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Kim HK, Jeong TD, Ji M, Kim S, Lee W, Chun S. Automated calculation and reporting of vancomycin area under the concentration-time curve: a simplified single-trough concentration-based equation approach. Antimicrob Agents Chemother 2024:e0069924. [PMID: 39194211 DOI: 10.1128/aac.00699-24] [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: 05/10/2024] [Accepted: 08/07/2024] [Indexed: 08/29/2024] Open
Abstract
Vancomycin, a crucial antibiotic for Gram-positive bacterial infections, requires therapeutic drug monitoring (TDM). Contemporary guidelines advocate for AUC-based monitoring; however, using Bayesian programs for AUC estimation poses challenges. We aimed to develop and evaluate a simplified AUC estimation equation using a steady-state trough concentration (Ctrough) value. Utilizing 1,034 TDM records from 580 general hospitalized patients at a university-affiliated hospital in Ulsan, we created an equation named SSTA that calculates the AUC by applying Ctrough, body weight, and single dose as input variables. External validation included 326 records from 163 patients at a university-affiliated hospital in Seoul (EWUSH) and literature data from 20 patients at a university-affiliated hospital in Bangkok (MUSI). It was compared with other AUC estimation models based on the Ctrough, including a linear regression model (LR), a sophisticated model based on the first-order equation (VancoPK), and a Bayesian model (BSCt). Evaluation metrics, such as median absolute percentage error (MdAPE) and the percentage of observations within ±20% error (P20), were calculated. External validation using the EWUSH data set showed that SSTA, LR, VancoPK, and BSCt had MdAPE values of 6.4, 10.1, 6.6, and 7.5% and P20 values of 87.1, 82.5, 87.7, and 83.4%, respectively. External validation using the MUSI data set showed that SSTA, LR, and VancoPK had MdAPEs of 5.2, 9.4, and 7.2%, and P20 of 95, 90, and 95%, respectively. Owing to its decent AUC prediction performance, simplicity, and convenience for automated calculation and reporting, SSTA could be used as an adjunctive tool for the AUC-based TDM.
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Affiliation(s)
- Hyun-Ki Kim
- Department of Laboratory Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Tae-Dong Jeong
- Department of Laboratory Medicine, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Misuk Ji
- Department of Laboratory Medicine, Veterans Health Service (VHS) Medical Center, Seoul, South Korea
| | - Sollip Kim
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Woochang Lee
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Sail Chun
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
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2
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Aguilo Lafarga I, Pérez Moreno M, Herranz Bayo E, Merchante Andreu M, Huarte Lacunza R. Recommended doses of endovenous vancomycin are insufficient to achieve therapeutic concentrations in paediatric patients. Eur J Hosp Pharm 2024; 31:474-479. [PMID: 37105712 DOI: 10.1136/ejhpharm-2023-003694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
OBJECTIVES Vancomycin therapeutic drug monitoring is challenging, especially in the paediatric population where evidence is scarce. The main objective of this study was to analyse the achievement of therapeutic concentrations of vancomycin in paediatric patients and to evaluate the current monitoring method (trough levels), doses used, and the time required to achieve target concentrations. METHODS Paediatric patients on treatment and monitored with vancomycin from November 2019 to December 2021 were included. Those with only one determination of serum vancomycin concentration were excluded. Demographic variables, analytical and microbiological parameters and toxicity data were collected. Pharmacokinetic parameters were assessed at baseline and during treatment. RESULTS 225 patients (40.9% female; 108 neonates, 49 infants and 68 children or adolescents) were included in the study. The main indications for vancomycin treatment were sepsis (33.9%) and fever of unknown origin (29.3%). Microbiological cultures were positive in 71.1%, mostly with Gram-positive bacteria (60.4%). Therapeutic levels of vancomycin were reached in only 20.1% of the participants in the first determination. After pharmacokinetic monitoring, 81.7% of patients reached therapeutic concentrations, requiring a 23% increase in the initial dose, a 2-day lag time and 1-2 dosage adjustments until the therapeutic concentration was reached. Of the total patients, 13 developed nephrotoxicity, nine neutropenia and one patient developed red man syndrome. CONCLUSIONS In our sample of paediatric patients, the recommended doses of vancomycin were insufficient to achieve therapeutic concentrations. Revision of the recommendations and/or a change in the method of pharmacokinetic monitoring is crucial to optimise treatment in this population.
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Affiliation(s)
| | - María Pérez Moreno
- Pharmacy Service, Hospital Universitario Miguel Servet, Zaragoza, Aragon, Spain
| | - Elena Herranz Bayo
- Pharmacy Service, Hospital Universitario Miguel Servet, Zaragoza, Aragon, Spain
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3
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Tootooni MS, Barreto EF, Wutthisirisart P, Kashani KB, Pasupathy KS. Determining steady-state trough range in vancomycin drug dosing using machine learning. J Crit Care 2024; 82:154784. [PMID: 38503008 PMCID: PMC11139571 DOI: 10.1016/j.jcrc.2024.154784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/05/2024] [Accepted: 03/10/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Vancomycin is a renally eliminated, nephrotoxic, glycopeptide antibiotic with a narrow therapeutic window, widely used in intensive care units (ICU). We aimed to predict the risk of inappropriate vancomycin trough levels and appropriate dosing for each ICU patient. METHODS Observed vancomycin trough levels were categorized into sub-therapeutic, therapeutic, and supra-therapeutic levels to train and compare different classification models. We included adult ICU patients (≥ 18 years) with at least one vancomycin concentration measurement during hospitalization at Mayo Clinic, Rochester, MN, from January 2007 to December 2017. RESULT The final cohort consisted of 5337 vancomycin courses. The XGBoost models outperformed other machine learning models with the AUC-ROC of 0.85 and 0.83, specificity of 53% and 47%, and sensitivity of 94% and 94% for sub- and supra-therapeutic categories, respectively. Kinetic estimated glomerular filtration rate and other creatinine-based measurements, vancomycin regimen (dose and interval), comorbidities, body mass index, age, sex, and blood pressure were among the most important variables in the models. CONCLUSION We developed models to assess the risk of sub- and supra-therapeutic vancomycin trough levels to improve the accuracy of drug dosing in critically ill patients.
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Affiliation(s)
- M Samie Tootooni
- Department of Health Informatics and Data Science, Loyola University Chicago, Maywood, IL, United States of America.
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, United States of America
| | - Phichet Wutthisirisart
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States of America
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Kalyan S Pasupathy
- Department of Biomedical and Health Information Sciences, University of Illinois Chicago, Chicago, IL, United States of America.
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Iida M, Horita Y, Asaoka M, Ohashi K, Noda M, Wachino C, Hirose T, Nomura Y, Hisada Y, Nagamizu M, Kawahara M, Morishita N, Kondo M, Hotta Y, Nakamura A, Furukawa-Hibi Y. Evaluation of target area under the concentration-time curve of vancomycin in an initial dosing design: a retrospective cohort study. J Antimicrob Chemother 2024:dkae249. [PMID: 39028649 DOI: 10.1093/jac/dkae249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 07/03/2024] [Indexed: 07/21/2024] Open
Abstract
OBJECTIVES Area under the concentration-time curve (AUC)-guided dosing of vancomycin was introduced in a clinical setting; however, the target range of non-steady-state AUCs, such as Day 1 AUC and Day 2 AUC, remains controversial. Therefore, we sought to determine pharmacokinetic parameter thresholds and identify independent risk factors associated with acute kidney injury (AKI) to establish a safe initial dosing design for vancomycin administration. METHODS A single-centre, retrospective, cohort study of hospitalized patients treated with vancomycin was conducted to determine the threshold of both non-steady-state AUCs (Day 1 and 2 AUCs) and trough levels at the first blood sampling point (therapeutic drug monitoring, TDM). In addition, independent risk factors associated with AKI were evaluated using univariate and multivariate logistic regression analyses. RESULTS The thresholds for predicting AKI were estimated as 456.6 mg·h/L for AUC0-24h, 554.8 mg·h/L for AUC24-48h, 1080.8 mg·h/L for AUC0-48h and 14.0 μg/mL for measured trough levels, respectively. In a multivariate analysis, Day 2 AUC ≥ 554.8 mg·h/L [adjusted odds ratio (OR), 57.16; 95% confidence interval (CI), 11.95-504.05], piperacillin/tazobactam (adjusted OR, 15.84; 95% CI, 2.73-127.70) and diuretics (adjusted OR, 4.72; 95% CI, 1.13-21.01) were identified as risk factors for AKI. CONCLUSIONS We identified thresholds for both AUCs in the non-steady-state and trough levels at the first TDM. Our results highlight the importance of monitoring not only the AUC but also trough levels during vancomycin treatment to reduce the likelihood of AKI.
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Affiliation(s)
- Moeko Iida
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Yasuhiro Horita
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Division of Infection Prevention and Control, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Minami Asaoka
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Kazuki Ohashi
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Division of Infection Prevention and Control, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Masato Noda
- Department of Pharmacy, Nagoya City University East Medical Center, 1-2-23 Wakamizu, Chikusa-ku, Nagoya, Aichi 464-8547, Japan
| | - Chiharu Wachino
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University East Medical Center, 1-2-23 Wakamizu, Chikusa-ku, Nagoya, Aichi 464-8547, Japan
| | - Toa Hirose
- School of Pharmacy, Aichi Gakuin University, 1-100 Kusumoto-cho, Chikusa-ku, Nagoya, Aichi 464-8650, Japan
| | - Yuki Nomura
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Yoshinori Hisada
- Department of Pharmacy, Nagoya City University West Medical Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya, Aichi 462-8508, Japan
| | - Masaya Nagamizu
- Department of Pharmacy, Nagoya City University West Medical Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya, Aichi 462-8508, Japan
| | - Masami Kawahara
- School of Pharmacy, Aichi Gakuin University, 1-100 Kusumoto-cho, Chikusa-ku, Nagoya, Aichi 464-8650, Japan
| | - Nobuyuki Morishita
- Department of Pharmacy, Nagoya City University West Medical Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya, Aichi 462-8508, Japan
| | - Masahiro Kondo
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University East Medical Center, 1-2-23 Wakamizu, Chikusa-ku, Nagoya, Aichi 464-8547, Japan
| | - Yuji Hotta
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Atsushi Nakamura
- Division of Infection Prevention and Control, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Yoko Furukawa-Hibi
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
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Dyer CJ, De Waele JJ, Roberts JA. Antibiotic dose optimisation in the critically ill: targets, evidence and future strategies. Curr Opin Crit Care 2024:00075198-990000000-00194. [PMID: 39150038 DOI: 10.1097/mcc.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW To highlight the recent evidence for antibiotic pharmacokinetics and pharmacodynamics (PK/PD) in enhancing patient outcomes in sepsis and septic shock. We also summarise the limitations of available data and describe future directions for research to support translation of antibiotic dose optimisation to the clinical setting. RECENT FINDINGS Sepsis and septic shock are associated with poor outcomes and require antibiotic dose optimisation, mostly due to significantly altered pharmacokinetics. Many studies, including some randomised controlled trials have been conducted to measure the clinical outcome effects of antibiotic dose optimisation interventions including use of therapeutic drug monitoring. Current data support antibiotic dose optimisation for the critically ill. Further investigation is required to evolve more timely and robust precision antibiotic dose optimisation approaches, and to clearly quantify whether any clinical and health-economic benefits support expanded use of this treatment intervention. SUMMARY Antibiotic dose optimisation appears to improve outcomes in critically ill patients with sepsis and septic shock, however further research is required to quantify the level of benefit and develop a stronger knowledge of the role of new technologies to facilitate optimised dosing.
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Affiliation(s)
- Christopher J Dyer
- Herston Institute of Infectious Diseases (HeIDI), Metro North Health
- Pharmacy Department
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital (RBWH), Herston, Australia
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital
- Dept of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jason A Roberts
- Herston Institute of Infectious Diseases (HeIDI), Metro North Health
- Pharmacy Department
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital (RBWH), Herston, Australia
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, University of Queensland, Herston, Australia
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Shen X, Li X, Lu J, Zhu J, He Y, Zhang Z, Chen Z, Zhang J, Fan X, Li W. Population pharmacokinetic analysis for dose regimen optimization of vancomycin in Southern Chinese children. CPT Pharmacometrics Syst Pharmacol 2024; 13:1201-1213. [PMID: 38686551 PMCID: PMC11247118 DOI: 10.1002/psp4.13151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/19/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
Changes in physiological factors may result in large pharmacokinetic variability of vancomycin in pediatric patients, thereby leading to either supratherapeutic or subtherapeutic exposure and potentially affecting clinical outcomes. This study set out to characterize the disposition of vancomycin, quantify the exposure target and establish an optimal dosage regimen among the Southern Chinese pediatric population. Routine therapeutic drug monitoring data of 453 patients were available. We performed a retrospective population pharmacokinetic analysis of hospitalized children prescribed intravenous vancomycin using NONMEM® software. A one-compartment PPK model of vancomycin with body weight and renal functions as covariates based on a cutoff of 2 years old children was proposed in this study. Both internal and external validation showing acceptable and robust predictive performance of the model to estimate PK parameters. The value of area under the curve over 24 h to minimum inhibitory concentration ratio (AUC0-24/MIC) ≥ 260 was a significant predictor for therapeutic efficacy. Monte Carlo simulations served as a model-informed precision dosing approach and suggested that different optimal dose regimens in various scenarios should be considered rather than flat dosing. The evaluation of vancomycin exposure-efficacy relationship indicated that lower target level of AUC0-24/MIC may be needed to achieve clinical effectiveness in children, which was used to derive the recommended dosing regimen. Further prospective studies will be needed to corroborate and elucidate these results.
