaffari S, Hadi AM, Najmeddin F, Shahrami B, Rouini MR, Najafi A, Mojtahedzadeh M. Evaluation of amikacin dosing schedule in critically ill elderly patients with different stages of renal dysfunction. Eur J Hosp Pharm 2022; 29:e67-e71. [PMID: 34588225 PMCID: PMC8899630 DOI: 10.1136/ejhpharm-2021-002986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/07/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Amikacin is still a widely used aminoglycoside for the treatment of life-threatening infections. The pharmacokinetic parameters of this antibiotic may be altered in critically ill conditions. Moreover, in the elderly population, pathophysiological changes affect these pharmacokinetic variables, making it difficult to predict the appropriate dose and dosing schedule for amikacin. This study aimed to characterise the pharmacokinetics of amikacin in critically ill elderly patients with renal dysfunction, and to evaluate if the available dose adjustment schedules dependent on renal function would be appropriate for empirical dosing. METHODS Critically ill patients aged >60 years with a creatinine clearance of >20 mL/min in need of treatment with amikacin were randomly enrolled. All the patients received approximately 25 mg/kg amikacin. The patients were then divided into three groups according to the stages of their renal dysfunction based on creatinine clearance, and the optimum time to re-dosing was calculated for each group. The pharmacokinetic parameters of the patients were calculated and estimated as population pharmacokinetic data. RESULTS Of 30 patients, only 20% attained the target peak levels of amikacin of >64 mg/L. In addition, the mean volume of distribution was 0.47 L/kg. There was a poor correlation between amikacin clearance and creatinine clearance. The difference in amikacin half-life was not statistically significant among any of the stages of renal impairment. CONCLUSIONS The initial dosing of amikacin in critically ill elderly patients should not be reduced, even in the context of renal impairment. Regarding the dose adjustment in renal impairment, dosing intervals estimation, no decision can be made based on the creatinine clearance and the first dose individualisation method in terms of the two-sample measurements may be considered as an appropriate strategy.
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Affiliation(s)
| | | | - Farhad Najmeddin
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Bita Shahrami
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Atabak Najafi
- Department of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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9
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Therapeutic Drug Monitoring of Antibiotics in the Elderly: A Narrative Review. Ther Drug Monit 2021; 44:75-85. [PMID: 34750337 DOI: 10.1097/ftd.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/08/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Antibiotic dosing adaptation in elderly patients is frequently complicated by age-related changes affecting the processes of drug absorption, distribution, metabolism, and/or elimination. These events eventually result in treatment failure and/or development of drug-related toxicity. Therapeutic drug monitoring (TDM) can prevent suboptimal antibiotic exposure in adult patients regardless of age. However, little data are available concerning the specific role of TDM in the elderly. METHODS This review is based on a PubMed search of the literature published in the English language. The search involved TDM studies of antibiotics in the elderly performed between 1990 and 2021. Additional studies were identified from the reference lists of the retrieved articles. Studies dealing with population pharmacokinetic modeling were not considered. RESULTS Only a few studies, mainly retrospective and with observational design, have specifically dealt with appropriate antibiotic dosing in the elderly based on TDM. Nevertheless, some clinical situations in which the selection of optimal antibiotic dosing in the elderly was successfully guided by TDM were identified. CONCLUSIONS Elderly patients are at an increased risk of bacterial infections and inadequate drug dosing compared to younger patients. Therefore, the availability of TDM services can improve the appropriateness of antibiotic prescriptions in this population.
