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Singu BS, Pieper CH, Verbeeck RK, Ette EI. Predictors of gentamicin therapy failure in neonates with sepsis. Pharmacol Res Perspect 2024; 12:e1250. [PMID: 39105353 DOI: 10.1002/prp2.1250] [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: 02/27/2024] [Revised: 06/15/2024] [Accepted: 07/04/2024] [Indexed: 08/07/2024] Open
Abstract
Sepsis is a common disease with high morbidity and mortality among newborns in intensive care units world-wide. Gram-negative bacillary bacteria are the major source of infection in neonates. Gentamicin is the most widely used aminoglycoside antibiotic in empiric therapy against early-onset sepsis. However, therapy failure may result due to various factors. The purpose of this study was to identify predictors of gentamicin therapy failure in neonates with sepsis. This was a prospective cross-sectional study at the Neonatal Intensive Care Unit at Windhoek Central Hospital over a period of 5 months in 2019. Neonates received intravenous gentamicin 5 mg/kg/24 h in combination with either benzylpenicillin 100 000 IU/kg/12 h or ampicillin 50 mg/kg/8 h. Logistic regression modeling was performed to determine the predictors of treatment outcomes. 36% of the 50 neonates were classified as having gentamicin treatment failure. Increasing treatment duration by 1 day resulted in odds of treatment failure increasing from 1.0 to 2.41. Similarly, one unit increase in CRP increases odds of gentamicin treatment failure by 49%. The 1 kg increase in birthweight reduces the log odds of treatment failure by 6.848, resulting in 99.9% decrease in the odds of treatment failure. One unit increase in WBC reduces odds of gentamicin treatment failure by 27%. Estimates of significant predictors of treatment failure were precise, yielding odds ratios that were within 95% confidence interval. This study identified the following as predictors of gentamicin therapy failure in neonates: prolonged duration of treatment, elevated C-reactive protein, low birthweight, and low white blood cell count.
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Affiliation(s)
| | | | - Roger Karel Verbeeck
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Ene I Ette
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
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Villanueva-Bueno C, Montecatine-Alonso E, Jiménez-Parrilla F, González-López M, Manrique-Rodríguez S, Moreno-Ramos F, Cañete-Ramírez C, Dolz E, García-Robles A, Caro-Teller JM, Moral-Pumarega MT, Bergon-Sendin E, Gómez-Trevecedo Calvo MT, Gallego-Fernández C, del Vayo-Benito CÁ, Mejías-Trueba M, Gil-Navarro MV. Antimicrobial Defined Daily Dose in Neonatal Population: Validation in the Clinical Practice. Antibiotics (Basel) 2023; 12:antibiotics12030602. [PMID: 36978469 PMCID: PMC10044623 DOI: 10.3390/antibiotics12030602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/21/2023] [Accepted: 03/09/2023] [Indexed: 03/19/2023] Open
Abstract
Background: Currently, there is no validated method for estimating antimicrobial consumption in the neonatal population, as it exists for adults using Defined Daily Doses (DDD). In neonatology, although there are different methods, each one with advantages and disadvantages, there is no unified criterion for use. The aim of this study is to validate the neonatal DDD designed as a new standardised form of antimicrobial consumption over this population. Methods: The validation of the neonatal DDD, Phase II of the research project, was carried out through a descriptive observational study. Periodic cut-offs were performed to collect antimicrobial prescriptions of neonates admitted to the neonatology and intensive care units of nine Spanish hospitals. The data collected included demographic variables (gestational age, postnatal age, weight and sex), antimicrobial dose, frequency and route of administration. The selection of the optimal DDD value takes into account power value, magnitude obtained from the differences in the DDD, statistical significance obtained by the Wilcoxon test and degree of agreement in the stipulated doses. Results: Set of 904 prescriptions were collected and finally 860 were analysed based on the established criteria. The antimicrobials were mostly prescribed in the intensive care unit (63.1%). 32 different antimicrobials were collected, and intravenous administration was the most commonly used route. Neonatal DDD were defined for 11 different antimicrobials. A potency > 80% was obtained in 7 antibiotics. The 57.1% of the selected DDD correspond to phase I and 21.4% from phase II. Conclusion: DDD validation has been achieved for the majority of intravenously administered antimicrobials used in clinical practice in the neonatal population. This will make it possible to have an indicator that will be used globally to estimate the consumption of antimicrobials in this population, thus confirming its usefulness and applicability.