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Affiliation(s)
- Xianhuan Shen
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Xuejuan Li
- Shenzhen Children's HospitalShenzhenChina
| | - Jieluan Lu
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Jiahao Zhu
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Yaodong He
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Zhou Zhang
- Shenzhen Children's HospitalShenzhenChina
| | - Zebin Chen
- Shenzhen Children's HospitalShenzhenChina
| | | | - Xiaomei Fan
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Wenzhou Li
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
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Figueroa SC, Pincheira DS, Navarrete CB, Panés JH, Montecinos SM, Cabrera LF. Usefulness of vancomycin treatment individualization via Bayesian algorithms: a 5-year study in critical patients. Per Med 2024; 21:243-255. [PMID: 38940364 DOI: 10.1080/17410541.2024.2365616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 06/05/2024] [Indexed: 06/29/2024]
Abstract
Aim: Compare two vancomycin dosing strategies in critical patients with methicillin-resistant Staphylococcus aureus (MRSA) infections, considering the heterogeneity of the dosing regimens administered and their implications for toxicity and efficacy. Materials & methods: Longitudinal retrospective observational study in two patient cohorts (standard dosing vs dosing via Bayesian algorithms). Results: The group of Bayesian algorithms received substantially higher and significantly heterogeneous doses, with an absence of nephrotoxicity. The speed of decrease observed in CRP and PCT was greater for the Bayesian strategy (p = 0.045 and 0.0009, respectively). Conclusion: Applying Bayesian algorithms to vancomycin dosage individualization allows for administering much higher doses than with standard regimens, facilitating a quicker clinical response in the absence of nephrotoxicity.
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Affiliation(s)
- Salvador Cabrera Figueroa
- Personalized Therapy Unit, Regional Clinical Dr. Guillermo Grant Benavente Hospital, San Martín 1436, Concepción, Chile
- Pharmacy Department, Pharmacy Faculty, University of Concepcion, Víctor Lamas 1290, Concepción, Chile
| | - Diego Salazar Pincheira
- Personalized Therapy Unit, Regional Clinical Dr. Guillermo Grant Benavente Hospital, San Martín 1436, Concepción, Chile
- Pharmacy Department, Pharmacy Faculty, University of Concepcion, Víctor Lamas 1290, Concepción, Chile
| | - Claudio Bustos Navarrete
- Psychology Department, Faculty of Social Sciences, University of Concepcion, Víctor Lamas 1290, Concepción, Chile
| | - Juan Hermosilla Panés
- Department of Internal Medicine, Medicine Faculty & Science, San Sebastian University, Lientur 1457, Concepción, Chile
| | - Sergio Mella Montecinos
- Infectious Disease Unit, Regional Clinical Dr. Guillermo Grant Benavente Hospital, San Martín 1436, Concepción, Chile
- Department of Medicine, Medicine Faculty, University of Concepcion, Víctor Lamas 1290, Concepción, Chile
| | - Leonila Ferreira Cabrera
- Critical Patients Unit, Regional Clinical Dr. Guillermo Grant Benavente Hospital, San Martín 1436, Concepción, Chile
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Polášková L, Murínová I, Gregorová J, Slanař O, Šíma M. Vancomycin population pharmacokinetics and dosing proposal for the initial treatment in obese adult patients. Front Pharmacol 2024; 15:1364681. [PMID: 38895623 PMCID: PMC11183791 DOI: 10.3389/fphar.2024.1364681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/13/2024] [Indexed: 06/21/2024] Open
Abstract
Aim The aim of this study was to develop a vancomycin population pharmacokinetic model in adult obese patients and propose covariate-based dosing individualization in order to maximize the achievement of the newly recommended PK/PD target, according to a revised consensus guideline from 2020. Methods Therapeutic drug monitoring data from initial vancomycin therapy (first 3 days of treatment) in adult obese (BMI ≥ 30 kg/m2) patients from 2013 to 2022 were analyzed using a non-linear mixed-effects modeling method, and Monte Carlo simulations were then used to find the optimal dosage maximizing the PK/PD target attainment. Results A total of 147 vancomycin serum levels obtained from 138 patients were included in the analysis. Based on the covariate model diagnosis among all tested variables, no reliable predictor of vancomycin volume of distribution (Vd) was identified, while clearance (CL) was positively correlated with eGFR and lean body mass. Creatinine-based eGFR predicted vancomycin CL better than cystatin C-based eGFR. The median (interquartile range) value from conditional modes of individual estimates of Vd, CL, and elimination half-life in our population was 74.0 (70.5-75.4) L, 6.65 (4.95-8.42) L/h, and 7.7 (6.0-10.0) h, respectively. Conclusion We proposed dosing individualization based on the covariate found in order to maximize the achievement of the newly recommended PK/PD target of the AUC/MIC ratio of 400-600. Clinical pharmacy/pharmacology interventions may lead to an improvement in vancomycin dosing with a reflection in PK/PD target attainment.
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Affiliation(s)
- Lucie Polášková
- Department of Clinical Pharmacy, Military University Hospital Prague, Prague, Czechia
| | - Irena Murínová
- Department of Clinical Pharmacy, Military University Hospital Prague, Prague, Czechia
- Department of Applied Pharmacy, Faculty of Pharmacy, Masaryk University, Brno, Czechia
| | - Jana Gregorová
- Department of Clinical Pharmacy, Bulovka University Hospital, Prague, Czechia
| | - Ondřej Slanař
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Martin Šíma
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
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Yang W, Zhang K, Chen Y, Fan Y, Zhang J. Is It Still Beneficial to Monitor the Trough Concentration of Vancomycin? A Quantitative Meta-Analysis of Nephrotoxicity and Efficacy. Antibiotics (Basel) 2024; 13:497. [PMID: 38927164 PMCID: PMC11200798 DOI: 10.3390/antibiotics13060497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
This study conducted a quantitative meta-analysis to investigate the association of vancomycin indicators, particularly area under the curve over 24 h (AUC24) and trough concentrations (Ctrough), and their relationship with both nephrotoxicity and efficacy. Literature research was performed in PubMed and Web of Science on vancomycin nephrotoxicity and efficacy in adult inpatients. Vancomycin Ctrough, AUC24, AUC24/minimum inhibitory concentration (MIC), nephrotoxicity evaluation and treatment outcomes were extracted. Logistic regression and Emax models were conducted, stratified by evaluation criterion for nephrotoxicity and primary outcomes for efficacy. Among 100 publications on nephrotoxicity, 29 focused on AUC24 and 97 on Ctrough, while of 74 publications on efficacy, 27 reported AUC24/MIC and 68 reported Ctrough. The logistic regression analysis indicated a significant association between nephrotoxicity and vancomycin Ctrough (odds ratio = 2.193; 95% CI 1.582-3.442, p < 0.001). The receiver operating characteristic curve had an area of 0.90, with a cut-off point of 14.55 mg/L. Additionally, 92.3% of the groups with a mean AUC24 within 400-600 mg·h/L showed a mean Ctrough of 10-20 mg/L. However, a subtle, non-statistically significant association was observed between the AUC24 and nephrotoxicity, as well as between AUC24/MIC and Ctrough concerning treatment outcomes. Our findings suggest that monitoring vancomycin Ctrough remains a beneficial and valuable approach to proactively identifying patients at risk of nephrotoxicity, particularly when Ctrough exceeds 15 mg/L. Ctrough can serve as a surrogate for AUC24 to some extent. However, no definitive cut-off values were identified for AUC24 concerning nephrotoxicity or for Ctrough and AUC24/MIC regarding efficacy.
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Affiliation(s)
- Wanqiu Yang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Kaiting Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yuancheng Chen
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China;
| | - Yaxin Fan
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
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10
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Cafaro A, Stella M, Mesini A, Castagnola E, Cangemi G, Mattioli F, Baiardi G. Dose optimization and target attainment of vancomycin in children. Clin Biochem 2024; 125:110728. [PMID: 38325652 DOI: 10.1016/j.clinbiochem.2024.110728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/09/2024]
Abstract
Vancomycin is a glycopeptide antibiotic that has been adopted in clinical practice to treat gram-positive infections for more than 70 years. Despite vancomycin's long history of therapeutic use, optimal dose adjustments and pharmacokinetic/pharmacodynamic (PK/PD) target attainment in children are still under debate. Therapeutic drug monitoring (TDM) has been widely integrated into pediatric clinical practice to maximize efficacy and safety of vancomycin treatment. Area under the curve (AUC)-guided TDM has been recently recommended instead of trough-only TDM to ensure PK/PD target attainment of AUC0-24h/minimal inhibitory concentration (MIC) > 400 to 600 and minimize acute kidney injury risk. Bayesian forecasting in pediatric patients allows estimation of population PK to accurately predict individual vancomycin concentrations over time, and consequently total vancomycin exposure. AUC-guided TDM for vancomycin, preferably with Bayesian forecasting, is therefore suggested for all pediatric age groups and special pediatric populations. In this review we aim to analyze the current literature on the pediatric use of vancomycin and summarize the current knowledge on dosing optimization for target attainment in special patient populations.
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Affiliation(s)
- Alessia Cafaro
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina, Gaslini, Genova, Italy
| | - Manuela Stella
- UOC Servizio di Sperimentazioni Cliniche Pediatriche, IRCCS Istituto Giannina Gaslini, Genova, Italy; Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genova, Italy
| | - Alessio Mesini
- Infectious Disease Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Elio Castagnola
- Infectious Disease Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina, Gaslini, Genova, Italy.
| | - Francesca Mattioli
- Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genova, Italy; Clinical Pharmacology Unit, Ente Ospedaliero Ospedali Galliera, Genova, Italy
| | - Giammarco Baiardi
- Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genova, Italy; Clinical Pharmacology Unit, Ente Ospedaliero Ospedali Galliera, Genova, Italy
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11
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Pehlivanli A, Yanik Yalçin T, Yeşiler Fİ, Şahintürk H, Kurt Azap Ö, Zeyneloğlu P, Başgut B. Antimicrobial dosing recommendations during continuous renal replacement therapy: different databases, different doses. J Chemother 2024:1-9. [PMID: 38409748 DOI: 10.1080/1120009x.2024.2321015] [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: 09/12/2023] [Accepted: 02/14/2024] [Indexed: 02/28/2024]
Abstract
Meticulous antimicrobial management is essential among critically ill patients with acute kidney injury, particularly if renal replacement therapy is needed. Many factors affect drug removal in patients undergoing continuous renal replacement therapy CRRT. In this study, we aimed to compare current databases that are frequently used to adjust CRRT dosages of antimicrobial drugs with the gold standard. The dosage recommendations from various databases for antimicrobial drugs eliminated by CRRT were investigated. The book 'Renal Pharmacotherapy: Dosage Adjustment of Medications Eliminated by the Kidneys' was chosen as the gold standard. There were variations in the databases. Micromedex, UpToDate, and Sanford had similar rates to the gold standard of 45%, 35%, and 30%, respectively. The Micromedex database shows the most similar results to the gold standard source. In addition, a consensus was reached as a result of the expert panel meetings established to discuss the different antimicrobial dose recommendations of the databases.
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Affiliation(s)
- Aysel Pehlivanli
- Pharmacology Department, Faculty of Pharmacy, Başkent University
- Clinical Pharmacy and Drug Information Center, Ankara Hospital, Başkent University
| | - Tuğba Yanik Yalçin
- Infectious Diseases and Clinical Microbiology Department, Faculty of Medicine, Başkent University
| | - Fatma İrem Yeşiler
- Anesthesiology and Critical Care Unit Department, Faculty of Medicine, Başkent University
| | - Helin Şahintürk
- Anesthesiology and Critical Care Unit Department, Faculty of Medicine, Başkent University
| | - Özlem Kurt Azap
- Infectious Diseases and Clinical Microbiology Department, Faculty of Medicine, Başkent University
| | - Pınar Zeyneloğlu
- Anesthesiology and Critical Care Unit Department, Faculty of Medicine, Başkent University
| | - Bilgen Başgut
- Pharmacology Department, Faculty of Pharmacy, Başkent University
- Clinical Pharmacy and Drug Information Center, Ankara Hospital, Başkent University
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12
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Saito N, Tsuchiya J, Itoga M, Okamura Y, Tsuyama H, Kimura M, Inoue F, Kimura T, Ozaki H, Tono Y, Minakawa S, Tomita H. Multiple Blood Culture Sampling, Proper Antimicrobial Choice, and Adequate Dose in Definitive Therapy Supported by the Antimicrobial Stewardship Team Could Decrease 30-Day Sepsis Mortality Rates. Infect Drug Resist 2024; 17:207-219. [PMID: 38283110 PMCID: PMC10812706 DOI: 10.2147/idr.s445917] [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: 10/21/2023] [Accepted: 01/11/2024] [Indexed: 01/30/2024] Open
Abstract
Objective This study aimed to identify factors that should be focused on by the antimicrobial stewardship team for treating patients with sepsis, by investigating the mortality of patients with sepsis within 30 days and the mortality-related factors in our hospital over a 10-year period from the perspective of appropriate antimicrobial use. Methods Factors associated with 30-day mortality were investigated using hierarchical multiple logistic regression in 1406 patients with pathogen-identified sepsis in Hirosaki University Hospital. These factors were clinical data, microbiological data, antimicrobials used in empiric and definitive therapies, presence/absence of ineffective use, underdosing as evaluated using Monte Carlo simulation, and practice of de-escalation. Results The ineffective use of antimicrobials in empiric therapy and the underdosing and ineffective use in definitive therapy were significantly associated with 30-day mortality (odds ratio [OR] = 2.70, 3.72, and 3.65, respectively). Multiple blood culture sampling was inversely associated with these inappropriate antimicrobial uses. Every year, the 30-day mortality rate has been decreasing, in line with the increase in multiple blood culture sampling and de-escalation; the inappropriate use of antimicrobials has also decreased. Conclusion Multiple blood culture sampling, proper choice of antimicrobial, and using an adequate dose in definitive therapy could decrease the 30-day mortality rate in patients with sepsis and these factors could be supported by the antimicrobial stewardship team.
