1
|
Hodiamont CJ, van den Broek AK, de Vroom SL, Prins JM, Mathôt RAA, van Hest RM. Clinical Pharmacokinetics of Gentamicin in Various Patient Populations and Consequences for Optimal Dosing for Gram-Negative Infections: An Updated Review. Clin Pharmacokinet 2022; 61:1075-1094. [PMID: 35754071 PMCID: PMC9349143 DOI: 10.1007/s40262-022-01143-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/04/2022]
Abstract
Gentamicin is an aminoglycoside antibiotic with a small therapeutic window that is currently used primarily as part of short-term empirical combination therapy. Gentamicin dosing schemes still need refinement, especially for subpopulations where pharmacokinetics can differ from pharmacokinetics in the general adult population: obese patients, critically ill patients, paediatric patients, neonates, elderly patients and patients on dialysis. This review summarizes the clinical pharmacokinetics of gentamicin in these patient populations and the consequences for optimal dosing of gentamicin for infections caused by Gram-negative bacteria, highlighting new insights from the last 10 years. In this period, several new population pharmacokinetic studies have focused on these subpopulations, providing insights into the typical values of the most relevant pharmacokinetic parameters, the variability of these parameters and possible explanations for this variability, although unexplained variability often remains high. Both dosing schemes and pharmacokinetic/pharmacodynamic (PK/PD) targets varied widely between these studies. A gentamicin starting dose of 7 mg/kg based on total body weight (or on adjusted body weight in obese patients) appears to be the optimal strategy for increasing the probability of target attainment (PTA) after the first administration for the most commonly used PK/PD targets in adults and children older than 1 month, including critically ill patients. However, evidence that increasing the PTA results in higher efficacy is lacking; no studies were identified that show a correlation between estimated or predicted PK/PD target attainment and clinical success. Although it is unclear if performing therapeutic drug monitoring (TDM) for optimization of the PTA is of clinical value, it is recommended in patients with highly variable pharmacokinetics, including patients from all subpopulations that are critically ill (such as elderly, children and neonates) and patients on intermittent haemodialysis. In addition, TDM for optimization of the dosing interval, targeting a trough concentration of at least < 2 mg/L but preferably < 0.5–1 mg/L, has proven to reduce nephrotoxicity and is therefore recommended in all patients receiving more than one dose of gentamicin. The usefulness of the daily area under the plasma concentration–time curve for predicting nephrotoxicity should be further investigated. Additionally, more research is needed on the optimal PK/PD targets for efficacy in the clinical situations in which gentamicin is currently used, that is, as monotherapy for urinary tract infections or as part of short-term combination therapy.
Collapse
Affiliation(s)
- Caspar J Hodiamont
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Annemieke K van den Broek
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Suzanne L de Vroom
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan M Prins
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| |
Collapse
|
2
|
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
|
3
|
Aminoglycosides in Critically Ill Septic Patients With Acute Kidney Injury Receiving Intermittent Hemodialysis: A Multicenter, Observational Study. Clin Ther 2021; 43:1125-1131. [PMID: 34108081 DOI: 10.1016/j.clinthera.2021.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/19/2021] [Accepted: 04/23/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE Data on aminoglycoside stewardship in critically ill septic patients with acute kidney injury (AKI) needing intermittent hemodialysis (IH) are scarce. The first objective of the study was to evaluate whether aminoglycoside administration occurs before vs after IH in the real-life management of critically ill septic patients with AKI needing IH. The second objective was to assess the delay in achieving a potential reinjection window for a second dose of aminoglycoside, which should be obtained with a postdialysis vs predialysis regimen. METHODS A post hoc observational analysis of a multicenter randomized trial of critically ill patients with AKI needing renal replacement therapy was conducted. Inclusion criteria consisted of any patients receiving IH for AKI during an antimicrobial therapy for a septic episode. FINDINGS Among 206 of 341 septic patients (60%) receiving aminoglycosides, 90 underwent IH (46 with previous continuous renal replacement therapy and 44 without). Amikacin and gentamicin were administered for a mean (SD) of 2.2 (1.5) and 2.5 (2.1) days with mean (SD) doses of 20.6 (6.6) and 5.4 (2.5) mg/kg, respectively. In the 44 patients undergoing exclusive IH, aminoglycosides were administered in a predialysis in 53% of episodes versus 35% in a postdialysis schedule. The first Cmin target was obtained earlier with a predialysis vs postdialysis schedule (33.9 [14.2] hours vs 50.9 [12.2] hours, P = 0.009). IMPLICATIONS Despite being less frequently used than a predialysis schedule, the postdialysis administration of aminoglycosides remains a regular practice in the intensive care unit. A predialysis schedule of administration in IH reduces the interval time to tolerable aminoglycoside redosing.