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Affiliation(s)
- Cristina Villanueva-Bueno
- Department of Pharmacy, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañon, 28007 Madrid, Spain
- Correspondence:
| | | | | | - María González-López
- Department of Neonatology, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Silvia Manrique-Rodríguez
- Department of Pharmacy, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañon, 28007 Madrid, Spain
| | | | - Carme Cañete-Ramírez
- Department of Pharmacy, Hospital Universitario Vall d’Hebron, 08035 Barcelona, Spain
| | - Elisenda Dolz
- Department of Pharmacy, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Las Palmas de Gran Canarias, Spain
| | - Ana García-Robles
- Division of Pharmacy, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - José Manuel Caro-Teller
- Department of Pharmacy, Hospital Universitario 12 de Octubre, Research Institute 12 de Octubre i+12, 28041 Madrid, Spain
| | | | - Elena Bergon-Sendin
- Department of Neonatology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
| | | | | | | | - Marta Mejías-Trueba
- Department of Pharmacy, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain (M.M.-T.)
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, 41013 Seville, Spain
| | - María Victoria Gil-Navarro
- Department of Pharmacy, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain (M.M.-T.)
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital, CSIC, University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, 28029 Madrid, Spain
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Hu L, Zhang J, He J, Zhang S, Liu D, Shao H. Quantitation of meropenem in dried blood spots using microfluidic-based volumetric sampling coupled with LC-MS/MS bioanalysis in preterm neonates. J Chromatogr B Analyt Technol Biomed Life Sci 2023; 1217:123625. [PMID: 36753842 DOI: 10.1016/j.jchromb.2023.123625] [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: 10/18/2022] [Revised: 12/08/2022] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
Meropenem, a carbapenem antibiotic, has been used for empirical and definitive therapy of severe infections for many years. Therapeutic drug monitoring (TDM) plays an indispensable role in the individualization of meropenem particularly in the preterm neonates, a population in which adjusting proper dosages has always been one of the most challenging tasks for their growth changes. In this report, a simple and accurate method for the quantitative analysis of meropenem in dried blood spot (DBS) samples by LC-MS/MS was developed. The traditional DBS drawbacks were conquered in this study by combining microfluidic-based volumetric sampling, shorten drying procedure, and sensitive detection. Moreover, the on-card stability of meropenem was improved obviously. The DBS-based method validation included hematocrit (Hct) effect, selectivity, carry-over, linearity, accuracy, precision, matrix effect, recovery and stability (high temperature and humidity). The calibration linear range of meropenem was 0.3-100 µg/mL. The acceptance criteria of accuracy (relative error < 4.53 %) and precision (coefficient of variation < 8.63 %) were met in all levels of quality control samples. The DBS samples was stable at 40 °C for 12 h, room temperature for 1 day, 4 °C for 7 days, -20 °C for 14 days and -40 °C for 30 days, respectively. A good correlation was observed between DBS concentration and plasma concentration of meropenem. There was 93.4 % of the samples between estimated plasma concentration and plasma concentration within 20 % of the mean of concentration, and no significant Hct effect was observed on the quantification. It has been successfully applied to samples derived from preterm neonates with severe infections. The supported data indicated that the DBS-based method using microfluidic-based volumetric sampling could be an alternative strategy to carry on TDM of meropenem in preterm neonates, with satisfactory performance and logistics advantages.
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Affiliation(s)
- Linlin Hu
- Department of Pharmacy, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China; Office of Medication Clinical Institution, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China.
| | - Jinlu Zhang
- School of Medicine, Southeast University, Nanjing, China
| | - Jie He
- Department of Pharmacy, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Siliang Zhang
- Jiangyin Tianjiang Pharmaceutical Co., Ltd., Jiangyin, China
| | - Dongxue Liu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Hua Shao
- Department of Pharmacy, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China.