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Pérez-Blanco JS, Sáez Fernández EM, Calvo MV, Lanao JM, Martín-Suárez A. Amikacin initial dosage in patients with hypoalbuminaemia: an interactive tool based on a population pharmacokinetic approach. J Antimicrob Chemother 2021; 75:2222-2231. [PMID: 32363405 DOI: 10.1093/jac/dkaa158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/25/2020] [Accepted: 03/29/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To characterize amikacin population pharmacokinetics in patients with hypoalbuminaemia and to develop a model-based interactive application for amikacin initial dosage. METHODS A population pharmacokinetic model was developed using a non-linear mixed-effects modelling approach (NONMEM) with amikacin concentration-time data collected from clinical practice (75% hypoalbuminaemic patients). Goodness-of-fit plots, minimum objective function value, prediction-corrected visual predictive check, bootstrapping, precision and bias of parameter estimates were used for model evaluation. An interactive model-based simulation tool was developed in R (Shiny and R Markdown). Cmax/MIC ratio, time above MIC and AUC/MIC were used for optimizing amikacin initial dose recommendation. Probabilities of reaching targets were calculated for the dosage proposed. RESULTS A one-compartment model with first-order linear elimination best described the 873 amikacin plasma concentrations available from 294 subjects (model development and external validation groups). Estimated amikacin population pharmacokinetic parameters were CL (L/h) = 0.525 + 4.78 × (CKD-EPI/98) × (0.77 × vancomycin) and V (L) = 26.3 × (albumin/2.9)-0.51 × [1 + 0.006 × (weight - 70)], where CKD-EPI is calculated with the Chronic Kidney Disease Epidemiology Collaboration equation. AMKdose is a useful interactive model-based application for a priori optimization of amikacin dosage, using individual patient and microbiological information together with predefined pharmacokinetic/pharmacodynamic (PKPD) targets. CONCLUSIONS Serum albumin, total bodyweight, estimated glomerular filtration rate (using the CKD-EPI equation) and co-medication with vancomycin showed a significant impact on amikacin pharmacokinetics. A powerful interactive initial dose-finding tool has been developed and is freely available online. AMKdose could be useful for guiding initial amikacin dose selection before any individual pharmacokinetic information is available.
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Affiliation(s)
- Jonás Samuel Pérez-Blanco
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Eva María Sáez Fernández
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain.,Pharmacy Service, University Hospital of Salamanca, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - M Victoria Calvo
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain.,Pharmacy Service, University Hospital of Salamanca, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - José M Lanao
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Ana Martín-Suárez
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
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11
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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.
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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.)
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12
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Sardella R, Xiroudaki S, Mercolini L, Sabbatini S, Monari C, Perito S, Ianni F, Vecchiarelli A, Giovagnoli S. Optimized Extraction of Amikacin from Murine Whole Blood. Molecules 2021; 26:molecules26030665. [PMID: 33513993 PMCID: PMC7865403 DOI: 10.3390/molecules26030665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/16/2022] Open
Abstract
Amikacin (Amk) analysis and quantitation, for pharmacokinetics studies and other types of investigations, is conventionally performed after extraction from plasma. No report exists so far regarding drug extraction from whole blood (WB). This can represent an issue since quantification in plasma does not account for drug partitioning to the blood cell compartment, significantly underrating the drug fraction reaching the blood circulation. In the present work, the optimization of an extraction method of Amk from murine WB has been described. The extraction yield was measured by RP-HPLC-UV after derivatization with 1-fluoro-2,4-dinitrobenzene, which produced an appreciably stable derivative with a favorable UV/vis absorption. Several extraction conditions were tested: spiked Amk disulfate solution/acetonitrile/WB ratio; presence of organic acids and/or ammonium hydroxide and/or ammonium acetate in the extraction mixture; re-dissolution of the supernatant in water after a drying process under vacuum; treatment of the supernatant with a solution of inorganic salts. The use of 5% (by volume) of ammonium hydroxide in a hydro-organic solution with acetonitrile, allowed the almost quantitative (95%) extraction of the drug from WB.
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Affiliation(s)
- Roccaldo Sardella
- Department of Pharmaceutical Sciences, University of Perugia, Via Fabretti 48, 06123 Perugia, Italy; (R.S.); (S.X.); (S.G.)