Collapse
|
4
|
Giroux M, Bouchard N, Henderson A, Lam L, Tran VAS, Projean D, Tessier JF, Lepage L, Gavra P, Ouellet G, Vallée M, Lafrance JP. Pharmacokinetics of Tobramycin Administered at the Beginning of Intermittent Hemodialysis Session (ESRD Study). Can J Kidney Health Dis 2021; 8:2054358120987061. [PMID: 33680482 PMCID: PMC7897820 DOI: 10.1177/2054358120987061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/06/2020] [Indexed: 11/21/2022] Open
Abstract
Background and Objectives: There is a renewed interest in the successful use of aminoglycosides due to increasing resistance in gram-negative infections. Few studies to date have examined the pharmacokinetics (PK) of intradialytic infusions of tobramycin. This study sought to characterize the pharmacokinetic profile of intradialytically administered tobramycin in infected patients receiving chronic intermittent hemodialysis and to determine whether it is possible to achieve favorable PK targets. Design, Setting, Participants, and Measurements: In this prospective pharmacokinetic study, a single dose (5 mg/kg) of tobramycin was administered intradialytically to 11 noncritically ill patients undergoing chronic intermittent hemodialysis. Blood samples were collected at selected time to determine tobramycin serum concentrations. The PK analysis was performed using Phoenix™ NLME. The efficacy exposure outcome for nonsevere gram-negative infections sensitive to tobramycin with a minimum inhibitory concentration ≤1 were maximum concentration (Cmax ≥ 10 mg/L) and area under the curve (AUC24 h > 30 mg⋅h/L). For toxicity, the goal was to identify plasma trough concentrations <2 mg/L. Results: Tobramycin disposition was best described by a one-compartment model using a total clearance composed of the systemic clearance and a transitory hemodialysis clearance. Tobramycin mean (SD) Cmax, trough levels, and AUC24h were 13.1 (1.3) mg/L, 1.32 (0.47) mg/L, and 61 (23) mg⋅h/L, respectively. Monte Carlo simulation run with 1000 virtual patients showed that a 5 mg/kg dose of tobramycin administered intradialytically can outperformed the usual low-dose postdialysis dosing (80% meeting all targets versus <1%, respectively). Conclusions: A single high dose of tobramycin can achieve favorable PK outcome when administered using intradialytic infusions in hemodialysis patients. This practical dosing regimen may represent an effective and safer alternative to the usual dosing in the treatment of nonsevere gram-negative infections.