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Daniels EA, McPherson CC, Newland JG, Lee BR. Variation in ampicillin dosing for lower respiratory tract infections and neonatal bacterial infections in US children's hospitals. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e85. [PMID: 36483411 PMCID: PMC9726562 DOI: 10.1017/ash.2022.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE We examined ampicillin dosing in pediatric patients across 3 conditions: (1) bacterial lower respiratory tract infections (LRTIs) in infants and children >3 months, (2) neonates with suspected or proven sepsis, and (3) neonates with suspected central nervous system (CNS) infections. We compared our findings to dosing guidance for these specific indications. DESIGN Retrospective cohort study. SETTING The study included data from 32 children's hospitals in the United States. METHODS We reviewed prescriptions from the SHARPS study of antimicrobials, a survey of antibiotic prescribing from July 2016 to December 2017. Prescriptions were analyzed for indication, total daily dose per kilogram, and presence of antimicrobial stewardship program (ASP) review. LRTI prescriptions were compared to IDSA recommendations for community-acquired pneumonia. Neonatal prescriptions were compared to recommendations from the American Academy of Pediatrics (AAP). Prescriptions were categorized as "optimal" (80%-120% of recommended dosing), "suboptimal" (<80% of recommended dosing), or "excessive" (>120% of recommended dosing). RESULTS Among 1,038 ampicillin prescriptions, we analyzed 88 prescriptions for LRTI, 499 prescriptions for neonatal sepsis, and 27 prescriptions for neonatal CNS infection. Of the LRTI prescriptions, 77.3%were optimal. Of prescriptions for neonatal sepsis, 81.6% were excessive compared to AAP bacteremia recommendations but 78.8% were suboptimal compared to AAP meningitis guidelines. Also, 48.1% of prescriptions for neonatal CNS infection were suboptimal, and 50.6% of prescriptions were not reviewed by the ASP. CONCLUSIONS LRTI dosing is generally within the IDSA-recommended range. However, dosing for neonatal sepsis often exceeds the recommendation for bacteremia but is below the recommendation for meningitis. This variability points to an important opportunity for future antimicrobial stewardship efforts.
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Affiliation(s)
- Elizabeth A. Daniels
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | | | - Jason G. Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Brian R. Lee
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
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Neonatal multidrug-resistant gram-negative infection: epidemiology, mechanisms of resistance, and management. Pediatr Res 2022; 91:380-391. [PMID: 34599280 PMCID: PMC8819496 DOI: 10.1038/s41390-021-01745-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/11/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023]
Abstract
Infants admitted to the neonatal intensive care unit, particularly those born preterm, are at high risk for infection due to the combination of an immature immune system, prolonged hospitalization, and frequent use of invasive devices. Emerging evidence suggests that multidrug-resistant gram-negative (MDR-GN) infections are increasing in neonatal settings, which directly threatens recent and ongoing advances in contemporary neonatal care. A rising prevalence of antibiotic resistance among common neonatal pathogens compounds the challenge of optimal management of suspected and confirmed neonatal infection. We review the epidemiology of MDR-GN infections in neonates in the United States and internationally, with a focus on extended-spectrum β-lactamase (ESBL)-producing Enterobacterales and carbapenem-resistant Enterobacterales (CRE). We include published single-center studies, neonatal collaborative reports, and national surveillance data. Risk factors for and mechanisms of resistance are discussed. In addition, we discuss current recommendations for empiric antibiotic therapy for suspected infections, as well as definitive treatment options for key MDR organisms. Finally, we review best practices for prevention and identify current knowledge gaps and areas for future research. IMPACT: Surveillance and prevention of MDR-GN infections is a pediatric research priority. A rising prevalence of MDR-GN neonatal infections, specifically ESBL-producing Enterobacterales and CRE, compounds the challenge of optimal management of suspected and confirmed neonatal infection. Future studies are needed to understand the impacts of MDR-GN infection on neonatal morbidity and mortality, and studies of current and novel antibiotic therapies should include a focus on the pharmacokinetics of such agents among neonates.