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Affiliation(s)
- Norihiro Saito
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Junichiro Tsuchiya
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Masamichi Itoga
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yuji Okamura
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hiromasa Tsuyama
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Masahiko Kimura
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Fumio Inoue
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Toshiyuki Kimura
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hiromi Ozaki
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Yuka Tono
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Satoko Minakawa
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hirofumi Tomita
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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13
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Andrianopoulou A, Sokolowski K, Wenzler E, Bulman ZP, Gemeinhart RA. Assessment of antibiotic release and antibacterial efficacy from pendant glutathione hydrogels using ex vivo porcine skin. J Control Release 2024; 365:936-949. [PMID: 38070603 PMCID: PMC10843833 DOI: 10.1016/j.jconrel.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 11/22/2023] [Accepted: 12/03/2023] [Indexed: 12/22/2023]
Abstract
Acute bacterial skin and skin structure infections (ABSSSIs) confer a substantial burden on the healthcare system. Local antibiotic delivery systems can provide controlled drug release directly to the site of infection to maximize efficacy and minimize systemic toxicity. The purpose of this study was to examine the antibacterial activity of antibiotic-loaded glutathione-conjugated poly(ethylene glycol) hydrogels (GSH-PEG) against ABSSSIs utilizing an ex vivo porcine dermal explant model. Vancomycin- or meropenem-loaded GSH-PEG hydrogels at 3 different dose levels were loaded over 1 h. Drug release was monitored in vitro under submerged conditions, by the Franz cell diffusion method, and ex vivo utilizing a porcine dermis model. Antibacterial activity was assessed ex vivo on porcine dermis explants inoculated with Staphylococcus aureus or Pseudomonas aeruginosa isolates treated with vancomycin- or meropenem-loaded GSH-PEG hydrogels, respectively. Histological assessment of the explants was conducted to evaluate tissue integrity and viability in the context of the experimental conditions. A dose-dependent release was observed from vancomycin and meropenem hydrogels, with in vitro Franz cell diffusion data closely representing ex vivo vancomycin release, but not high dose meropenem release. High dose vancomycin-loaded hydrogels resulted in a >3 log10 clearance against all S. aureus isolates at 48 h. High dose meropenem-loaded hydrogels achieved 6.5, 4, and 2 log10 reductions in CFU/ml against susceptible, intermediate, and resistant P. aeruginosa isolates, respectively. Our findings demonstrate the potential application of GSH-PEG hydrogels for flexible, local antibiotic delivery against bacterial skin infections.
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Affiliation(s)
| | - Karol Sokolowski
- Department of Pharmaceutical Sciences, University of Illinois Chicago, Chicago, IL, USA
| | - Eric Wenzler
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL, USA
| | - Zackery P Bulman
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL, USA
| | - Richard A Gemeinhart
- Department of Pharmaceutical Sciences, University of Illinois Chicago, Chicago, IL, USA; Department of Biomedical Engineering, University of Illinois Chicago, Chicago, IL, USA; Department of Chemical Engineering, University of Illinois Chicago, Chicago, IL, USA; Department of Ophthalmology and Visual Sciences, University of Illinois Chicago, Chicago, IL, USA.
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14
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Viertel K, Feles E, Schulte M, Annecke T, Mattner F. Serum concentration of continuously administered vancomycin influences efficacy and safety in critically ill adults: a systematic review. Int J Antimicrob Agents 2023; 62:107005. [PMID: 37839714 DOI: 10.1016/j.ijantimicag.2023.107005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/12/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES Vancomycin is used to treat Gram-positive infections in critically ill adults. For vancomycin administered by continuous infusion (CI), various target ranges have been used, ranging from 15-20 mg/L to 30-40 mg/L. This systematic literature review was conducted to investigate the impact of steady-state serum concentration (Css) of CI on safety and efficacy of therapy in critically ill adults. METHODS Relevant literature was identified by searching two electronic databases (PubMed, Cochrane Library) and Google Scholar from inception until July 2023, focusing on studies reporting measured Css and treatment outcomes (e.g. mortality, nephrotoxicity) with CI. Due to study heterogeneity, a narrative synthesis of the evidence was performed. RESULTS Twenty-one publications were included with a total of 2949 patients. Mortality was higher (two studies, n = 388 patients) and clinical cure was lower (one study, n = 40 patients) with Css < 15 mg/L measured 24 h after initiation of CI (C24). An adequate loading dose appeared most important for maintaining higher C24. Generally, higher Css was associated with higher rates of acute kidney injury (AKI) (15 studies, n = 2331 patients). It was calculated that Css < 25 mg/L (versus ≥25 mg/L) was preferable for reducing nephrotoxicity (three studies, n = 515 patients). CONCLUSIONS Despite sparse data availability, the target range of 15-25 mg/L in CI may increase clinical cure and reduce mortality and AKI. In future research, vancomycin Css cohorts should be formed to allow evaluation of the impact of Css of CI on treatment outcomes.
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Affiliation(s)
- Katrin Viertel
- Central Pharmacy, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Institute of Hygiene, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Division of Hygiene and Environmental Medicine, Department of Human Medicine, Faculty of Health, Witten/Herdecke University, Witten, Alfred-Herrhausen-Straße 50, 58455 Witten, Germany.
| | - Elisabeth Feles
- Central Pharmacy, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Institute of Hygiene, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Division of Hygiene and Environmental Medicine, Department of Human Medicine, Faculty of Health, Witten/Herdecke University, Witten, Alfred-Herrhausen-Straße 50, 58455 Witten, Germany
| | - Melanie Schulte
- Central Pharmacy, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Thorsten Annecke
- Department of Anaesthesiology and Intensive Care Medicine, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Frauke Mattner
- Institute of Hygiene, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Division of Hygiene and Environmental Medicine, Department of Human Medicine, Faculty of Health, Witten/Herdecke University, Witten, Alfred-Herrhausen-Straße 50, 58455 Witten, Germany
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15
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Greybe L, Eley BS, Tootla HD, Botha AM, Basera W, Nuttall JJ. A descriptive study of vancomycin use at Red Cross War Memorial Children's Hospital, Cape Town. S Afr J Infect Dis 2023; 38:528. [PMID: 38058658 PMCID: PMC10696575 DOI: 10.4102/sajid.v38i1.528] [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: 03/26/2023] [Accepted: 08/21/2023] [Indexed: 12/08/2023] Open
Abstract
Background Antimicrobial stewardship principles guide the clinical use of antimicrobials, including vancomycin, but paediatric vancomycin prescribing practices have not been evaluated in South Africa. Objectives To document the use, prescribing practices and monitoring of intravenous vancomycin and the spectrum of bacteria isolated on microbiological culture in children treated with intravenous vancomycin during a 12-month period at Red Cross War Memorial Children's Hospital (RCWMCH). Method A retrospective audit of intravenous vancomycin use in children admitted to RCWMCH during 2019 was performed. Results All 158 vancomycin prescription episodes for 143 children were included. Overall usage of intravenous vancomycin was 63 days of therapy per 1000 patient days (interquartile range [IQR]: 38-72). The median starting dose was 15 mg/kg per dose (IQR: 14-15) and median daily dose was 45 mg/kg per day (IQR: 43-60). Vancomycin was prescribed as empiric (127/158, 80%) and directed (31/158, 20%) treatment. The median duration of treatment for the directed group (7 days) was longer than the empiric group (4 days) (p = 0.001). Vancomycin serum trough concentrations were performed in 65/98 (66%) episodes where vancomycin treatment exceeded 3 days, with only 16/65 (25%) of these samples obtained before the fourth dose. Prolonged antibiotic treatment of 14 days or more was not associated with Gram-positive bacteria on culture (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 0.17-4.2). Conclusion Dosing errors, prolonged empiric treatment and inappropriate vancomycin monitoring were problems associated with vancomycin prescriptions. Contribution The study identified multiple opportunities for improved vancomycin prescribing and monitoring. Further research and implementation of improved prescribing practices could contribute to the preservation of vancomycin as an effective antibiotic.
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Affiliation(s)
- Leonore Greybe
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Brian S. Eley
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Hafsah D. Tootla
- Department of Medical Microbiology, Faculty of Pathology, National Health Laboratory Service (Red Cross War Memorial Children’s Hospital), Cape Town, South Africa
| | - Anna M.M. Botha
- Department of Pharmacy, Faculty of Health, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - Wisdom Basera
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - James J.C. Nuttall
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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16
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Keil E, Wrenn RH, Deri CR, Slaton CN, Shroba J, Parish A, Erkanli A, Spivey J. Comparison of Open-Access, Trough-Only Online Calculators Versus Trapezoidal Method for Calculation of Vancomycin Area Under the Curve (AUC). Ann Pharmacother 2023; 57:940-947. [PMID: 36453697 DOI: 10.1177/10600280221138867] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Vancomycin area-under-the-curve (AUC) monitoring is associated with reduced nephrotoxicity but may increase cost and workload for personnel compared to trough monitoring. OBJECTIVE The purpose of this study was to compare the accuracy of vancomycin AUC calculated by open-access, online, trough-only calculators to AUCs calculated by the trapezoidal method (TM) using peak and trough concentrations. METHODS This retrospective, multi-center study included adults ≥18 years old with stable renal function who received vancomycin with steady-state peak and trough concentrations. Areas under the curve calculated by TM were compared to AUCs calculated by 3 online calculators using trough-only options for calculation: ClinCalc, VancoVanco, and VancoPK. The primary outcome was actual difference in AUC between TM and the online calculators. Secondary outcomes were percent difference in AUC and clinical alignment in dose adjustments between methods. RESULTS Seventy patients were included for analysis. There was a statistically significant difference in AUC between TM and ClinCalc (median actual difference: -52, P < 0.001) and VancoVanco (median actual difference: 95, P < 0.001), whereas there was no significant difference between TM and VancoPK (median actual difference: -0.8, P = 0.827). Discordant dose adjustments were indicated when comparing ClinCalc, VancoVanco, and VancoPK to TM in 28%, 36%, and 12% of cases, respectively. CONCLUSION The AUC calculator most closely aligned with TM was VancoPK, whereas other included calculators were statistically different. Owing to the cost and complexity of obtaining multiple levels, our findings support using a single steady-state trough using VancoPK as an alternative to TM for calculation of vancomycin AUC.
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Affiliation(s)
- Elizabeth Keil
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
| | - Rebekah H Wrenn
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
| | - Connor R Deri
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
| | - Cara N Slaton
- Department of Pharmacy, Orlando Health, Orlando, FL, USA
| | - Jenny Shroba
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
- Department of Pharmacy, Duke Raleigh Hospital, Durham, NC, USA
| | - Alice Parish
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Alaattin Erkanli
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
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17
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Oda K, Saito H, Jono H. Bayesian prediction-based individualized dosing of anti-methicillin-resistant Staphylococcus aureus treatment: Recent advancements and prospects in therapeutic drug monitoring. Pharmacol Ther 2023; 246:108433. [PMID: 37149156 DOI: 10.1016/j.pharmthera.2023.108433] [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: 12/26/2022] [Revised: 04/19/2023] [Accepted: 05/02/2023] [Indexed: 05/08/2023]
Abstract
As one of the efficient techniques for TDM, the population pharmacokinetic (popPK) model approach for dose individualization has been developed due to the rapidly growing innovative progress in computer technology and has recently been considered as a part of model-informed precision dosing (MIPD). Initial dose individualization and measurement followed by maximum a posteriori (MAP)-Bayesian prediction using a popPK model are the most classical and widely used approach among a class of MIPD strategies. MAP-Bayesian prediction offers the possibility of dose optimization based on measurement even before reaching a pharmacokinetically steady state, such as in an emergency, especially for infectious diseases requiring urgent antimicrobial treatment. As the pharmacokinetic processes in critically ill patients are affected and highly variable due to pathophysiological disturbances, the advantages offered by the popPK model approach make it highly recommended and required for effective and appropriate antimicrobial treatment. In this review, we focus on novel insights and beneficial aspects of the popPK model approach, especially in the treatment of infectious diseases with anti-methicillin-resistant Staphylococcus aureus agents represented by vancomycin, and discuss the recent advancements and prospects in TDM practice.
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Affiliation(s)
- Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, Japan
| | - Hideyuki Saito
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, Japan; Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University; 1-1-1, Honjo, Chuo-ku, Kumamoto, Japan
| | - Hirofumi Jono
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, Japan; Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University; 1-1-1, Honjo, Chuo-ku, Kumamoto, Japan.