Collapse
Affiliation(s)
- Marjolaine Giroux
- Université de Montréal, QC, Canada.,Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada
| | - Nicolas Bouchard
- Université de Montréal, QC, Canada.,Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada
| | - Anik Henderson
- Université de Montréal, QC, Canada.,Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada
| | - Lesly Lam
- Université de Montréal, QC, Canada.,Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada
| | - Van Anh Sylvie Tran
- Université de Montréal, QC, Canada.,Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada
| | - Denis Projean
- Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada
| | - Jean-François Tessier
- Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada
| | - Laurence Lepage
- Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada
| | - Paul Gavra
- Université de Montréal, QC, Canada.,Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada
| | - Georges Ouellet
- Université de Montréal, QC, Canada.,Service de Néphrologie, Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada
| | - Michel Vallée
- Université de Montréal, QC, Canada.,Service de Néphrologie, Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada
| | - Jean-Philippe Lafrance
- Service de Néphrologie, Hôpital Maisonneuve-Rosemont, Centre intégré universitaire de santé et de services sociaux de l'Est-de-l'Île-de-Montréal, QC, Canada.,Centre de recherche de l'Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada.,Département de pharmacologie et physiologie, Université de Montréal, QC, Canada
| |
Collapse
|
5
|
Guisado-Gil AB, Herrera-Hidalgo L, Santos-Rubio MD, Gil-Sacaluga L, Molina J, Lepe-Jiménez JA, Camacho-Martínez P, Gil-Navarro MV. Gentamicin as Empirical Treatment in Hemodialysis Patients: Safety, Pharmacokinetics, and Pharmacodynamics. Ther Apher Dial 2019; 23:550-555. [PMID: 30980613 DOI: 10.1111/1744-9987.12810] [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: 12/11/2018] [Revised: 03/08/2019] [Accepted: 04/11/2019] [Indexed: 01/13/2023]
Abstract
The aim of this study was to describe the safety profile and pharmacokinetic/pharmacodynamic parameters in end-stage renal disease patients who received gentamicin as empirical treatment in catheter-related bacteremia when they showed infection signs, regardless of the timing of the next HD. Patients received gentamicin 3 mg/kg before blood culture extraction when they showed infection signs and regardless of the timing of next hemodialysis session. Serum concentrations were collected after the gentamicin administration (peak level) and before the next HD (trough level). Toxicities and adverse drug events were registered. The main pharmacokinetic/pharmacodynamic goal for Gram-negative infections was peak:minimum inhibitory concentration (MIC) ≥10. Sixteen patients were included. Nephrotoxicity was not assessed in this population, and no ototoxicity was found. According to microbial isolation and gentamicin susceptibility, the value of peak:MIC was 5.4 ± 2.0. The administration of gentamicin in these conditions was safe. Estimated pharmacokinetic values were consistent with previous studies and appropriate according to peak:MIC goal for Gram-negative organisms with MIC ≤1 mg/L.
Collapse
Affiliation(s)
- Ana B Guisado-Gil
- Department of Pharmacy, University Hospital Virgen del Rocio, Seville, Spain
| | | | | | - Luis Gil-Sacaluga
- Department of Nephrology, University Hospital Virgen del Rocio, Seville, Spain
| | - José Molina
- Department of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocio, Seville, Spain
| | - José A Lepe-Jiménez
- Department of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocio, Seville, Spain
| | - Pedro Camacho-Martínez
- Department of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocio, Seville, Spain
| | - María V Gil-Navarro
- Department of Pharmacy, University Hospital Virgen del Rocio, Seville, Spain
| |
Collapse
|
6
|