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Knowledge gaps in late-onset neonatal sepsis in preterm neonates: a roadmap for future research. Pediatr Res 2022; 91:368-379. [PMID: 34497356 DOI: 10.1038/s41390-021-01721-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 12/16/2022]
Abstract
Late-onset neonatal sepsis (LONS) remains an important threat to the health of preterm neonates in the neonatal intensive care unit. Strategies to optimize care for preterm neonates with LONS are likely to improve survival and long-term neurocognitive outcomes. However, many important questions on how to improve the prevention, early detection, and therapy for LONS in preterm neonates remain unanswered. This review identifies important knowledge gaps in the management of LONS and describe possible methods and technologies that can be used to resolve these knowledge gaps. The availability of computational medicine and hypothesis-free-omics approaches give way to building bedside feedback tools to guide clinicians in personalized management of LONS. Despite advances in technology, implementation in clinical practice is largely lacking although such tools would help clinicians to optimize many aspects of the management of LONS. We outline which steps are needed to get possible research findings implemented on the neonatal intensive care unit and provide a roadmap for future research initiatives. IMPACT: This review identifies knowledge gaps in prevention, early detection, antibiotic, and additional therapy of late-onset neonatal sepsis in preterm neonates and provides a roadmap for future research efforts. Research opportunities are addressed, which could provide the means to fill knowledge gaps and the steps that need to be made before possible clinical use. Methods to personalize medicine and technologies feasible for bedside clinical use are described.
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7
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van der Veen A, Somers A, Vanhaesebrouck S, Ter Heine R, Brüggemann R, Allegaert K, De Cock P. Variation in vancomycin dosing and therapeutic drug monitoring practices in neonatal intensive care units. Int J Clin Pharm 2021; 44:564-569. [PMID: 34727280 DOI: 10.1007/s11096-021-01345-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 10/19/2021] [Indexed: 11/29/2022]
Abstract
Background Vancomycin is a frequently used antibiotic in neonates. However, there is no consensus guideline on the optimal dosing regimen and therapeutic drug monitoring (TDM) practices in this patient population. Objective To document the variability in the current dosing and TDM practices in neonatal intensive care units (NICU). Setting Belgian and Dutch NICUs. Method An online questionnaire was disseminated by e-mail to potential respondents. Main outcome measure Differences in vancomycin dosing and TDM practices in comparison with a reference source, the Dutch Paediatric Formulary. Results Eighteen NICUs (response rate 62%) participated. Eleven different dosing regimens are applied, with 83% using intermittent dosing regimens. Stratifying covariates used to determine the (initial) dosage include gestational age, postnatal age, serum creatinine, concurrent use of non-steroidal anti-inflammatory drugs, birth weight and current weight. Large variability is observed with regard to TDM practice as well, both for the concentration target range and the times of (re)sampling. Dosing calculators are more commonly used in the Netherlands than Belgium. Conclusion Significant inter-centre variability in dosing and TDM practices was found. The development of international consensus guidelines is required to optimize therapy. Dosing calculators to guide dosing are not yet considered as part of standard-of-care.
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Affiliation(s)
- Anouk van der Veen
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan, 10, 9000, Ghent, Belgium
| | - Annemie Somers
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan, 10, 9000, Ghent, Belgium.,Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | | | - Rob Ter Heine
- Department of Pharmacy and Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger Brüggemann
- Department of Pharmacy and Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karel Allegaert
- Department of Development and Regeneration, and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pieter De Cock
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan, 10, 9000, Ghent, Belgium. .,Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium. .,Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium.