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18
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Downes KJ, Zuppa AF, Sharova A, Neely MN. Optimizing Vancomycin Therapy in Critically Ill Children: A Population Pharmacokinetics Study to Inform Vancomycin Area under the Curve Estimation Using Novel Biomarkers. Pharmaceutics 2023; 15:1336. [PMID: 37242578 PMCID: PMC10220925 DOI: 10.3390/pharmaceutics15051336] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Area under the curve (AUC)-directed vancomycin therapy is recommended, but Bayesian AUC estimation in critically ill children is difficult due to inadequate methods for estimating kidney function. We prospectively enrolled 50 critically ill children receiving IV vancomycin for suspected infection and divided them into model training (n = 30) and testing (n = 20) groups. We performed nonparametric population PK modeling in the training group using Pmetrics, evaluating novel urinary and plasma kidney biomarkers as covariates on vancomycin clearance. In this group, a two-compartment model best described the data. During covariate testing, cystatin C-based estimated glomerular filtration rate (eGFR) and urinary neutrophil gelatinase-associated lipocalin (NGAL; full model) improved model likelihood when included as covariates on clearance. We then used multiple-model optimization to define the optimal sampling times to estimate AUC24 for each subject in the model testing group and compared the Bayesian posterior AUC24 to AUC24 calculated using noncompartmental analysis from all measured concentrations for each subject. Our full model provided accurate and precise estimates of vancomycin AUC (bias 2.3%, imprecision 6.2%). However, AUC prediction was similar when using reduced models with only cystatin C-based eGFR (bias 1.8%, imprecision 7.0%) or creatinine-based eGFR (bias -2.4%, imprecision 6.2%) as covariates on clearance. All three model(s) facilitated accurate and precise estimation of vancomycin AUC in critically ill children.
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Affiliation(s)
- Kevin J. Downes
- The Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Athena F. Zuppa
- The Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Anna Sharova
- The Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Clinical Futures, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Michael N. Neely
- Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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19
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Dalton BR. What Is the Best Vancomycin Therapeutic Drug Monitoring Parameter to Assess Efficacy? A Critical Review of Experimental Data and Assessment of the Need for Individual Patient Minimum Inhibitory Concentration Value. Microorganisms 2023; 11:microorganisms11030567. [PMID: 36985141 PMCID: PMC10051726 DOI: 10.3390/microorganisms11030567] [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: 01/19/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/30/2023] Open
Abstract
Therapeutic drug monitoring is recommended for the use of vancomycin, but a recent widely publicized US medical society consensus statement has changed the suggested optimal method(s) of dose adjustment. Specifically, 24 h area under the curve (AUC24)-based monitoring is has been recommended for vancomycin in preference to monitoring of trough concentrations. One reason cited for this change is the claim that AUC24 is a superior correlate to efficacy than trough (Cmin). Evidence from a number of retrospective analyses have been critically reviewed and determined to have weaknesses. This narrative review focuses on the experimental studies performed in vivo in animal models of infection and in vitro to determine the extent to which these data may provide a compelling distinction between pharmacokinetic/pharmacodynamics (PKPD) parameters that may translate to clinical use in therapeutic drug monitoring. Animal in vivo studies have been presented at conferences, but no original peer reviewed studies could be found that compare various PKPD parameters. These conference proceeding findings were supportive but unconvincing, even though they were favorably presented subsequently in review articles and clinical practice guidelines. In vitro data are somewhat conflicting, but the range of concentrations may play a role in the discrepancies found. It has been suggested that MIC may be assumed to have a value of 1 mg/L; however, it can be demonstrated that this assumption may lead to considerable discrepancy from results with an actual MIC value. The AUC24 parameter has been weighed against the percentage of time above the MIC (%T > MIC) as a comparative PKPD parameter, yet this may be an inappropriate comparison for vancomycin since all clinically useful dosing provides 100% T > MIC. Regardless, there is a distinction between clinical TDM parameters and PKPD parameters, so, in practice, the change to AUC24:MIC based on animal experiments and in vitro evidence for vancomycin may be premature.
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Affiliation(s)
- Bruce R Dalton
- Pharmacy Department, Alberta Health Services, Calgary, AB T2N 2T9, Canada
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He P, Li X, Guo X, Bian X, Wang R, Wang Y, Huang S, Qi M, Liu Y, Feng M. Pharmacokinetics and Pharmacodynamics of a Novel Vancomycin Derivative LYSC98 in a Murine Thigh Infection Model Against Staphylococcus aureus. Infect Drug Resist 2023; 16:1019-1028. [PMID: 36845018 PMCID: PMC9946004 DOI: 10.2147/idr.s399150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
Introduction LYSC98 is a novel vancomycin derivative used for gram-positive bacterial infections. Here we compared the antibacterial activity of LYSC98 with vancomycin and linezolid in vitro and in vivo. Besides, we also reported the pharmacokinetic/pharmacodynamic (PK/PD) index and efficacy-target values of LYSC98. Methods The MIC values of LYSC98 were identified through broth microdilution method. A mice sepsis model was established to investigate the protective effect of LYSC98 in vivo. Single-dose pharmacokinetics of LYSC98 was studied in thigh-infected mice and liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was used to determine LYSC98 concentration in plasma. Dose fractionation studies were performed to evaluate different PK/PD indices. Two methicillin-resistant Staphylococcus aureus (MRSA) clinical strains were used in the dose ranging studies to determine the efficacy-target values. Results LYSC98 showed a universal antibacterial effect in Staphylococcus aureus with a MIC range of 2-4 µg/mL. In vivo, LYSC98 demonstrated distinctive mortality protection in mice sepsis model with an ED50 value of 0.41-1.86 mg/kg. The pharmacokinetics results displayed maximum plasma concentration (Cmax) 11,466.67-48,866.67 ng/mL, area under the concentration-time curve from 0 to 24 h (AUC0-24) 14,788.42-91,885.93 ng/mL·h, and elimination half-life (T1/2) 1.70-2.64 h, respectively. Cmax/MIC (R 2 0.8941) was proved to be the most suitable PK/PD index for LYSC98 to predict its antibacterial efficacy. The magnitude of LYSC98 Cmax/MIC associated with net stasis, 1, 2, 3 and 4 - log 10 kill were 5.78, 8.17, 11.14, 15.85 and 30.58, respectively. Conclusion Our study demonstrates that LYSC98 is more effective than vancomycin either in killing vancomycin-resistant Staphylococcus aureus (VRSA) in vitro or treating S. aureus infections in vivo, making it a novel and promising antibiotic. The PK/PD analysis will also contribute to the LYSC98 Phase I dose design.
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Affiliation(s)
- Peng He
- Department of Biological Medicines & Shanghai Engineering Research Center of Immunotherapeutics, Fudan University School of Pharmacy, Shanghai, 201203, People’s Republic of China
| | - Xin Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Xiaohan Guo
- Department of Biological Medicines & Shanghai Engineering Research Center of Immunotherapeutics, Fudan University School of Pharmacy, Shanghai, 201203, People’s Republic of China
| | - Xingchen Bian
- Department of Biological Medicines & Shanghai Engineering Research Center of Immunotherapeutics, Fudan University School of Pharmacy, Shanghai, 201203, People’s Republic of China
| | - Rui Wang
- Department of Biological Medicines & Shanghai Engineering Research Center of Immunotherapeutics, Fudan University School of Pharmacy, Shanghai, 201203, People’s Republic of China
| | - Yue Wang
- Department of Biological Medicines & Shanghai Engineering Research Center of Immunotherapeutics, Fudan University School of Pharmacy, Shanghai, 201203, People’s Republic of China
| | - Sijing Huang
- Department of Biological Medicines & Shanghai Engineering Research Center of Immunotherapeutics, Fudan University School of Pharmacy, Shanghai, 201203, People’s Republic of China
| | - Mengya Qi
- Department of Biological Medicines & Shanghai Engineering Research Center of Immunotherapeutics, Fudan University School of Pharmacy, Shanghai, 201203, People’s Republic of China
| | - Yuanxia Liu
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Department of Pathology, Shanghai, People’s Republic of China,Yuanxia Liu, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Department of Pathology, Shanghai, People’s Republic of China, Email
| | - Meiqing Feng
- Department of Biological Medicines & Shanghai Engineering Research Center of Immunotherapeutics, Fudan University School of Pharmacy, Shanghai, 201203, People’s Republic of China,Correspondence: Meiqing Feng, Department of Biological Medicines & Shanghai Engineering Research Center of Immunotherapeutics, Fudan University School of Pharmacy, Shanghai, 201203, People’s Republic of China, Tel +86 21 51980035, Email
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Impact of Pharmacist-Led Multidisciplinary Team to Attain Targeted Vancomycin Area under the Curved Monitoring in a Tertiary Care Center in Thailand. Antibiotics (Basel) 2023; 12:antibiotics12020374. [PMID: 36830284 PMCID: PMC9952732 DOI: 10.3390/antibiotics12020374] [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: 01/05/2023] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
Vancomycin Area Under the Curve (AUC) monitoring has been recommended to ensure successful clinical outcomes and minimize the risk of nephrotoxicity, rather than traditional trough concentration. However, vancomycin AUC monitoring by a pharmacist-led multidisciplinary team (PMT) has not been well established in Southeast Asia. This study was conducted at Thammasat University Hospital. Adult patients aged ≥ 18 years who were admitted and received intravenous vancomycin ≥48 h were included. The pre-PMT period (April 2020-September 2020) was defined as a period using traditional trough concentration, while the post-PMT period (October 2020-March 2021) was defined as a period using PMT to monitor vancomycin AUC. The primary outcome was the rate of achievement of the therapeutic target of an AUC/MIC ratio of 400-600. There was a significantly higher rate of achievement of therapeutic target vancomycin AUC during post-PMT period (66.7% vs. 34.3%, p < 0.001). Furthermore, there was a significant improvement in the clinical cure rate (92.4% vs. 69.5%, p < 0.001) and reduction in 30-day ID mortality (2.9% vs. 12.4%, p = 0.017) during the post-PMT period. Our study demonstrates that PMT was effective to help attain a targeted vancomycin AUC, improve the clinical cure rate, and reduce 30-day ID mortality. This intervention should be encouraged to be implemented in Southeast Asia.
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Chanapiwat P, Paiboonvong T, Rattanaumpawan P, Montakantikul P. Comparison of the mathematical equation and trapezoidal approach for 24 h area under the plasma concentration-time curve calculation in patients who received intravenous vancomycin in an acute care setting. Pharmacol Res Perspect 2023; 11:e01046. [PMID: 36588162 PMCID: PMC9806189 DOI: 10.1002/prp2.1046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 12/11/2022] [Indexed: 01/03/2023] Open
Abstract
The current recommendation for therapeutic monitoring of vancomycin has recently suggested AUC-guided dosing in patients with serious methicillin-resistant Staphylococcus aureus infections. The study objective was to evaluate mathematical equations and trapezoidal methods for calculating the 24 h area under the plasma vancomycin concentration-time curve (AUC24). The analysis of plasma vancomycin concentrations was performed in 20 adult patients treated with intravenous vancomycin. For each patient, AUC24 was estimated using two methods including, equation and trapezoidal calculation. The AUC24 from two methods was analyzed for correlation. The correlation between the equation and trapezoidal methods was strong. The coefficient of determination (R2 ) values was greater than .99. The two plasma vancomycin concentrations to achieve the highest correlation were concentration at 2.5 to 3 h after starting the infusion and concentration at 1 h before the next dose. Moreover, the AUC24 calculation from trapezoidal and equation methods showed that 19 out of 20 patients (95%) had AUC24 of more than 400 mg·h/L, and more than 50% in this group had AUC24/MIC greater than 600. Of those patients with AUC-trapezoidal >600, 15.38% of patients had trough under 15 mg/L, 15.38% of patients had trough in the range 15 to 20 mg/L and 69.23% of patients had trough more than 20 mg/L. The results of AUC-equation were similar to those of the AUC-trapezoidal method. Our study confirmed that the AUC monitoring is more appropriate than the trough vancomycin concentration. Given these considerations, the AUC-equation method is better and more practical to use in part of a point-of-care treatment, especially in the part of the Bayesian program is not available. The best sampling time point of the peak concentration was 0.5-1 h after 2-h infusion.
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Affiliation(s)
- Pimonrat Chanapiwat
- Department of Pharmacy, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Taniya Paiboonvong
- Department of Pharmacy Practice, College of PharmacyRangsit UniversityPathum ThaniThailand
| | - Pinyo Rattanaumpawan
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Preecha Montakantikul
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of PharmacyMahidol UniversityBangkokThailand
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Area-Under-Curve-Guided Versus Trough-Guided Monitoring of Vancomycin and Its Impact on Nephrotoxicity: A Systematic Review and Meta-Analysis. Ther Drug Monit 2023:00007691-990000000-00088. [PMID: 36728329 DOI: 10.1097/ftd.0000000000001075] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/07/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Conventionally, vancomycin trough levels have been used for therapeutic drug monitoring (TDM). Owing to the increasing evidence of trough levels being poor surrogates of area under the curve (AUC) and the advent of advanced pharmacokinetics software, a paradigm shift has been made toward AUC-guided dosing. This study aims to evaluate the impact of AUC-guided versus trough-guided TDM on vancomycin-associated nephrotoxicity. METHODS A systematic review was conducted using PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Google scholar, and Cochrane library databases; articles published from January 01, 2009, to January 01, 2021, were retrieved and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Studies that evaluated trough-guided or AUC-guided vancomycin TDM and vancomycin-associated nephrotoxicity were included. Random-effects models were used to compare the differences in nephrotoxicity. RESULTS Of the 1191 retrieved studies, 57 were included. Most studies included adults and older adults (n = 47, 82.45%). The pooled prevalence of nephrotoxicity was lower in AUC-guided TDM [6.2%; 95% confidence interval (CI): 2.9%-9.5%] than in trough-guided TDM (17.0%; 95% CI: 14.7%-19.2%). Compared with the trough-guided approach, the AUC-guided approach had a lower risk of nephrotoxicity (odds ratio: 0.53; 95% CI: 0.32-0.89). The risk of nephrotoxicity was unaffected by the AUC derivation method. AUC thresholds correlated with nephrotoxicity only within the first 96 hours of therapy. CONCLUSIONS The AUC-guided approach had a lower risk of nephrotoxicity, supporting the updated American Society of Health-System Pharmacists guidelines. Further studies are needed to evaluate the optimal AUC-derivation methods and clinical utility of repeated measurements of the AUC and trough levels of vancomycin.
