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Thibault C, Moorthy GS, Vedar C, Naim MY, DiLiberto MA, Zuppa AF. Pharmacokinetics of Cefepime in Children on Extracorporeal Membrane Oxygenation: External Model Validation, Model Improvement and Dose Optimization. Pediatr Infect Dis J 2022; 41:217-223. [PMID: 34817416 DOI: 10.1097/inf.0000000000003371] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cefepime is a first-line therapy for Gram-negative infections in children on extracorporeal membrane oxygenation. Cefepime pharmacokinetics (PK) in children on extracorporeal membrane oxygenation still needs to be better established. METHODS This was a prospective single-center PK study. A maximum of 12 PK samples per patient were collected in children <18 years old on extracorporeal membrane oxygenation who received clinically indicated cefepime. External validation of a previously published population PK model was performed by applying the model in a new data set. The predictive performance of the model was determined by calculating prediction errors. Because of poor predictive performance, a revised model was developed using NONMEM and a combined data set that included data from both studies. Dose-exposure simulations were performed using the final model. Optimal dosing was judged based on the ability to maintain free cefepime concentrations above the minimal inhibitory concentration (MIC) for 68% and 100% of the dosing interval. RESULTS Seventeen children contributed 105 PK samples. The mean (95% CI) and median (interquartile range) prediction errors were 33.7% (19.8-47.7) and 17.5% (-22.6 to 74.4). A combined data set was created, which included 33 children contributing 310 PK samples. The final improved 2-compartment model included weight and serum creatinine on clearance and oxygenator day and blood transfusion on volume of the central compartment. At an MIC of 8 mg/L, 50 mg/kg/dose every 8 hours reached target concentrations. CONCLUSIONS Dosing intervals of 8 hours were needed to reach adequate concentrations at an MIC of 8 mg/L. Longer dosing intervals were adequate with higher serum creatinine and lower MICs.
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Affiliation(s)
- Céline Thibault
- From the Department of Pediatrics, Division of Critical Care Medicine, CHU Sainte-Justine, Montreal, QC, Canada
| | - Ganesh S Moorthy
- Department of Anesthesiology and Critical Care Medicine
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christina Vedar
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine
| | - Mary Ann DiLiberto
- Department of Anesthesiology and Critical Care Medicine
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
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Moorthy GS, Vedar C, Zane NR, Downes KJ, Prodell JL, DiLiberto MA, Zuppa AF. Development and validation of a volumetric absorptive microsampling- liquid chromatography mass spectrometry method for the analysis of cefepime in human whole blood: Application to pediatric pharmacokinetic study. J Pharm Biomed Anal 2019; 179:113002. [PMID: 31785929 DOI: 10.1016/j.jpba.2019.113002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 01/07/2023]
Abstract
Cefepime is a fourth-generation cephalosporin antibiotic with an extended spectrum of activity against many Gram-positive and Gram-negative bacteria. There is a growing need to develop sensitive, small volume assays, along with less invasive sample collection to facilitate pediatric pharmacokinetic clinical trials and therapeutic drug monitoring. The volumetric absorptive microsampling (VAMS™) approach provides an accurate and precise collection of a fixed volume of blood (10 μL), reducing or eliminating the volumetric blood hematocrit assay-bias associated with the dried blood spotting technique. We developed a high-performance liquid chromatographic method with tandem mass spectrometry detection for quantification of cefepime. Sample extraction from VAMS™ devices, followed by reversed-phase chromatographic separation and selective detection using tandem mass spectrometry with a 4 min runtime per sample was employed. Standard curves were linear between 0.1-100 μg/mL for cefepime. Intra- and inter-day accuracies were within 95.4-113% and precision (CV) was < 15 % based on a 3-day validation study. Recoveries ranged from 40.8 to 62.1% and the matrix effect was within 89.5-96.7% for cefepime. Cefepime was stable in human whole blood under assay conditions (3 h at room temperature, 24 h in autosampler post-extraction). Cefepime was also stable for at least 1 week (7 days) at 4 °C, 1 month (39 days) at -20 °C and 3 months (91 days) at -78 °C as dried microsamples. This assay provides an efficient quantitation of cefepime and was successfully implemented for the analysis of whole blood microsamples in a pediatric clinical trial.