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Wu YE, Wang T, Yang HL, Tang BH, Kong L, Li X, Gao Q, Li X, Yao BF, Shi HY, Huang X, Wang WQ, Jacqz-Aigrain E, Allegaert K, van den Anker J, Tian XY, Zhao W. Population pharmacokinetics and dosing optimization of azlocillin in neonates with early-onset sepsis: a real-world study. J Antimicrob Chemother 2021; 76:699-709. [PMID: 33188385 DOI: 10.1093/jac/dkaa468] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/15/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Nowadays, real-world data can be used to improve currently available dosing guidelines and to support regulatory approval of drugs for use in neonates by overcoming practical and ethical hurdles. This proof-of-concept study aimed to assess the population pharmacokinetics of azlocillin in neonates using real-world data, to make subsequent dose recommendations and to test these in neonates with early-onset sepsis (EOS). METHODS This prospective, open-label, investigator-initiated study of azlocillin in neonates with EOS was conducted using an adaptive two-step design. First, a maturational pharmacokinetic-pharmacodynamic model of azlocillin was developed, using an empirical dosing regimen combined with opportunistic samples resulting from waste material. Second, a Phase II clinical trial (ClinicalTrials.gov: NCT03932123) of this newly developed model-based dosing regimen of azlocillin was conducted to assure optimized target attainment [free drug concentration above MIC during 70% of the dosing interval ('70% fT>MIC')] and to investigate the tolerance and safety in neonates. RESULTS A one-compartment model with first-order elimination, using 167 azlocillin concentrations from 95 neonates (31.7-41.6 weeks postmenstrual age), incorporating current weight and renal maturation, fitted the data best. For the second step, 45 neonates (30.3-41.3 weeks postmenstrual age) were subsequently included to investigate target attainment, tolerance and safety of the pharmacokinetic-pharmacodynamic model-based dose regimen (100 mg/kg q8h). Forty-three (95.6%) neonates reached their pharmacokinetic target and only two neonates experienced adverse events (feeding intolerance and abnormal liver function), possibly related to azlocillin. CONCLUSIONS Target attainment, tolerance and safety of azlocillin was shown in neonates with EOS using a pharmacokinetic-pharmacodynamic model developed with real-world data.
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Affiliation(s)
- Yue-E Wu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Tao Wang
- Department of Pharmacy, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin 300100, China
| | - Hua-Liang Yang
- Department of Pharmacy, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin 300100, China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Li Kong
- Department of Neonatology, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin 300100, China
| | - Xin Li
- Department of Neonatology, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin 300100, China
| | - Qi Gao
- Department of Neonatology, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin 300100, China.,Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin 300100, China
| | - Xue Li
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Hai-Yan Shi
- Department of Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Xin Huang
- Department of Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Wen-Qi Wang
- Clinical Research Centre, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France.,Clinical Investigation Centre CIC1426, Hôpital Robert Debré, Paris, France.,University of Paris, Paris, France
| | - Karel Allegaert
- Department of Development and Regeneration and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Clinical Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA.,Departments of Pediatrics, Pharmacology & Physiology, Genomics and Precision Medicine, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.,Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland
| | - Xiu-Ying Tian
- Department of Neonatology, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin 300100, China.,Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin 300100, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China.,Department of Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China.,Clinical Research Centre, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