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Alsultan A, Al Munjem MF, Atiq KM, Aljehani ZK, Al Muqati H, Almohaizeie A, Ballal DA, Refaei TM, Al Jeraisy M, Assiri A, Abouelkheir M. Population pharmacokinetics of vancomycin in very low birth weight neonates. Front Pediatr 2023; 11:1093171. [PMID: 37063687 PMCID: PMC10101232 DOI: 10.3389/fped.2023.1093171] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/03/2023] [Indexed: 04/18/2023] Open
Abstract
Introduction Vancomycin dosing in very low birth weight (VLBW) neonates is challenging. Compared with the general neonatal population, VLBW neonates are less likely to achieve the vancomycin therapeutic targets. Current dosing recommendations are based on studies of the general neonatal population, as only a very limited number of studies have evaluated vancomycin pharmacokinetics in VLBW neonates. The main aim of this study was to develop a vancomycin population pharmacokinetic model to optimize vancomycin dosing in VLBW neonates. Methods This multicenter study was conducted at six major hospitals in Saudi Arabia. The study included VLBW neonates who received vancomycin and had at least one vancomycin serum trough concentration measurement at a steady state. We developed a pharmacokinetic model and performed Monte Carlo simulations to develop an optimized dosing regimen for VLBW infants. We evaluated two different targets: AUC0-24 of 400-600 or 400-800 µg. h/mL. We also estimated the probability of trough concentrations >15 and 20 µg/mL. Results In total, we included 236 neonates, 162 in the training dataset, and 74 in the validation dataset. A one-compartment model was used, and the distribution volume was significantly associated only with weight, whereas clearance was significantly associated with weight, postmenstrual age (PMA), and serum creatinine (Scr). Discussion We developed dosing regimens for VLBW neonates, considering the probability of achieving vancomycin therapeutic targets, as well as different toxicity thresholds. The dosing regimens were classified according to PMA and Scr. These dosing regimens can be used to optimize the initial dose of vancomycin in VLBW neonates.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Correspondence: Abdullah Alsultan Manal Abouelkheir
| | | | | | - Zekra Kamel Aljehani
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Hessa Al Muqati
- Pharmacy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdullah Almohaizeie
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Dalia Ahmed Ballal
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Tahani Makki Refaei
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Majed Al Jeraisy
- Pharmacy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulmohsen Assiri
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Manal Abouelkheir
- Department of Clinical Pharmacy, Faculty of Pharmacy, Misr International University, Cairo, Egypt
- Correspondence: Abdullah Alsultan Manal Abouelkheir
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Maluangnon C, Tongyoo S, Permpikul C. Continuous Vancomycin Infusion versus Intermittent Infusion in Critically Ill Patients. Infect Drug Resist 2022; 15:7751-7760. [PMID: 36597455 PMCID: PMC9805718 DOI: 10.2147/idr.s395385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/10/2022] [Indexed: 12/29/2022] Open
Abstract
Background Vancomycin is the best-choice medication for methicillin-resistant staphylococcal and enterococcal infections, which are major problems in intensive care units (ICUs). Intermittent infusion is standard for vancomycin, although delayed therapeutic target achievement and supra- and subtherapeutic levels are concerns. A recently proposed alternative with superior therapeutic target achievement is continuous infusion. Objective To compare the benefits of continuous (CVI) and intermittent (IVI) vancomycin infusion. Methods This quasi-experimental study used propensity score-matched historical controls and adult patients in medical and surgical ICUs for whom vancomycin was indicated. The experimental group received CVI for ≥ 48 hours. Data on patients receiving IVI between January 2018 and October 2020 were reviewed. Capability to achieve serum vancomycin therapeutic targets (48 and 96 hours), episodes of supra- and subtherapeutic levels, treatment success, mortality, and incidence of acute kidney injury (AKI) were analyzed before and after one-to-two propensity score matching. Results The CVI group had 31 patients, while the unmatched IVI group had 125. More CVI patients achieved the therapeutic target within 48 hours (54.8% vs 25.6%; P=0.002). CVI patients had a higher median number of supratherapeutic episodes (2 vs 1; P=0.007) but a lower median for subtherapeutic episodes (0 vs 1; P=0.003). Other outcomes demonstrated no differences. After propensity score matching, target achievement within 48 hours (54.8% vs 22.6%; P=0.002) and fewer subtherapeutic episodes (0 vs 1; P=0.014) remained significant. Conclusion CVI's rapid therapeutic target achievement and fewer subtherapeutic episodes make it superior to IVI. No differences in treatment success, mortality, or AKI are evident.
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Affiliation(s)
- Chailat Maluangnon
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Surat Tongyoo
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chairat Permpikul
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand,Correspondence: Chairat Permpikul, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2, Wanglang Road, Siriraj, Bangkoknoi, Bangkok, 10700, Thailand, Tel +66 81 408 1676, Fax +66 2 419 8597, Email
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When and How to Use MIC in Clinical Practice? Antibiotics (Basel) 2022; 11:antibiotics11121748. [PMID: 36551405 PMCID: PMC9774413 DOI: 10.3390/antibiotics11121748] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
Bacterial resistance to antibiotics continues to be a global public health problem. The choice of the most effective antibiotic and the use of an adapted dose in the initial phase of the infection are essential to limit the emergence of resistance. This will depend on (i) the isolated bacteria and its resistance profile, (ii) the pharmacodynamic (PD) profile of the antibiotic used and its level of toxicity, (iii) the site of infection, and (iv) the pharmacokinetic (PK) profile of the patient. In order to take account of both parameters to optimize the administered treatment, a minimal inhibitory concentration (MIC) determination associated with therapeutic drug monitoring (TDM) and their combined interpretation are required. The objective of this narrative review is thus to suggest microbiological, pharmacological, and/or clinical situations for which this approach could be useful. Regarding the microbiological aspect, such as the detection of antibiotic resistance and its level, the preservation of broad-spectrum β-lactams is particularly discussed. PK-PD profiles are relevant for difficult-to-reach infections and specific populations such as intensive care patients, cystic fibrosis patients, obese, or elderly patients. Finally, MIC and TDM are tools available to clinicians, who should not hesitate to use them to manage their patients.
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RUIZ J, GARCÍA-ROBLES A, MARQUÉS MR, COMPANY MJ, SOLANA A, POVEDA JL. Influence of pharmacokinetic/pharmacodynamic ratio on vancomycin treatment response in pediatric patients with Staphylococcus aureus bacteremia. Minerva Pediatr (Torino) 2022; 74:525-529. [DOI: 10.23736/s2724-5276.18.04978-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Sequence Type 5 (ST5) as a Possible Predictor of Bacterial Persistence in Adult Patients with Methicillin-Resistant Staphylococcus aureus Pneumonia Treated with Vancomycin. Microbiol Spectr 2022; 10:e0134822. [PMID: 36094217 PMCID: PMC9603198 DOI: 10.1128/spectrum.01348-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Vancomycin remains the mainstay of treatment for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. This study assessed risk factors for vancomycin failure in 63 patients with MRSA pneumonia through detailed clinical, microbiological, pharmacokinetic/pharmacodynamic, and genetic analyses of prospective multicenter studies conducted from February 2012 to July 2018. Therapeutic drug monitoring was performed during vancomycin treatment, and the 24-h area under the curve (AUC0-24) was calculated. All baseline strains were collected for MIC determination, heterogeneous vancomycin-intermediate S. aureus (hVISA) screening, and biofilm determination. Whole-genome sequencing was performed on the isolates to analyze their molecular typing and virulence and adhesion genes. Clinical signs and symptoms improved in 44 patients (44/63, 69.8%), with vancomycin daily dose (P = 0.045), peak concentration (P = 0.020), and sdrC (P = 0.047) being significant factors. Isolates were eradicated in 51 patients (51/63, 81.0%), with vancomycin daily dose (P = 0.009), cardiovascular disease (P = 0.043), sequence type 5 (ST5; P = 0.017), tst (P = 0.050), and sec gene (P = 0.044) associated with bacteriological failure. Although the AUC0-24/MIC was higher in the groups with bacterial eradication, the difference was not statistically significant (P = 0.108). Multivariate analysis showed that no variables were associated with clinical efficacy; ST5 was a risk factor for bacterial persistence (adjusted odds ratio, 4.449; 95% confidence interval, 1.103 to 17.943; P = 0.036). ST5 strains had higher frequencies of the hVISA phenotype, biofilm expression, and presence of some adhesion and virulence genes such as fnbB, tst, and sec than non-ST5 strains. Our study suggests that ST5 is a possible predictor of bacterial persistence in MRSA pneumonia treated with vancomycin. IMPORTANCE Few studies have simultaneously examined the influence of clinical characteristics of patients with pneumonia, the vancomycin pharmacokinetic/pharmacodynamic (PK/PD) index, and the phenotypic and genetic characteristics of methicillin-resistant Staphylococcus aureus (MRSA) strains. We assessed risk factors for vancomycin failure in patients with MRSA pneumonia by analyzing these influences in a prospective multicenter study. Sequence type 5 (ST5) was a possible predictor of bacterial persistence in adult patients with MRSA pneumonia (adjusted odds ratio, 4.449). We found that this may be related to ST5 strains having higher levels of vancomycin heterogeneous resistance, biofilms, and the presence of adhesion and virulence genes such as fnbB, tst, and sec.
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Association between Vancomycin Pharmacokinetic Parameters and Clinical and Microbiological Efficacy in a Cohort of Neonatal Patients. Antimicrob Agents Chemother 2022; 66:e0110922. [PMID: 36222533 PMCID: PMC9664865 DOI: 10.1128/aac.01109-22] [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: 11/20/2022] Open
Abstract
Vancomycin pharmacokinetic/pharmacodynamic (PK/PD) targets have not been validated in the neonatal population as no specifically designed studies are available. The main goal of this study was to analyze the therapeutic vancomycin regimen, the 24-h area under the curve (AUC24), and the trough plasma concentration (Ct) obtained that achieved clinical and microbiological effectiveness in a cohort of neonates. This was an observational, prospective, single-center study covering a period of 2 years. Eligible patients were neonates and young infants who were undergoing treatment with intravenous vancomycin for ≥72 h with ≥1 Ct available. The primary outcome was the association of Ct and AUC24 with clinical and microbiological efficacy at the beginning (early clinical evolution [ECE]) and the end (late clinical evolution [LCE]) of treatment with vancomycin. A total of 43 patients were included, 88.4% of whom were cured. In ECE, the cutoff points of the receiver operating characteristic (ROC) curve were 238 mg · h/L (sensitivity of 61% and specificity of 88%) for AUC24 and 6.8 μg/mL (sensitivity of 61% and specificity of 92%) for Ct. In LCE, the Ct value was 11 μg/mL, with a sensitivity of 80% and a specificity of 92%. In this analysis, AUC24 was not considered a good predictor. Logistic regression showed that a vancomycin Ct of ≤6.8 μg/mL was associated with an unfavorable ECE (P = 0.001), being 18 times more likely to progress poorly compared to those with higher levels. AUC24 and Ct are good predictors of ECE in this population. Concentrations close to 7 μg/mL and an AUC24 of around 240 mg · h/L 48 h after antibiotic initiation seem to be sufficient to achieve clinical cure in most cases.
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Luxton TN, King N, Wälti C, Jeuken LJC, Sandoe JAT. A Systematic Review of the Effect of Therapeutic Drug Monitoring on Patient Health Outcomes during Treatment with Carbapenems. Antibiotics (Basel) 2022; 11:antibiotics11101311. [PMID: 36289971 PMCID: PMC9598625 DOI: 10.3390/antibiotics11101311] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Adjusting dosing regimens based on measurements of carbapenem levels may improve carbapenem exposure in patients. This systematic review aims to describe the effect carbapenem therapeutic drug monitoring (TDM) has on health outcomes, including the emergence of antimicrobial resistance (AMR). Four databases were searched for studies that reported health outcomes following adjustment to dosing regimens, according to measurements of carbapenem concentration. Bias in the studies was assessed with risk of bias analysis tools. Study characteristics and outcomes were tabulated and a narrative synthesis was performed. In total, 2 randomised controlled trials (RCTs), 17 non-randomised studies, and 19 clinical case studies were included. Significant variation in TDM practice was seen; consequently, a meta-analysis was unsuitable. Few studies assessed impacts on AMR. No significant improvement on health outcomes and no detrimental effects of carbapenem TDM were observed. Five cohort studies showed significant associations between achieving target concentrations and clinical success, including suppression of resistance. Studies in this review showed no obvious improvement in clinical outcomes when TDM is implemented. Optimisation and standardisation of carbapenem TDM practice are needed to improve intervention success and enable study synthesis. Further suitably powered studies of standardised TDM are required to assess the impact of TMD on clinical outcomes and AMR.