- Center for Perinatal and Reproductive Medicine, University of Perugia, Santa Maria della Misericordia University Hospital, 06132 Perugia, Italy
| | - Styliani Xiroudaki
- Department of Pharmaceutical Sciences, University of Perugia, Via Fabretti 48, 06123 Perugia, Italy; (R.S.); (S.X.); (S.G.)
| | - Laura Mercolini
- Department of Pharmacy and Biotechnology (FaBiT), Alma Mater Studiorum, University of Bologna, Via Belmeloro 6, 40126 Bologna, Italy;
| | - Samuele Sabbatini
- Department of Medicine and Surgery, University of Perugia, Piazzale Gambuli 1, 06132 Perugia, Italy; (S.S.); (C.M.); (S.P.); (A.V.)
| | - Claudia Monari
- Department of Medicine and Surgery, University of Perugia, Piazzale Gambuli 1, 06132 Perugia, Italy; (S.S.); (C.M.); (S.P.); (A.V.)
| | - Stefano Perito
- Department of Medicine and Surgery, University of Perugia, Piazzale Gambuli 1, 06132 Perugia, Italy; (S.S.); (C.M.); (S.P.); (A.V.)
| | - Federica Ianni
- Department of Pharmaceutical Sciences, University of Perugia, Via Fabretti 48, 06123 Perugia, Italy; (R.S.); (S.X.); (S.G.)
- Correspondence: ; Tel.: +39-075-585-7919
| | - Anna Vecchiarelli
- Department of Medicine and Surgery, University of Perugia, Piazzale Gambuli 1, 06132 Perugia, Italy; (S.S.); (C.M.); (S.P.); (A.V.)
| | - Stefano Giovagnoli
- Department of Pharmaceutical Sciences, University of Perugia, Via Fabretti 48, 06123 Perugia, Italy; (R.S.); (S.X.); (S.G.)
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13
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The role of single- and multi-walled carbon nanotube in breast cancer treatment. Ther Deliv 2020; 11:653-672. [DOI: 10.4155/tde-2020-0019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Numerous studies have been conducted to design new strategies for breast cancer treatment. Past studies have shown a wide range of carbon-nanomaterials properties, such as single- and multi-walled carbon nanotubes (SWCNTs and MWCNTs) in breast cancer diagnosis and treatment. In this regard, the current study aims to review the role of both SWCNTs and MWCNTs in breast cancer treatment and diagnosis. For reaching this goal, we reviewed the literature by using various searching engines such as Scopus, PubMed, Google Scholar, Web of Science and MEDLINE. This comprehensive review showed that CNTs could dramatically improve breast cancer treatment and could be used as a novel modality to increase diagnostic accuracy; however, no clinical studies have been conducted based on CNTs. In addition, the literature review demonstrates a lack of enough studies to evaluate the side effects of using CNTs.
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14
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Far-reaching advances in the role of carbon nanotubes in cancer therapy. Life Sci 2020; 257:118059. [PMID: 32659368 DOI: 10.1016/j.lfs.2020.118059] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/27/2020] [Accepted: 07/02/2020] [Indexed: 12/16/2022]
Abstract
Cancer includes a group of diseases involving unregulated cell growth with the potential to invade or expand to other parts of the body, resulting in an estimate of 9.6 million deaths worldwide in 2018. Manifold studies have been conducted to design more efficacious techniques for cancer therapy due to the inadequacy of conventional treatments including chemotherapy, surgery, and radiation therapy. With the advances in the biomedical applications of nanotechnology-based systems, nanomaterials have gained increasing attention as promising vehicles for targeted cancer therapy and optimizing treatment outcomes. Owing to their outstanding thermal, electrical, optical and chemical properties, carbon nanotubes (CNTs) have been profoundly studied to explore the various perspectives of their application in cancer treatment. The current study aims to review the role of CNTs whether as a carrier or mediator in cancer treatment for enhancing the efficacy as well as the specificity of therapy and reducing adverse side effects. This comprehensive review indicates that CNTs have the capability to be the next generation nanomaterials to actualize noninvasive targeted eradication of tumors. However, further studies are needed to evaluate the consequences of their biomedical application before the transition into clinical trials, since possible adverse effects of CNTs on biological systems have not been clearly understood.