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Sridharan K, Al Jufairi M, Qader AM, Elsegai OAM. Dose Optimization of Gentamicin in Critically Ill Neonates. Curr Drug Metab 2021; 21:270-280. [PMID: 32394828 DOI: 10.2174/1389200221666200512111131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/11/2020] [Accepted: 04/09/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Appropriate dosing of gentamicin in critically ill neonates is still debated. OBJECTIVE To assess the peak concentration (Cmax) and area-under-the-time-concentration curve (AUC0-24) of gentamicin and to simulate the recommended doses using the Monte Carlo method. METHODS This was a retrospective study on critically ill neonates carried over a one-year period. The demographic characteristics, dosage regimen and gentamicin concentrations were recorded for each neonate. Using Bayesian pharmacokinetic modeling, Cmax and AUC0-24 were predicted. Dose recommendations for the target Cmax (μg/ml) of 12 were obtained, and Monte Carlo simulation (100,000 iterations) was used for predicting the pharmacokinetic parameters and recommended doses for various birth weight categories. RESULTS Eighty-two critically ill neonates (with an average gestational age of 33.7 weeks; and birth weight of 2.1 kg) were recruited. Higher Cmax and AUC0-24 values were predicted in premature neonates, with greater cumulative AUCs in extremely preterm neonates. The average administered dose was 4 mg/kg/day and 75% of the participants had Cmax greater than 12 μg/ml following a single dose, and 85% were found to be at steady state. On the contrary, only 25% of the study population had the recommended AUC0-24 (above 125 μg-hr/ml). Simulation tests indicate that 90% of the critically ill neonates would achieve recommended Cmax with doses ranging between 5 and 6 mg/kg/day. CONCLUSION Currently used dose of 4 mg/kg/day is adequate to maintain Cmax in a large majority of the study population, with one-fourth population reporting the recommended AUC0-24. Increasing the dose to 5-6 mg/kg/day will more likely help to achieve both the recommended Cmax and AUC0-24 values.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Muna Al Jufairi
- Department of Pediatrics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Bahrain.,Neonatal Intensive Care Unit, Salmaniya Medical Hospital, Ministry of Health, Manama, Bahrain
| | - Ali Mohamed Qader
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Ola A M Elsegai
- Department of Pathology-Biochemistry, Salmaniya Medical Hospital, Ministry of Health, Manama, Bahrain
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10
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Bartlett JW, Gillon J, Hale J, Jimenez-Truque N, Banerjee R. Incidence of Acute Kidney Injury Among Infants in the Neonatal Intensive Care Unit Receiving Vancomycin With Either Piperacillin/Tazobactam or Cefepime. J Pediatr Pharmacol Ther 2020; 25:521-527. [PMID: 32839656 DOI: 10.5863/1551-6776-25.6.521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To determine whether combination therapy with vancomycin and TZP is associated with a higher incidence of acute kidney injury (AKI) compared with vancomycin with cefepime in infants admitted to the NICU. METHODS This retrospective cohort study included infants in the NICU who received vancomycin/cefepime or vancomycin/TZP for at least 48 hours. The primary outcome was incidence of AKI, which was defined by the neonatal modified Kidney Disease Improving Global Outcomes AKI criteria. RESULTS Forty-two infants who received vancomycin with cefepime and 58 infants who received vancomycin with TZP were included in the analysis. The median gestational age at birth, birth weight, and dosing weight were lower in the TZP group, but other baseline characteristics were comparable, including corrected gestational age. Two patients (3%) receiving vancomycin/TZP versus 2 patients (5%) receiving vancomycin/cefepime met criteria for AKI during their antibiotic course (p = 1.00). There were no clinically significant changes in serum creatinine or urine output from baseline to the end of combination antibiotic treatment in either group. CONCLUSIONS Among infants admitted to our NICU, AKI incidence associated with vancomycin and either TZP or cefepime therapy was low and did not differ by antibiotic combination.
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Rieder M. Adverse Drug Reactions Across the Age Continuum: Epidemiology, Diagnostic Challenges, Prevention, and Treatments. J Clin Pharmacol 2019; 58 Suppl 10:S36-S47. [PMID: 30248196 DOI: 10.1002/jcph.1115] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 02/11/2018] [Indexed: 12/15/2022]
Abstract
Adverse drug reactions (ADRs) are common and important complications of drug therapy for children. The risk for ADRs changes over childhood, as do the nature and types of ADRs. Importantly, the risk and nature of ADRs in children are markedly different from those of adults, and adult data cannot be relied on to guide safe drug therapy in children. There are groups of children, notably those with complex and chronic diseases, who are at substantial risk for ADRs. The evaluation of an undesired effect during therapy is ideally accomplished by an organized approach that is a skill that clinicians who care for children-especially those children at high risk for ADRs must have. Additionally, clinicians as well as drug regulatory agencies and industry need to be both vigilant and astute as well as aware that ADRs in children are often different in nature and frequency from those in adults. The increasing use of pharmacogenomics to guide drug dosing and the increasing number of biological agents will provide new sets of challenges to clinicians over the next decade.