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Affiliation(s)
- Timothy N. Luxton
- School of Biomedical Sciences, University of Leeds, Leeds LS2 9JT, UK
- Correspondence:
| | - Natalie King
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Christoph Wälti
- School of Electronic and Electrical Engineering, University of Leeds, Leeds LS2 9JT, UK
| | - Lars J. C. Jeuken
- Leiden Institute of Chemistry, Leiden University, P.O. Box 9502, 2300 RA Leiden, The Netherlands
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Vancomycin Area under the Concentration-Time Curve Estimation Using Bayesian Modeling versus First-Order Pharmacokinetic Equations: A Quasi-Experimental Study. Antibiotics (Basel) 2022; 11:antibiotics11091239. [PMID: 36140021 PMCID: PMC9495010 DOI: 10.3390/antibiotics11091239] [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: 08/29/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/22/2022] Open
Abstract
Aim: To evaluate the efficiency of Bayesian modeling software and first-order pharmacokinetic (PK) equations to calculate vancomycin area under the concentration-time curve (AUC) estimations. Methods: Unblinded, crossover, quasi-experimental study at a tertiary care hospital for patients receiving intravenous vancomycin. Vancomycin AUC monitoring was compared using Bayesian modeling software or first-order PK equations. The primary endpoint was the time taken to estimate the AUC and determine regimen adjustments. Secondary endpoints included the percentage of vancomycin concentrations usable for AUC calculations and acute kidney injury (AKI). Results: Of the 124 patients screened, 34 patients had usable vancomycin concentrations that led to 44 AUC estimations. Without electronic health record (EHR) integration, the time from assessment to intervention in the Bayesian modeling platform was a median of 9.3 min (quartiles Q1–Q3 7.8–12.4) compared to 6.8 min (Q1–Q3 4.8–8.0) in the PK equations group (p = 0.004). With simulated Bayesian software integration into the EHR, however, the median time was 3.8 min (Q1–Q3 2.3–6.9, p = 0.019). Vancomycin concentrations were usable in 88.2% in the Bayesian group compared to 48.3% in the PK equation group and there were no cases of AKI. Conclusion: Without EHR integration, Bayesian software was more time-consuming to assess vancomycin dosing than PK equations. With simulated integration, however, Bayesian software was more time efficient. In addition, vancomycin concentrations were more likely to be usable for calculations in the Bayesian group.
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32
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Simeoli R, Cairoli S, Decembrino N, Campi F, Dionisi Vici C, Corona A, Goffredo BM. Use of Antibiotics in Preterm Newborns. Antibiotics (Basel) 2022; 11:antibiotics11091142. [PMID: 36139921 PMCID: PMC9495226 DOI: 10.3390/antibiotics11091142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022] Open
Abstract
Due to complex maturational and physiological changes that characterize neonates and affect their response to pharmacological treatments, neonatal pharmacology is different from children and adults and deserves particular attention. Although preterms are usually considered part of the neonatal population, they have physiological and pharmacological hallmarks different from full-terms and, therefore, need specific considerations. Antibiotics are widely used among preterms. In fact, during their stay in neonatal intensive care units (NICUs), invasive procedures, including central catheters for parental nutrition and ventilators for respiratory support, are often sources of microbes and require antimicrobial treatments. Unfortunately, the majority of drugs administered to neonates are off-label due to the lack of clinical studies conducted on this special population. In fact, physiological and ethical concerns represent a huge limit in performing pharmacokinetic (PK) studies on these subjects, since they limit the number and volume of blood sampling. Therapeutic drug monitoring (TDM) is a useful tool that allows dose adjustments aiming to fit plasma concentrations within the therapeutic range and to reach specific drug target attainment. In this review of the last ten years’ literature, we performed Pubmed research aiming to summarize the PK aspects for the most used antibiotics in preterms.
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Affiliation(s)
- Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Nunzia Decembrino
- Neonatal Intensive Care Unit, University Hospital “Policlinico-San Marco” Catania, Integrated Department for Maternal and Child’s Health Protection, 95100 Catania, Italy
| | - Francesca Campi
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Carlo Dionisi Vici
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
- Correspondence: ; Tel.: +39-0668592174; Fax: + 39-0668593009
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Erstad BL, Matthias KR, Nix DE. Vancomycin dosing in patients with obesity. Am J Health Syst Pharm 2022; 79:2058-2069. [PMID: 35981345 DOI: 10.1093/ajhp/zxac229] [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: 11/13/2022] Open
Abstract
In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Kathryn R Matthias
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - David E Nix
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
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Li Y, Lu W, Zheng X, Zhang L, Dong W, Zhao X, Zhao Z, Zhang Z. Norvancomycin for the Treatment of Central Nervous System MRSA Infections: a Randomized Controlled Trial: Norvancomycin for the Treatment of Central nervous system MRSA infections. Eur J Pharm Sci 2022; 177:106266. [PMID: 35868433 DOI: 10.1016/j.ejps.2022.106266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/20/2022]
Abstract
Combined intravenous and intrathecal administration of norvancomycin (NVCM) is routinely employed in treating methicillin-resistant Staphylococcus aureus (MRSA) ventriculitis in patients following craniotomy. However, the optimal dosing regimen, the pharmacokinetics (PK) of NVCM in cerebrospinal fluid (CSF), and the clinical outcome are yet to be elucidated. Herein, a single-center randomized controlled trial was conducted in the Neurosurgery Department of the Second Hospital of Hebei Medical University (Shijiazhuang, China). Patients with MRSA ventriculitis after craniotomy were randomly assigned to two groups. The control group received 800 mg NVCM intravenously every 12 h, and the experimental group received 800 mg NVCM intravenously every 12 h and 16 mg NVCM intrathecal administration every 24 h. The primary outcome was the length of therapy, while the secondary outcomes included the area under the concentration-time curve in 0-24 h/minimum inhibitory concentration ratio (AUC0-24h/MIC) of NVCM in CSF. A total of 29 patients (14 in the experimental group and 15 in the control group) were included in this study. Of these, 24 constituted the final analysis population, with 12 in each group. The average length of therapy in the experimental group was markedly shorter than that of the control group (11.2 ± 2.6 days vs. 16.6 ± 5.2 days, P = 0.005), while the AUC0-24h/MIC in the experimental group was significantly higher than that in the control group (2306.57 ± 928.58 vs. 46.83 ± 27.48, P <0.001) with no increase in adverse reactions. Combined intravenous and intrathecal administration can shorten the treatment time of intracranial infection without higher adverse reaction risks in our research. Further studies with larger sample size are warranted to verify its safety and efficacy.
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Affiliation(s)
- Yaqian Li
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wenpeng Lu
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xuecheng Zheng
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Linhui Zhang
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Weichong Dong
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoxiao Zhao
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zongmao Zhao
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
| | - Zhiqing Zhang
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
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External Validation of a Vancomycin Population Pharmacokinetic Model and Developing a New Dosage Regimen in Neonates. Eur J Drug Metab Pharmacokinet 2022; 47:687-697. [PMID: 35804218 DOI: 10.1007/s13318-022-00781-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE Vancomycin is the drug of choice in the treatment of MRSA infections. In a published vancomycin population pharmacokinetic study on neonates in Singapore healthcare institutions, it was found that vancomycin clearance was predicted by weight, postmenstrual age, and serum creatinine. The aim of this study was to externally validate the vancomycin population pharmacokinetic model to develop a new dosage regimen in neonates, and to compare this regimen with the existing institutional and NeoFax® dosage regimens. METHODS A retrospective chart review of neonates who received vancomycin therapy and therapeutic drug monitoring was conducted. The median prediction error percentage was calculated to assess bias, while the median absolute prediction error percentage and the root mean squared error percentage were calculated to assess precision. The new dosage regimen was developed using Monte Carlo simulation. RESULTS A total of 20 neonates were included in the external validation dataset. Eighteen of them were premature, with a median gestational age of 27.7 (25.9-31.5) weeks and postmenstrual age of 30.5 (27.3-34.3) weeks at the point of vancomycin initiation. No apparent systematic bias was found in the predictions of the model. The external validation performed in the current study found the model to be generally unbiased. Our new vancomycin dosage regimen was able to achieve target trough concentrations and area under the curve (AUC24) at a greater proportion as compared to existing institutional and NeoFax® dosage regimens. CONCLUSION The pharmacokinetic model built in the previous study can be used to conduct reliable population simulations of our Asian neonatal population in Singapore. The new dosage regimen was able to achieve target trough concentrations and AUC24 better than existing institutional and NeoFax® dosage regimens.
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Schatz LM, Zoller M, Scharf C, Liebchen U. [Therapeutic drug monitoring and pharmacokinetic models as a strategy for rational antibiotic therapy in intensive care patients]. DIE ANAESTHESIOLOGIE 2022; 71:495-501. [PMID: 35925054 DOI: 10.1007/s00101-022-01150-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Antibiotic dosing in intensive care patients is complex due to pharmacokinetic (PK) alterations. The aim of this article is to illustrate the role of therapeutic drug monitoring (TDM) and PK models to individualize antibiotic dosing. MATERIAL AND METHODS Guidelines and recommendations are discussed in the context of clinical practice and the prerequisites for routine TDM of different antibiotics are presented. In addition, the benefits and limitations of TDM are discussed. The advantages and disadvantages of TDM and PK models are described and the resulting future options are presented. RESULTS In the clinical routine, the peak or trough concentrations of antibiotics in blood are measured depending on the antibiotic class. Prerequisites for a purposeful TDM are a coordinated blood sampling and a prompt reporting of findings. As target ranges are not uniformly defined following rules, dosage adjustments are difficult. The PK models offer a valid possibility to individualize the antibiotic therapy of intensive care patients. Areas of application are the calculation of the loading dose and the combination with TDM for treatment control. For whom and how often TDM is necessary and how it can best be combined with PK models or even replace them should be investigated in the future, in addition to evaluation of the optimal target area. CONCLUSION The routine use of TDM for antibiotics in intensive care patients is only effective under the abovementioned conditions. By combination with PK models the treatment could be optimized in the future.
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Affiliation(s)
- Lea Marie Schatz
- Institut für Klinische Pharmazie, Westfälische Wilhelms-Universität Münster, Münster, Deutschland
| | - Michael Zoller
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland
| | - Christina Scharf
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland
| | - Uwe Liebchen
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland.
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Dilworth TJ, Schulz LT, Micek ST, Kollef MH, Rose WE. β-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: Weighing the Challenges and Opportunities to Assess Clinical Value. Crit Care Explor 2022; 4:e0726. [PMID: 35815181 PMCID: PMC9259115 DOI: 10.1097/cce.0000000000000726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE β-lactams are the cornerstone of empiric and targeted antibiotic therapy for critically ill patients. Recently, there have been calls to use β-lactam therapeutic drug monitoring (TDM) within 24-48 hours after the initiation of therapy in critically ill patients. In this article, we review the dynamic physiology of critically ill patients, β-lactam dose response in critically ill patients, the impact of pathogen minimum inhibitory concentration (MIC) on β-lactam TDM, and pharmacokinetics in critically ill patients. Additionally, we highlight available clinical data to better inform β-lactam TDM for critically ill patients. DATA SOURCES We retrospectively analyzed patients admitted for sepsis or septic shock at a single academic medical center who were treated with β-lactam antibiotics. STUDY SELECTION Indexed studies in PubMed in English language were selected for review on topics relative to critical care physiology, β-lactams, pharmacokinetics/pharmacodynamics, TDM, and antibiotic susceptibility. DATA EXTRACTION We reviewed potentially related studies on β-lactams and TDM and summarized their design, patients, and results. This is a synthetic, nonsystematic, review. DATA SYNTHESIS In the retrospective analysis of patients treated with β-lactam antibiotics, approximately one-third of patients received less than 48 hours of β-lactam therapy. Of those who continued beyond 48 hours, only 13.7% had patient-specific factors (augmented renal clearance, fluid overload, morbid obesity, and/or surgical drain), suggesting a potential benefit of β-lactam TDM. CONCLUSIONS These data indicate that a strategy of comprehensive β-lactam TDM for critically ill patients is unwarranted as it has not been shown yet to improve patient-oriented outcomes. This review demonstrates that β-lactam TDM in the ICU, while laudable, layers ambiguous β-lactam exposure thresholds upon uncertain/unknown MIC data within a dynamic, unpredictable patient population for whom TDM results will not be available fast enough to significantly affect care. Judicious, targeted TDM for those with risk factors for β-lactam over- or underexposure is a better approach but requires further study. Clinically, choosing the correct antibiotic and dosing β-lactams aggressively, which have a wide therapeutic index, to overcome critical illness factors appears to give critically ill patients the best likelihood of survival.