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15
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Abedi A, Razzaghi MR, Rahavian A, Hazrati E, Aliakbari F, Vahedisoraki V, Allameh F. Is Holmium Laser Enucleation of the Prostate a Good Surgical Alternative in Benign Prostatic Hyperplasia Management? A Review Article. J Lasers Med Sci 2020; 11:197-203. [PMID: 32273963 DOI: 10.34172/jlms.2020.33] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Several therapeutic approaches such as holmium laser enucleation of the prostate (HoLEP) have been introduced to relieve bladder outlet obstruction caused by benign prostatic hyperplasia (BPH). Compared with other techniques including the transurethral resection of the prostate (TURP) and simple open prostatectomy, HoLEP results in a shorter hospital stay and catheterization time and fewer blood loss and transfusions. HoLEP is a size-independent treatment option for BPH with average gland size from 36 g to 170 g. HoLEP is a safe procedure in patients receiving an anticoagulant and has no significant influence on the hemoglobin level. Also, HoLEP is an easy and safe technique in patients with a prior history of prostate surgery and a need for retreatment because of adenoma regrowth. The postoperative erectile dysfunction rate of patients treated with HoLEP is similar to TURP or open prostatectomy and about 77% of these patients experience loss of ejaculation. Patients with transitional zone volume less than 30 mL may suffer from persistent stress urinary incontinence following HoLEP so other surgical techniques like bipolar TURP are a good choice for these patients. In young patients, considering HoLEP with high prostate-specific antigen density and a negative standard template prostate biopsy, multiparametric MRI needs to be considered to exclude prostate cancer.
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Affiliation(s)
- Amirreza Abedi
- Urology Department, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Razzaghi
- Laser Application in Medical Science Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amirhossein Rahavian
- Urology Department, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ebrahim Hazrati
- School of Medicine, 501 Hospital (Imam Reza), AJA University of Medical Sciences, Tehran, Iran
| | - Fereshte Aliakbari
- Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Vahid Vahedisoraki
- Department of Urology, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farzad Allameh
- Laser Application in Medical Science Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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16
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Shahrami B, Najmeddin F, Rouini MR, Najafi A, Sadeghi K, Amini S, Khezrnia SS, Sharifnia HR, Mojtahedzadeh M. Evaluation of Amikacin Pharmacokinetics in Critically Ill Patients with Intra-abdominal Sepsis. Adv Pharm Bull 2019; 10:114-118. [PMID: 32002369 PMCID: PMC6983982 DOI: 10.15171/apb.2020.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/07/2019] [Accepted: 09/18/2019] [Indexed: 12/23/2022] Open
Abstract
Purpose: Although the current widespread use of amikacin is in intra-abdominal sepsis treatment, its pharmacokinetic changes in the present setting are not yet well known. This study was aimed to evaluate the amikacin pharmacokinetic profile in critically ill patients with intraabdominal sepsis compared to pneumosepsis.
Methods: Adult septic patients received amikacin therapy were studied. Patients with intraabdominal sepsis were enrolled in group 1 (n=16), and patients with pneumosepsis were enrolled in group 2 (n=13). The amikacin serum concentrations were evaluated in the first, second, fourth and sixth hours after initiating 30-minute infusion. The pharmacokinetic parameters were calculated for each patient.