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Affiliation(s)
- Michael Rieder
- Department of Paediatrics, University of Western Ontario, London, Ontario, Canada
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12
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Allegaert K, Flint R, Smits A. Pharmacokinetic modelling and Bayesian estimation-assisted decision tools to optimize vancomycin dosage in neonates: only one piece of the puzzle. Expert Opin Drug Metab Toxicol 2019; 15:735-749. [PMID: 31402708 DOI: 10.1080/17425255.2019.1655540] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Vancomycin is commonly administered to neonates, while observational data on therapeutic drug monitoring (TDM, trough levels) suggest that vancomycin exposure and dosage remain substandard. Area covered: Data on vancomycin pharmacokinetics (PK) and its covariates are abundant. Consequently, modeling is an obvious tool to improve targeted exposure, with a shift from TDM trough levels to area under the curve (AUC24h) targets, as in adults. Continuous administration appeared as a practice to facilitate AUC24h target attainment, while Bayesian model-supported targeting emerged as a novel tool. However, the AUC24h/MIC (minimal inhibitory concentration) target itself should consider neonate-specific aspects (bloodstream infections, coagulase-negative staphylococci, protein binding, underexplored causes of variability, like assays, preparation and administration inaccuracies, or missing covariates). Expert opinion: To improve targeted exposure in neonates, initial vancomycin prescription should be based on 'a priori model-based individual dosing' using validated dosing regimens, followed by further tailoring by dosing optimization applying Bayesian estimation-assisted TDM. Future research should focus on the feasibility to integrate these tools (individualized dosing, Bayesian models) in clinical practice, and to perform PK/PD studies in the relevant animal models and human neonatal setting (coagulase-negative staphylococci, bloodstream infections).
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Affiliation(s)
- Karel Allegaert
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam , Rotterdam , the Netherlands.,Department of Development and Regeneration, KU Leuven , Leuven , Belgium
| | - Robert Flint
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam , Rotterdam , the Netherlands.,Department of Pharmacy, Erasmus University Medical Center , Rotterdam , The Netherlands
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven , Leuven , Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven , Leuven , Belgium
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13
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Seni J, Mwakyoma AA, Mashuda F, Marando R, Ahmed M, DeVinney R, Pitout JDD, Mshana SE. Deciphering risk factors for blood stream infections, bacteria species and antimicrobial resistance profiles among children under five years of age in North-Western Tanzania: a multicentre study in a cascade of referral health care system. BMC Pediatr 2019; 19:32. [PMID: 30684964 PMCID: PMC6347777 DOI: 10.1186/s12887-019-1411-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/18/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Blood stream infections (BSIs) cause a complex cascade of inflammatory events, resulting in significant morbidity and mortality in children in Tanzania. This study was designed to delineate circulating bacterial species, antimicrobial resistance (AMR) profiles and risk factors for BSIs and mortality among children in the cascade of referral health care facilities so as to guide comprehensive BSIs management. METHODS A multiple cross sectional analytical study was conducted between July 20, 2016 to October 04, 2017 involving 950 children less than five years of age in the North-western part of Tanzania. Children with clinical features suggestive of BSIs were included. Demographic, clinical and laboratory information on culture and antimicrobial susceptibility testing was collected from children; and analyzed using STATA version 13.0 software. RESULTS The prevalence of BSIs among children was 14.2% (95% CI: 12.1-16.6%), with specific prevalence in the district, regional and tertiary hospitals being 8.3, 6.4 and 20.0%, respectively. The most common bacterial pathogens isolated from 135 culture-positive children were Klebsiella pneumoniae (55, 40.4%), Staphylococcus aureus (23, 17.0%), and Escherichia coli (17, 12.6%). Multi-drug resistance (MDR) was higher in isolates from children at Bugando Medical Centre (BMC) tertiary hospital than isolates from district and regional hospitals [OR (95% CI): 6.36 (2.15-18.76); p = 0.001]. Independent risk factors for BSIs were neonatal period [OR (95% CI): 1.93 (1.07-3.48); p = 0.003] and admission at BMC [2.01 (1.08-3.74); p = 0.028)]. Approximately 6.6% (61/932) of children died, and risk factors for mortality were found to be children attending BMC [OR (95% CI): 4.95 (1.95-12.5); p = 0.001)], neonatal period [OR (95% CI): 2.25 (1.02-5.00); p = 0.045)], and children who had blood culture positive results [OR (95% CI): 1.95 (1.07-3.56); p = 0.028)]. CONCLUSIONS The prevalence of BSIs (14.2%) in this multi-centre study is high and predominantly caused by the MDR K. pneumoniae. Priority interventional measures to combat BSIs and mortality, specifically among neonates at BMC are urgently recommended.