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Affiliation(s)
- Thomas J Dilworth
- Department of Pharmacy Services, Advocate Aurora Health, Milwaukee, WI
| | | | - Scott T Micek
- Center for Health Outcomes Research and Education, University of Health Sciences and Pharmacy, St. Louis, MO
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Warren E Rose
- School of Pharmacy, University of Wisconsin-Madison, Madison, WI
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Association between Augmented Renal Clearance and Inadequate Vancomycin Pharmacokinetic/Pharmacodynamic Targets in Chinese Adult Patients: A Prospective Observational Study. Antibiotics (Basel) 2022; 11:antibiotics11070837. [PMID: 35884091 PMCID: PMC9312211 DOI: 10.3390/antibiotics11070837] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 02/04/2023] Open
Abstract
This study aimed to examine the risk factors of augmented renal clearance (ARC) and the association between ARC and vancomycin pharmacokinetic/pharmacodynamic (PK/PD) indices in Chinese adult patients. A prospective, observational, multicenter study was conducted, and 414 adult patients undergoing vancomycin therapeutic drug monitoring (TDM) were enrolled. Clinical and PK/PD data were compared between ARC and non-ARC groups. Independent risk factors were examined using a multivariate logistic regression analysis. The ARC and augmented renal clearance in trauma intensive care (ARCTIC) scoring systems were evaluated. Eighty-eight of the enrolled patients (88/414, 21.3%) had ARC before vancomycin therapy. Patients with ARC were more likely to have subtherapeutic vancomycin PK/PD indices, including trough concentration (p = 0.003) and 24 h area under the concentration−time curve (AUC24) to minimal inhibitory concentration (MIC) ratio (p < 0.001). Male sex (OR = 2.588), age < 50 years (OR = 2.713), overweight (OR = 2.072), receiving mechanical ventilation (OR = 1.785), enteral nutrition (OR = 2.317), neutrophil percentage (OR = 0.975), and cardiovascular diseases (OR = 0.281) were significantly associated with ARC. In conclusion, ARC is associated with subtherapeutic vancomycin trough concentration and AUC24/MIC; therefore, higher than routine doses may be needed. Risk factors and ARC risk scoring systems are valuable for early identification.
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Song X, Wu Y. Predicted Vancomycin Dosage Requirement in Patients With Hematological Malignancies and Dosage Dynamic Adjustment. Front Pharmacol 2022; 13:890748. [PMID: 35734407 PMCID: PMC9207402 DOI: 10.3389/fphar.2022.890748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose: The purpose of this study was 1) to predict the requisite vancomycin daily dose (Dvan) used in the target patients suffering from both bacterial infection and hematological malignancies and 2) to construct a vancomycin-dose-graphical tool to assist clinicians to develop vancomycin dosing regimens and further 3) to establish a programming process for vancomycin dynamic dosage adjustment to help clinicians to adjust vancomycin dosing regimens according to physiological and pathogenic factors of the target patients. Methods: The Dvan model associated with microbial susceptibility, vancomycin pharmacokinetics, and dosing parameters was established, and the Dvan was estimated based on the established Dvan model and using Monte Carlo simulations. Dvan achieving 90% of probability of target attainment (PTA) for bacterial isolate or cumulative fractions of response (CFR) for the bacterial population at a ratio of daily area under the curve (AUC24) to the minimum inhibitory concentration (MIC) [i.e., AUC24/MIC] of 400–600 was considered sufficient to treat infection occurring in the target patients. On the basis of the predicted Dvan, the physiological states of patients, and the pathogenic variables of infection, a vancomycin-dose-graphical tool for the target patients and a programming process for vancomycin dynamic dosage adjustment were constructed. Results: This study predicted the requisite Dvan used in patients suffering from both bacterial infection and hematological malignancies and constructed a vancomycin-dose-graphical tool for the target patients, at different physiological states and pathogenic variables, to formulate vancomycin dosing regimens. Also, this study established and expounded the formulation process of vancomycin dosage dynamic adjustment according to fluctuant renal function of the target patients. Conclusion: With the tools, the required Dvan or vancomycin dosing regimens for the target patients, at different physiological states and pathogenic variables, can be readily known, whether or not vancomycin dynamic dosage adjustment is required.
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40
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Ogawa A, Hira D, Tsujimoto M, Nishiguchi K, Endo M, Ono T, Hatta T, Terada T, Morita SY. Optimal Sampling Strategy and Threshold of Serum Vancomycin Concentration in Elderly Japanese Patients Undergoing High-Flux Hemodialysis. Ther Drug Monit 2022; 44:396-403. [PMID: 34407000 DOI: 10.1097/ftd.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optimal sampling points and thresholds for initial serum vancomycin (VCM) concentrations have not been determined in hemodialysis (HD) patients. To clarify this, multiple blood tests were performed, and the correlations between VCM concentrations at several sampling points and the area under the concentration-time curve for 24 hours (AUC24h) were analyzed. METHODS A single-center, prospective observational study was conducted. Patients with end-stage renal failure who received VCM treatment while undergoing chronic maintenance HD were enrolled in this study. HD was performed using a high-flux membrane as the dialyzer. After VCM administration, 7 points were sampled between the first and second HD. The AUC24h after the end of the first HD (AUC0-24) and that before the end of the second HD (AUC24-48) were calculated using the linear trapezoidal method. Correlation analysis and simple regression analysis between AUC24h and serum concentrations were performed at each sampling point. RESULTS Nine patients were evaluated. Strong correlations were found between AUC24-48 and serum concentrations at 24 hours after the initiation of VCM treatment following the first HD (C24h, R = 0.983 and P < 0.001), between AUC0-24 and C24h (R = 0.967 and P < 0.001), and between AUC24-48 and serum concentration just before the second HD (Cpre(HD2), R = 0.965 and P < 0.001). Regression equations with high coefficients of determination (R2 > 0.9) were obtained, and a C24h of ≥18.0 mg/L and a Cpre(HD2) of ≥16.5 mg/L were required to achieve an AUC24-48 value of ≥400 mg·h/L. In addition, a C24h of ≤23.3 mg/L was estimated to satisfy the AUC0-24 range of ≤600 mg·h/L. CONCLUSIONS C24h and Cpre(HD2) are optimal sampling points for predicting VCM-AUC24h in HD patients.
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Affiliation(s)
- Akio Ogawa
- Department of Pharmacy, Omihachiman Community Medical Center, Omihachiman, Shiga, Japan. Dr. Hatta is now with the Hatta Medical Clinic, Kyoto, Japan
- Department of Pharmacy, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan. Dr. Terada is now with the Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Daiki Hira
- Department of Pharmacy, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan. Dr. Terada is now with the Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
- College of Pharmaceutical Sciences, Ritsumeikan University, Kusatsu, Shiga, Japan ; and
| | - Masayuki Tsujimoto
- Department of Clinical Pharmacy, Kyoto Pharmaceutical University, Kyoto, Japan
| | - Kohshi Nishiguchi
- Department of Clinical Pharmacy, Kyoto Pharmaceutical University, Kyoto, Japan
| | - Masanori Endo
- Department of Pharmacy, Omihachiman Community Medical Center, Omihachiman, Shiga, Japan. Dr. Hatta is now with the Hatta Medical Clinic, Kyoto, Japan
| | - Toshiaki Ono
- Department of Pharmacy, Omihachiman Community Medical Center, Omihachiman, Shiga, Japan. Dr. Hatta is now with the Hatta Medical Clinic, Kyoto, Japan
| | - Tsuguru Hatta
- Department of Pharmacy, Omihachiman Community Medical Center, Omihachiman, Shiga, Japan. Dr. Hatta is now with the Hatta Medical Clinic, Kyoto, Japan
| | - Tomohiro Terada
- Department of Pharmacy, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan. Dr. Terada is now with the Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Shin-Ya Morita
- Department of Pharmacy, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan. Dr. Terada is now with the Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
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Uster DW, Wicha SG. Optimized sampling to estimate vancomycin drug exposure: Comparison of pharmacometric and equation-based approaches in a simulation-estimation study. CPT Pharmacometrics Syst Pharmacol 2022; 11:711-720. [PMID: 35259285 PMCID: PMC9197536 DOI: 10.1002/psp4.12782] [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: 10/08/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/31/2022] Open
Abstract
Vancomycin dosing should be accompanied by area under the concentration‐time curve (AUC)–guided dosing using model‐informed precision dosing software according to the latest guidelines. Although a peak plus a trough sample is considered the gold standard to determine the AUC, single‐sample strategies might be more economic. Yet, optimal sampling times for AUC determination of vancomycin have not been systematically evaluated. In the present study, automated one‐ or two‐sample strategies were systematically explored to estimate the AUC with a model averaging and a model selection algorithm. Both were compared with a conventional equation‐based approach in a simulation‐estimation study mimicking a heterogenous patient population (n = 6000). The optimal single‐sample timepoints were identified between 2–6.5 h post dose, with varying bias values between −2.9% and 1.0% and an imprecision of 23.3%–24.0% across the population pharmacokinetic approaches. Adding a second sample between 4.5–6.0 h improved the predictive performance (−1.7% to 0.0% bias, 17.6%–18.6% imprecision), although the difference in the two‐sampling strategies were minor. The equation‐based approach was always positively biased and hence inferior to the population pharmacokinetic approaches. In conclusion, the approaches always preferred samples to be drawn early in the profile (<6.5 h), whereas sampling of trough concentrations resulted in a higher imprecision. Furthermore, optimal sampling during the early treatment phase could already give sufficient time to individualize the second dose, which is likely unfeasible using trough sampling.
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Affiliation(s)
- David W Uster
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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42
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Chuphan C, Sukarnjanaset W, Puthanakit T, Wattanavijitkul T. Population Pharmacokinetics and Pharmacodynamics of Vancomycin in Pediatric Patients With Various Degrees of Renal Function. J Pediatr Pharmacol Ther 2022; 27:419-427. [DOI: 10.5863/1551-6776-27.5.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/18/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Although vancomycin dosage recommendations in the pediatric setting for methicillin-resistant Staphylococcus aureus (MRSA) infection indicate that ≥60 mg/kg/day is correlated to a desired area under the vancomycin concentration time curve from 0 to 24 hours to minimum inhibitory concentration ratio (AUC0–24 hr/MIC) ≥400, for some patients this dosage is inadequate or relates to toxicity. This study purposed to explore vancomycin dosing for pediatrics with various degrees of renal function.
METHODS
Routine monitoring data were retrospectively collected from patients, aged 1 month to 18 years. Population pharmacokinetic analysis was performed by using non-linear mixed-effect model with NONMEM software, and Monte Carlo simulation was conducted by using Crystal Ball software.
RESULTS
Two hundred twelve patients with 348 vancomycin serum concentrations were included. Median age was 3.5 years (IQR, 0.9–10.9), median weight was 14.0 kg (IQR, 7.2–30.4), with baseline estimated glomerular filtration rate (eGFR) ranging from 15.5 to 359.3 mL/min/1.73 m2. A 1-compartment model with first-order elimination sufficiently described vancomycin PK. The dosing targeting AUC0–24hr/MIC ≥400 and AUC0–24hr <800 mg•h/L for pediatric patients with eGFRs of 15 to 29, 30 to 59, 60 to 89, 90 to 129, and 130 to 160 mL/min/1.73 m2 was 12.5, 25, 40, 60, and 70 mg/kg/day, respectively. All vancomycin dosing obtained >85% of the cumulative fraction of response across the MIC distribution of MRSA.
CONCLUSIONS
Vancomycin dosing of 12.5, 25, 40, 60, and 70 mg/kg/day is suggested for pediatric patients with eGFRs of 15 to 29, 30 to 59, 60 to 89, 90 to 129, and 130 to 160 mL/min/1.73 m2, respectively.
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Affiliation(s)
- Chanika Chuphan
- Department of Pharmacy Practice (CC, TW), Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | | | - Thanyawee Puthanakit
- Department of Pediatrics (TP), Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thitima Wattanavijitkul
- Department of Pharmacy Practice (CC, TW), Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
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Implementation of a Vancomycin Dose-Optimization Protocol in Neonates: Impact on Vancomycin Exposure, Biological Parameters, and Clinical Outcomes. Antimicrob Agents Chemother 2022; 66:e0219121. [PMID: 35465728 DOI: 10.1128/aac.02191-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Vancomycin dosing used in neonates results frequently in insufficient concentrations. A vancomycin dose-optimization protocol consisting of an individualization of loading and maintenance doses (administered during continuous infusion) through a previously validated pharmacokinetic model was implemented in our center. This monocenter retrospective study aimed to compare vancomycin average concentration (Cavg) in the therapeutic range (15 to 25 mg/L) and biological and clinical parameters before and after implementation of this protocol. A total of 60 and 59 courses of vancomycin treatment in 45 and 49 patients were analyzed in groups before and after implementation, respectively. Initial vancomycin Cavg were more frequently in the therapeutic range in the group after implementation (74.6% versus 28.3%, P < 0.001), with 1.6-fold higher Cavg (20.3 [17.0-22.2] mg/L versus 12.9 [11.3-17.0] mg/L, P < 0.001). Considering all Cavg during longitudinal therapeutic drug monitoring (TDM), the frequency of therapeutic Cavg was higher in the group after implementation (74.8% [n = 103] versus 31% [n = 116], P < 0.001). The dose optimization protocol was also associated with a reduced time to obtain a negative blood culture (P < 0.001) and fewer antibiotic switches (P = 0.025), without increasing the frequency of nephrotoxicity. Clinical outcomes also appeared to be improved, with less periventricular leukomalacia (P = 0.021), trended toward less respiratory instability (P = 0.15) and a shorter duration of vasoactive drug use (P = 0.18) for neonates receiving personalized doses of vancomycin. This personalized vancomycin dose protocol improves vancomycin exposure in neonates, with good safety, and suggests an improvement in biological and clinical outcomes.