Results: There was no significant difference in the volume of distribution between the two groups (0.33±0.08 vs. 0.28±0.10 L/kg, P=0.193). The amikacin clearance was significantly lower in group 1 compared to group 2 (58.5±21.7 vs. 83.9±37.0 mL/min, P=0.029). There was no significant correlation between amikacin clearance and creatinine clearance estimated by Cockcroft-Gault formula in all patients (P=0.206). The half-life was significantly longer in group 1 compared to group 2 (5.3±2.8 vs. 3.4±3.2 hours, P=0.015).
Conclusion: Pathophysiologic changes following intra-abdominal sepsis can affect amikacin pharmacokinetics behavior. The clearance and half-life may change, but the alteration of the volume of distribution is not significantly different in comparison with pneumosepsis. Further studies are required to evaluate the pharmacokinetic variables of amikacin in critically ill patients with intra-abdominal sepsis.
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Affiliation(s)
- Bita Shahrami
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Najmeddin
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Rouini
- Department of Pharmaceutics, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabak Najafi
- Department of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | - Kourosh Sadeghi
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahideh Amini
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Hamid Reza Sharifnia
- Department of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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17
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Liao CH, Lee NY, Tang HJ, Lee SSJ, Lin CF, Lu PL, Wu JJ, Ko WC, Lee WS, Hsueh PR. Antimicrobial activities of ceftazidime-avibactam, ceftolozane-tazobactam, and other agents against Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa isolated from intensive care units in Taiwan: results from the Surveillance of Multicenter Antimicrobial Resistance in Taiwan in 2016. Infect Drug Resist 2019; 12:545-552. [PMID: 30881060 PMCID: PMC6404672 DOI: 10.2147/idr.s193638] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study was to investigate the in vitro antimicrobial susceptibilities of clinically important Gram-negative bacteria from seven intensive care units in Taiwan in 2016. Materials and methods In total, 300 non-duplicate isolates of Escherichia coli (n=100), Klebsiella pneumoniae (n=100), and Pseudomonas aeruginosa (n=100) collected from 300 patients were studied. The minimum inhibitory concentrations (MICs) of these isolates to antimicrobial agents were determined using the broth microdilution method. Carbapenemase-encoding genes (bla KPC, bla NDM, bla IMP, bla VIM, and bla OXA-48-like) were studied for the isolates that were not susceptible to any carbapenems. Sequencing analysis of the mcr genes (mcr-1-5) was conducted for all isolates with colistin MICs ≥4 mg/L. Results Ertapenem non-susceptibility was detected in 3% (n=3) E. coli and 12% (n=12) K. pneumoniae isolates. The susceptibility rates of imipenem, ceftazidime-avibactam (CAZ-AVB), and ceftolozane-tazobactam (CLZ-TAZ) were 99%, 99%, and 88%, respectively, for E. coli, 91%, 100%, and 80%, respectively, for K. pneumoniae, and 66%, 91%, and 93%, respectively, for P. aeruginosa. Carbapenemase-encoding genes were not detected in E. coli, were detected in four (33.3%) K. pneumoniae isolates that were not susceptible to ertapenem (three harboring bla KPC and one harboring bla OXA-48-like), and were not detected in P. aeruginosa isolates that were not susceptible to imipenem. One K. pneumoniae isolate was resistant to colistin (MIC 4 mg/L) and negative for mcr genes. Conclusion CAZ-AVB exhibited excellent activity against carbapenem-resistant Enterobacteriaceae, and CLZ-TAZ exhibited good activity against imipenem-resistant P. aeruginosa.
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Affiliation(s)
- Chun-Hsing Liao
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Yang-Ming University, Taipei, Taiwan
| | - Na-Yao Lee
- Department of Internal Medicine, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan
| | - Hung-Jen Tang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Susan Shin-Jung Lee
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chin-Fu Lin
- Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Po-Liang Lu
- Department of Internal Medicine, Kaohsiung Medical University Hospital, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jiunn-Jong Wu
- Department of Biotechnology and Laboratory Science in Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Chien Ko
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Sen Lee
- Division of Infectious Diseases, Department of Internal Medicine, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan, .,Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan,
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