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Affiliation(s)
- J. Seni
- Department of Microbiology and Immunology, Weill-Bugando School of Medicine, Catholic University of Health and Allied Sciences, P.O. Box 1464, Mwanza, Tanzania
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1 Canada
| | - A. A. Mwakyoma
- Department of Microbiology and Immunology, Weill-Bugando School of Medicine, Catholic University of Health and Allied Sciences, P.O. Box 1464, Mwanza, Tanzania
| | - F. Mashuda
- Department of Paediatrics and Child Health, Bugando Medical Centre, Catholic University of Health and Allied Sciences, P.O. Box 1370 - 1464, Mwanza, Tanzania
| | - R. Marando
- Department of Paediatrics and Child Health, Bugando Medical Centre, Catholic University of Health and Allied Sciences, P.O. Box 1370 - 1464, Mwanza, Tanzania
| | - M. Ahmed
- Department of Paediatrics and Child Health, Bugando Medical Centre, Catholic University of Health and Allied Sciences, P.O. Box 1370 - 1464, Mwanza, Tanzania
| | - R. DeVinney
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1 Canada
| | - J. D. D. Pitout
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1 Canada
| | - S. E. Mshana
- Department of Microbiology and Immunology, Weill-Bugando School of Medicine, Catholic University of Health and Allied Sciences, P.O. Box 1464, Mwanza, Tanzania
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14
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Cohen R, Tauzin M, Béchet S, Caeymaex L. Pharmacocinétique et pharmacodynamie des antibiotiques : est-ce différent en néonatologie ? Arch Pediatr 2018; 24 Suppl 3:S18-S23. [PMID: 29433693 DOI: 10.1016/s0929-693x(18)30040-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pharmacokinetic and pharmacodynamics (PK/PD) data on antimicrobial agents enable physicians to optimize their use in clinical practice. Neonates exhibit a large inter-individual variability in antibiotic levels due to immaturity and maturational changes in the first weeks of life. This variability explains the large therapeutic margins needed to ensure an optimal efficacy of antibiotics. These pharmacokinetic characteristics have to be taken into account when treating neonatal sepsis, along with pharmacodynamics targets for each antibiotic and notably minimal inhibitory concentration for usual causes of neonatal bacterial infections (group B streptococcus and Escherichia coli). This paper presents PK/PD data of antimicrobial agents mainly used in neonatology (ß-lactamines and aminoglycosides) to help physicians to rationalize their use of antibiotics.
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Affiliation(s)
- R Cohen
- ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, 27 Rue Inkermann, Saint-Maur des Fossés, France; üniversité Paris Est, IMRB-GRC GEMINI, 40 Avenue de Verdun 94000 Créteil, France; Centre de Recherche Clinique (CRC), Centre Hospitalier Intercommunal de Créteil, 40 Avenue de Verdun 94000 Créteil, France; Groupe de Pathologie Infectieuse Pédiatrique (GPIP), 27 Rue Inkermann, Saint-Maur des Fossés, France; ünité Court Séjour, Petits Nourrissons, Service de Néonatologie, Centre Hospitalier Intercommunal de Créteil, 40 Avenue de Verdun 94000 Créteil, France.
| | - M Tauzin
- Service de Réanimation Néonatale et Néonatalogie, Centre Hospitalier intercommunal de Créteil, 40 Avenue de Verdun 94000 Créteil, France
| | - S Béchet
- ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, 27 Rue Inkermann, Saint-Maur des Fossés, France; Centre de Recherche Clinique (CRC), Centre Hospitalier Intercommunal de Créteil, 40 Avenue de Verdun 94000 Créteil, France
| | - L Caeymaex
- Centre de Recherche Clinique (CRC), Centre Hospitalier Intercommunal de Créteil, 40 Avenue de Verdun 94000 Créteil, France; Service de Réanimation Néonatale et Néonatalogie, Centre Hospitalier intercommunal de Créteil, 40 Avenue de Verdun 94000 Créteil, France
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