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Giacobbe DR, Roberts JA, Abdul-Aziz MH, de Montmollin E, Timsit JF, Bassetti M. Treatment of ventilator-associated pneumonia due to carbapenem-resistant Gram-negative bacteria with novel agents: a contemporary, multidisciplinary ESGCIP perspective. Expert Rev Anti Infect Ther 2022; 20:963-979. [PMID: 35385681 DOI: 10.1080/14787210.2022.2063838] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION : In the past 15 years, treatment of VAP caused by carbapenem-resistant Gram-negative bacteria (CR-GNB) has represented an intricate challenge for clinicians. AREAS COVERED In this perspective article, we discuss the available clinical data about novel agents for the treatment of CR-GNB VAP, together with general PK/PD principles for the treatment of VAP, in the attempt to provide some suggestions for optimizing antimicrobial therapy of CR-GNB VAP in the daily clinical practice. EXPERT OPINION Recently, novel BL and BL/BLI combinations have become available that have shown potent in vitro activity against CR-GNB and have attracted much interest as novel, less toxic, and possibly more efficacious options for the treatment of CR-GNB VAP compared with previous standard of care. Besides randomized controlled trials, a good solution to enrich our knowledge on how to use these novel agents at best in the near future, while at the same time remaining adherent to current evidence-based guidelines, is to improve our collaboration to conduct larger multinational observational studies to collect sufficiently large populations treated in real life with those novel agents for which guidelines currently do not provide a recommendation (in favor or against) for certain causative organisms.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID)
| | - Jason A Roberts
- Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).,University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Etienne de Montmollin
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
| | - Jean-François Timsit
- Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
| | - Matteo Bassetti
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID)
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45
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Bian X, Qu X, Zhang J, Nang SC, Bergen PJ, Tony Zhou Q, Chan HK, Feng M, Li J. Pharmacokinetics and pharmacodynamics of peptide antibiotics. Adv Drug Deliv Rev 2022; 183:114171. [PMID: 35189264 PMCID: PMC10019944 DOI: 10.1016/j.addr.2022.114171] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 01/23/2022] [Accepted: 02/16/2022] [Indexed: 01/05/2023]
Abstract
Antimicrobial resistance is a major global health challenge. As few new efficacious antibiotics will become available in the near future, peptide antibiotics continue to be major therapeutic options for treating infections caused by multidrug-resistant pathogens. Rational use of antibiotics requires optimisation of the pharmacokinetics and pharmacodynamics for the treatment of different types of infections. Toxicodynamics must also be considered to improve the safety of antibiotic use and, where appropriate, to guide therapeutic drug monitoring. This review focuses on the pharmacokinetics/pharmacodynamics/toxicodynamics of peptide antibiotics against multidrug-resistant Gram-negative and Gram-positive pathogens. Optimising antibiotic exposure at the infection site is essential for improving their efficacy and minimising emergence of resistance.
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Affiliation(s)
- Xingchen Bian
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China
| | - Xingyi Qu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Sue C Nang
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Phillip J Bergen
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Meiqing Feng
- School of Pharmacy, Fudan University, Shanghai, China
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia.
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46
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Olney KB, Wallace KL, Mynatt RP, Burgess DS, Grieves K, Willett A, Mani J, Flannery AH. Comparison of Bayesian-derived and first-order analytic equations for calculation of vancomycin area under the curve. Pharmacotherapy 2022; 42:284-291. [PMID: 35134264 PMCID: PMC9750735 DOI: 10.1002/phar.2670] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Consensus guidelines recommend targeting a vancomycin area under the curve to minimum inhibitory concentration (AUC24 :MIC) ratio of 400-600 to improve therapeutic success and reduce nephrotoxicity. Although guidelines specify either Bayesian software or first-order equations may be used to estimate AUC24 , there are currently no large studies directly comparing these methods. OBJECTIVE To compare calculated vancomycin AUC24 using first-order equations with two-drug concentrations at steady state to Bayesian two- and one-concentration estimations. METHODS This was a single-center, retrospective cohort study of 978 adult hospitalized patients receiving intravenous vancomycin between 2017 and 2019. Patients were included if they received at least 72 h of vancomycin and had two-serum drug concentrations obtained. AUC24 was calculated using first-order analytic (linear), Bayesian two-concentration, and Bayesian one-concentration methods for each patient. The InsightRx™ software platform was used to calculate Bayesian AUC24 . Pearson's correlation and clinical agreement (based on AUC24 classified as subtherapeutic, therapeutic, or supratherapeutic) were used to assess agreement between methods. Bland-Altman plots were used to assess mean difference (MD) and 95% limits of agreement (LOA). RESULTS Excellent agreement was observed between linear and Bayesian two-concentration methods (r = 0.963, clinical agreement = 87.4%) and Bayesian two-concentration and one-concentration methods (r = 0.931, clinical agreement = 88.5%); however, a degree of variability was noted with 95% LOA -99 to 76 (MD = -11.5 mg*h/L) and -92 to 113 (MD = -10.4 mg*h/L), for the respective comparisons. The agreement between linear and Bayesian one-concentration approaches was less than prior comparisons (r = 0.823, clinical agreement = 76.8%) and demonstrated the greatest amount of variability with 95% LOA -197 to 153 (MD = -21.9 mg*h/L). CONCLUSIONS Linear and Bayesian two-concentration methods demonstrated high-level agreement with acceptable variability and may be considered comparable to estimate vancomycin AUC24 . As linear and Bayesian one-concentration methods demonstrated significant variability and suboptimal agreement, concerns exist surrounding the interchangeability of these methods in clinical practice, particularly at higher extremes of AUC24 .
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Affiliation(s)
- Katie B. Olney
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Katie L. Wallace
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Ryan P. Mynatt
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
| | - David S. Burgess
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Kaitlyn Grieves
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Austin Willett
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Johann Mani
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Alexander H. Flannery
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
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47
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A Systematic Review on Clinical Safety and Efficacy of Vancomycin Loading Dose in Critically Ill Patients. Antibiotics (Basel) 2022; 11:antibiotics11030409. [PMID: 35326872 PMCID: PMC8944428 DOI: 10.3390/antibiotics11030409] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 03/04/2022] [Accepted: 03/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The clinical significance of utilizing a vancomycin loading dose in critically ill patients remains unclear. Objective: The main aim of this systematic review is to evaluate the clinical safety and efficacy of the vancomycin loading dose in critically ill patients. Methods: We performed a systematic review using PRISMA guidelines. PubMed, the Web of Science, MEDLINE, Scopus, Google Scholar, the Saudi Digital Library and other databases were searched. Studies that reported clinical outcomes among patients receiving the vancomycin LD were considered eligible. Data for this study were collected using PubMed, the Web of Science, MEDLINE, Scopus, Google Scholar and the Saudi Digital Library using the following terms: “vancomycin”, “safety”, “efficacy” and “loading dose” combined with the Boolean operator “AND” or “OR”. Results: A total of 17 articles, including 2 RCTs, 11 retrospective cohorts and 4 other studies, met the inclusion/exclusion criteria out of a total 1189 studies. Patients had different clinical characteristics representing a heterogenous group, including patients in critical condition, with renal impairment, sepsis, MRSA infection and hospitalized patients for hemodialysis or in the emergency department. Conclusions: The study shows that the target therapeutic level is achieved more easily among patients receiving a weight-based LD as compared to patients received the usual dose without an increased risk of new-onset adverse drug reactions.
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48
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Abdul-Aziz MH, Brady K, Cotta MO, Roberts JA. Therapeutic Drug Monitoring of Antibiotics: Defining the Therapeutic Range. Ther Drug Monit 2022; 44:19-31. [PMID: 34750338 DOI: 10.1097/ftd.0000000000000940] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE In the present narrative review, the authors aimed to discuss the relationship between the pharmacokinetic/pharmacodynamic (PK/PD) of antibiotics and clinical response (including efficacy and toxicity). In addition, this review describes how this relationship can be applied to define the therapeutic range of a particular antibiotic (or antibiotic class) for therapeutic drug monitoring (TDM). METHODS Relevant clinical studies that examined the relationship between PK/PD of antibiotics and clinical response (efficacy and response) were reviewed. The review (performed for studies published in English up to September 2021) assessed only commonly used antibiotics (or antibiotic classes), including aminoglycosides, beta-lactam antibiotics, daptomycin, fluoroquinolones, glycopeptides (teicoplanin and vancomycin), and linezolid. The best currently available evidence was used to define the therapeutic range for these antibiotics. RESULTS The therapeutic range associated with maximal clinical efficacy and minimal toxicity is available for commonly used antibiotics, and these values can be implemented when TDM for antibiotics is performed. Additional data are needed to clarify the relationship between PK/PD indices and the development of antibiotic resistance. CONCLUSIONS TDM should only be regarded as a means to achieve the main goal of providing safe and effective antibiotic therapy for all patients. The next critical step is to define exposures that can prevent the development of antibiotic resistance and include these exposures as therapeutic drug monitoring targets.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Kara Brady
- Adult Intensive Care Unit and Pharmacy, The Prince Charles Hospital, Brisbane, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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49
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Katip W, Okonogi S, Oberdorfer P. The Thirty-Day Mortality Rate and Nephrotoxicity Associated With Trough Serum Vancomycin Concentrations During Treatment of Enterococcal Infections: A Propensity Score Matching Analysis. Front Pharmacol 2022; 12:773994. [PMID: 35153743 PMCID: PMC8831381 DOI: 10.3389/fphar.2021.773994] [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: 09/13/2021] [Accepted: 12/30/2021] [Indexed: 01/22/2023] Open
Abstract
The objective of this study was to evaluate the relationship between vancomycin trough levels in patients with documented enterococcal infections and mortality, clinical outcomes, microbiological outcomes, and nephrotoxicity. We conducted a retrospective cohort study of patients with enterococcus infections who were prescribed vancomycin with therapeutic drug monitoring during January 2010 and December 2019 at Chiang Mai University Hospital (CMUH). The study enrolled 300 participants who met the inclusion criteria and were prescribed vancomycin with therapeutic drug monitoring. The results of this study showed that, after propensity score matching, a vancomycin trough of ≥15 mg/L was associated with significant differences in 30-days mortality compared to a vancomycin trough of <15 mg/L (aHR: 0.41, 95% CI: 0.21–0.82; p = 0.011). Likewise, a vancomycin trough of ≥15 mg/L was associated with significant differences in the clinical response (aHR: 0.49, 95% CI: 0.26–0.94; p = 0.032), microbiological response (aHR: 0.32, 95% CI: 0.12–0.87; p = 0.025) and nephrotoxicity (aHR: 3.17, 95% CI: 1.39–7.23; p = 0.006), compared with a vancomycin trough of <15 mg/L. However, sub-group analysis found that very high trough levels (>20 mg/L) were also associated with a high rate of nephrotoxicity (aHR: 3.55, 95% CI 1.57–8.07, p = 0.002), when compared with a vancomycin trough of <15 mg/L. The target vancomycin trough concentration was ≥15 mg/L and this target can be an optimal alternative to the use of area under the curve (AUC) values for monitoring the treatment of enterococcal infection.
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Affiliation(s)
- Wasan Katip
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Research Center for Pharmaceutical Nanotechnology, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- *Correspondence: Wasan Katip,
| | - Siriporn Okonogi
- Research Center for Pharmaceutical Nanotechnology, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Peninnah Oberdorfer
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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50
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AbuSara AK, Abdelrahman DH, Habash KI, Al-Shaer MH, Le J, Nazer LH. Vancomycin therapeutic monitoring by measured trough concentration versus Bayesian-derived area under the curve in critically ill patients with cancer. Pharmacol Res Perspect 2022; 10:e00912. [PMID: 34990089 PMCID: PMC8929348 DOI: 10.1002/prp2.912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/17/2021] [Indexed: 11/16/2022] Open
Abstract
The updated vancomycin guideline and recent studies suggested that trough concentrations may result in underestimation of the actual area under the curve (AUC), leading to excessive dosing and nephrotoxicity. With limited data available on critically ill cancer patients, this study aimed to compare the two methods in this patient population. This was a 5‐year retrospective study on patients treated with vancomycin in the intensive care unit (ICU) of a comprehensive cancer center. The measured trough concentration was compared to Bayesian‐derived AUC/minimum‐inhibitory‐concentration (MIC), considering MIC as 1. Trough concentrations of 15–20 mg/L and AUC of 400–600 mg h/L were considered the targeted goal. Multivariate analysis was performed to identify factors associated with an AUC below the targeted goal. During the study period, 316 patients were included. The mean age was 54 years ±16 (SD); most patients had solid tumors (75%), and 11% had neutropenia. A targeted goal AUC and trough were recorded in 128 (41%) patients and in 64 (20%) patients, respectively. Of the 128 patients with targeted goal AUC, 31 (24%) had targeted goal trough concentrations and 91 (71%) had trough concentrations below 15 mg/L. Furthermore, among the patients with targeted goal trough concentration (n = 64), 33 (52%) had higher than targeted goal AUC. Augmented renal clearance (ARC), defined as a calculated creatinine‐clearance ≥130 ml/min, was associated with an AUC below the targeted goal. In a cohort of critically ill patients with cancer, over two‐thirds of the patients with a targeted goal Bayesian AUC/MIC had trough concentrations below the targeted goal. ARC was associated with AUC below the targeted goal.
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Affiliation(s)
- Aseel K AbuSara
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | | | - Khader I Habash
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | - Mohammad H Al-Shaer
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
| | - Lama H Nazer
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
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