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Affiliation(s)
- Ganesh S Moorthy
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States.
| | - Christina Vedar
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States
| | - Nicole R Zane
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States
| | - Kevin J Downes
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, United States
| | - Janice L Prodell
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States
| | - Mary Ann DiLiberto
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States
| | - Athena F Zuppa
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States
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Boehmer T, Vogler AJ, Thomas A, Sauer S, Hergenroether M, Straubinger RK, Birdsell D, Keim P, Sahl JW, Williamson CHD, Riehm JM. Phenotypic characterization and whole genome analysis of extended-spectrum beta-lactamase-producing bacteria isolated from dogs in Germany. PLoS One 2018; 13:e0206252. [PMID: 30365516 PMCID: PMC6203360 DOI: 10.1371/journal.pone.0206252] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/09/2018] [Indexed: 12/30/2022] Open
Abstract
Asymptomatic colonization with extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae has been described for humans, various mammal species, and birds. Here, antimicrobial resistant bacteria were recovered from dog feces originating in Germany, Kosovo, Afghanistan, Croatia, and Ukraine, with a subset of mostly E. coli isolates obtained from a longitudinal collection over twelve months. In vitro antimicrobial resistance testing revealed various patterns of resistance against single or all investigated beta-lactam antibiotics, with none of the 101 isolates resistant against two tested carbapenem antibiotics. Whole genome sequence analysis revealed bacteria species-specific patterns for 23 antimicrobial resistance coding DNA sequences (CDS) that were unapparent from the in vitro analysis alone. Phylogenetic analysis of single nucleotide polymorphisms (SNP) revealed clonal bacterial isolates originating from different dogs, suggesting transmission between dogs in the same community. However, individual resistant E. coli clones were not detected over a period longer than seven days. Multi locus sequence typing (MLST) of 85 E. coli isolates revealed 31 different sequence types (ST) with an accumulation of ST744 (n = 9), ST10 (n = 8), and ST648 (n = 6), although the world-wide hospital-associated CTX-M beta-lactamase producing ST131 was not detected. Neither the antimicrobial resistance CDSs patterns nor the phylogenetic analysis revealed an epidemiological correlation among the longitudinal isolates collected from a period longer than seven days. No genetic linkage could be associated with the geographic origin of isolates. In conclusion, healthy dogs frequently carry ESBL-producing bacteria, independent to prior treatment, which may be transmitted between individual dogs of the same community. Otherwise, these antimicrobial resistant bacteria share few commonalities, making their presence eerily unpredictable.
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Affiliation(s)
- Tim Boehmer
- Central Institute of the Bundeswehr Medical Service Munich, Garching, Bavaria, Germany
| | - Amy J. Vogler
- The Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Astrid Thomas
- Institute of Infectious Diseases and Zoonoses, Department of Veterinary Sciences, Faculty of Veterinary Medicine, Ludwig-Maximilian University, Munich, Germany
| | | | - Markus Hergenroether
- Central Institute of the Bundeswehr Medical Service Munich, Garching, Bavaria, Germany
| | - Reinhard K. Straubinger
- Institute of Infectious Diseases and Zoonoses, Department of Veterinary Sciences, Faculty of Veterinary Medicine, Ludwig-Maximilian University, Munich, Germany
| | - Dawn Birdsell
- The Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Paul Keim
- The Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Jason W. Sahl
- The Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Charles H. D. Williamson
- The Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Julia M. Riehm
- Central Institute of the Bundeswehr Medical Service Munich, Garching, Bavaria, Germany
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