Hui K, Patel K, Kong DC, Kirkpatrick CM. Impact of high-flux haemodialysis on the probability of target attainment for oral amoxicillin/clavulanic acid combination therapy. Int J Antimicrob Agents 2017; 50:110-113. [DOI: 10.1016/j.ijantimicag.2017.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 02/16/2017] [Accepted: 02/22/2017] [Indexed: 10/19/2022]
|
7
|
Jang SM, Cardone KE, Nolin TD, Mason DL, Grabe DW. Determination of vancomycin and gentamicin clearance in an in vitro, closed loop dialysis system. BMC Nephrol 2014; 15:204. [PMID: 25526750 PMCID: PMC4289559 DOI: 10.1186/1471-2369-15-204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 11/13/2014] [Indexed: 11/11/2022] Open
Abstract
Background The purpose of this study was to evaluate the feasibility of utilizing an in-vitro, closed loop hemodialysis system as a method to assess drug clearance. Secondarily, this study tested the influence of variables (blood flow rate, dialysate flow rate, and type of filter) in the hemodialysis procedure on the clearance of vancomycin and gentamicin. Methods An in-vitro, closed loop hemodialysis system was constructed. The vancomycin (30 mg/L) and gentamicin (25 mg/L) were added to a simulated blood system (SBS). Four conditions (C1-C4) were tested by defining the filter (Polyflux 170H or F180) and the blood and dialysate flow rates (BFR and DFR). All hemodialysis sessions were 3 hours in length and each condition was completed in duplicate. Dialysate effluent was collected in a 50 gallon polyethylene drum. Samples were collected (in duplicate) from the SBS and the dialysate effluent at baseline and at the end of the hemodialysis session. Samples were analyzed for vancomycin and gentamicin with an ultrahigh performance liquid chromatography/tandem mass spectrometry method. Results A total of eight 3-hour hemodialysis sessions were conducted. For all tested conditions (C1-C4), vancomycin was undetectable in the SBS at the end of dialysis. However, total vancomycin recovery in the dialysis effluent was 85±18%, suggesting that up to 15% may have adsorbed to the dialysis filter or tubing. Gentamicin clearance from SBS was >98% in all tested conditions. Average gentamicin recovery in the dialysate effluent was 99±15%. Conclusion Both vancomycin and gentamicin were readily removed by high-flux hemodialysis under all conditions studied. No significant differences in drug clearance were observed between conditions used in this in vitro study. The clinical implications of changing these hemodialysis parameters are unknown.
Collapse
Affiliation(s)
| | | | | | | | - Darren W Grabe
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, 106 New Scotland Avenue, Albany 12208, NY, USA.
| |
Collapse
|
8
|
Teigen MMB, Duffull S, Dang L, Johnson DW. Dosing of Gentamicin in Patients With End-Stage Renal Disease Receiving Hemodialysis. J Clin Pharmacol 2013; 46:1259-67. [PMID: 17050791 DOI: 10.1177/0091270006292987] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study was to evaluate dosing schedules of gentamicin in patients with end-stage renal disease and receiving hemodialysis. Forty-six patients were recruited who received gentamicin while on hemodialysis. Each patient provided approximately 4 blood samples at various times before and after dialysis for analysis of plasma gentamicin concentrations. A population pharmacokinetic model was constructed using NONMEM (version 5). The clearance of gentamicin during dialysis was 4.69 L/h and between dialysis was 0.453 L/h. The clearance between dialysis was best described by residual creatinine clearance (as calculated using the Cockcroft and Gault equation), which probably reflects both lean mass and residual clearance mechanisms. Simulation from the final population model showed that predialysis dosing has a higher probability of achieving target maximum concentration (Cmax) concentrations (> 8 mg/L) within acceptable exposure limits (area under the concentration-time curve [AUC] values > 70 and < 120 mg x h/L per 24 hours) than postdialysis dosing.
Collapse
|
9
|
Decker BS, Mohamed AN, Chambers M, Kraus MA, Moe SM, Sowinski KM. Gentamicin pharmacokinetics and pharmacodynamics during short-daily hemodialysis. Am J Nephrol 2012; 36:144-50. [PMID: 22813936 DOI: 10.1159/000339937] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 06/07/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Gentamicin pharmacokinetics have not been described in patients undergoing short-daily hemodialysis (SDHD). The aim of this study is to describe gentamicin pharmacokinetics and dialytic clearance (Cl(dial)) in SDHD patients and simulate gentamicin exposure after six dosing regimens to help guide future dosing. METHODS Six anuric patients undergoing SDHD were enrolled. Patients received intravenous infusion of 2 mg/kg gentamicin on day 1 after the first HD session followed by HD sessions on days 2, 3, and 4. Blood samples for determination of gentamicin concentrations were serially collected. Gentamicin pharmacokinetic parameters and Cl(dial) and interindividual variability terms (IIV) were estimated using NONMEM VII. Influence of patient weight on systemic clearance (Cl(s)) and central volume of distribution (V(c)) and influence of urea removal estimates on Cl(dial) were assessed. The model was used to simulate gentamicin concentrations after six dosing regimens including pre- and postdialysis as well as daily and every-other-day dosing. RESULTS A two-compartment model with first-order elimination from central compartment described gentamicin pharmacokinetics. Population estimates for Cl(s) and Cl(dial) were 7.6 and 134 ml/min, respectively. Patient weight was statistically significantly associated with Cl(s) and V(c). Predialysis every-other-day regimens were as effective (C(max) ≥8 mg/l and AUC(48 h) ≥140 mg·h/l) and less toxic (C(min) <2 mg/l and AUC(48 h) <240 mg·h/l) than postdialysis regimens. CONCLUSIONS Estimated gentamicin Cl(dial) is higher than previous estimates with thrice-weekly regimens. Predialysis every-other-day dosing may be recommended during SDHD.
Collapse
Affiliation(s)
- Brian S Decker
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN, USA
| | | | | | | | | | | |
Collapse
|
10
|
O’Shea S, Duffull S, Johnson DW. Aminoglycosides in Hemodialysis Patients: Is the Current Practice of Post Dialysis Dosing Appropriate? Semin Dial 2009; 22:225-30. [DOI: 10.1111/j.1525-139x.2008.00554.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
11
|
Pharmacokinetics of gentamicin in hemodialysis patients: a comparative study between diabetic and non-diabetic patients. Int Urol Nephrol 2008; 41:663-9. [DOI: 10.1007/s11255-008-9456-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Accepted: 08/06/2008] [Indexed: 10/21/2022]
|
12
|
Sowinski KM, Magner SJ, Lucksiri A, Scott MK, Hamburger RJ, Mueller BA. Influence of hemodialysis on gentamicin pharmacokinetics, removal during hemodialysis, and recommended dosing. Clin J Am Soc Nephrol 2008; 3:355-61. [PMID: 18235142 DOI: 10.2215/cjn.02920707] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Aminoglycoside antibiotics are commonly used in chronic kidney disease stage 5 patients. The purpose of this study was to characterize gentamicin pharmacokinetics, dialytic clearance, and removal by hemodialysis and to develop appropriate dosing strategies. Design Setting, Participants, and Measurements: Eight subjects receiving chronic, thrice-weekly hemodialysis with no measurable residual renal function received gentamicin after a hemodialysis session. Blood samples were collected serially, and serum concentrations of gentamicin were determined. RESULTS Median (range) systemic clearance, volume of distribution at steady state, and terminal elimination half-life were 3.89 ml/min (2.69-4.81 ml/min), 13.5 L (8.7-17.9 L), and 39.4 h (32.0-53.6 h), respectively. Median (range) dialytic clearance, estimated amount removed, and percent maximum rebound were 103.5 ml/min (87.2-132.7 ml/min), 39.6 mg (19.7-43.9 mg), and 38.7% (0%-71.8%), respectively. Gentamicin dialytic clearance was statistically significantly related to creatinine dialytic clearance (r(2) = 0.52, P = 0.04), although this relationship is not likely to be strong enough to serve as a surrogate for gentamicin monitoring. The pharmacokinetic model was used to simulate gentamicin serum concentrations over a one-wk period. CONCLUSIONS In clinical situations where gentamicin is used as the primary therapy in a patient receiving hemodialysis with a CAHP hemodialyzer, conventional doses after each dialysis session are not as efficient at achieving treatment targets as predialysis dosing with larger doses.
Collapse
Affiliation(s)
- Kevin M Sowinski
- Department of Pharmacy Practice, Purdue University, W7555 Building, 1001 West 10th Street, Indianapolis, IN 46202-2879, USA.
| | | | | | | | | | | |
Collapse
|
13
|
Pai AB, Pai MP. Optimizing antimicrobial therapy for gram-positive bloodstream infections in patients on hemodialysis. Adv Chronic Kidney Dis 2006; 13:259-70. [PMID: 16815231 DOI: 10.1053/j.ackd.2006.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Infections with gram-positive organisms are highly prevalent in hemodialysis patients and are a major cause of morbidity and mortality in this population. Antimicrobial therapy is widely used to treat these infections, and prolonged therapy with these agents is often necessary. Extensive use of antimicrobials in hemodialysis patients has resulted in a growing threat of resistance, especially among gram-positive bacteria such as Enterococcus spp and Staphylococcus aureus. Vancomycin-resistant enterococci and S. aureus isolates with reduced susceptibility to vancomycin are increasingly being reported in hemodialysis patients. Additionally, resistance of these organisms to newer agents, such as linezolid and daptomycin, has been documented. Appropriate utilization of antimicrobial therapy to treat these organisms requires an understanding of the pharmacokinetic and pharmacodynamic principles to optimize therapy and avoid adverse drug events. The pharmacokinetic and pharmacodynamic profile of antimicrobial agents can be significantly altered in patients with chronic kidney disease. This review will describe mechanisms of antimicrobial resistance among common gram-positive organisms. The pharmacokinetic and pharmacodynamic principles of cephalosporins, vancomycin, aminoglycosides, linezolid, and daptomycin and applications for use of these agents in the treatment of patients with bloodstream infections on hemodialysis are discussed.
Collapse
Affiliation(s)
- Amy Barton Pai
- Department of Pharmacy and Nephrology, University of New Mexico College of Pharmacy, Albuquerque, NM 87131, USA.
| | | |
Collapse
|
14
|
Ariano RE, Fine A, Sitar DS, Rexrode S, Zelenitsky SA. Adequacy of a Vancomycin Dosing Regimen in Patients Receiving High-Flux Hemodialysis. Am J Kidney Dis 2005; 46:681-7. [PMID: 16183423 DOI: 10.1053/j.ajkd.2005.07.018] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2005] [Accepted: 07/05/2005] [Indexed: 11/11/2022]
Abstract
BACKGROUND Some investigators have recommended the convenient practice of administering vancomycin doses during the last hour of the hemodialysis treatment. Accepting that a greater amount of vancomycin is lost to dialysis with this recent approach, the objective of this study is to determine the pharmacokinetics of vancomycin and assess the adequacy of this dosing regimen in maintaining therapeutic predialysis concentrations. METHODS A sampling of 22 consecutive patients administered intradialytic vancomycin, 1 g, intravenously (IV) and maintenance doses of 500 mg during the last hour of high-flux dialysis sessions was studied. A population-modeling program and Bayesian pharmacokinetic analysis were used to identify all global and unique pharmacokinetic parameters of interest based on measured vancomycin predialysis concentrations. RESULTS For the 22 patients studied, this regimen achieved the targeted predialysis concentration range of 5 to 20 microg/mL for 96% of levels, whereas more narrowly within 5 to 15 microg/mL for 86% of levels. Average amount of vancomycin removed during a standardized 3- to 4-hour dialytic session ranged from 30% +/- 7% to 38% +/- 8%. Average elimination half-life of vancomycin on hemodialysis treatment was 5.4 hours (interquartile range, 5.0 to 5.9 hours). Patients showed an average predialysis plasma concentration of 11 +/- 3 microg/mL for the first 7 days of therapy. CONCLUSION Our results indicate that intradialytic dosing with vancomycin using a 1-g IV load and 500 mg IV with subsequent high-flux dialysis sessions conveniently maintains adequate predialysis plasma concentrations. The lack of drug accumulation with this regimen provides convincing support for a limited blood sampling approach to plasma concentration determinations.
Collapse
Affiliation(s)
- Robert E Ariano
- Department of Pharmacy, St Boniface General Hospital, Canada.
| | | | | | | | | |
Collapse
|