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De Gregori S, Seminari E, Capone M, Giordani P, Bruno R, De Silvestri A. Daptomycin Exposure Prediction With a Limited Sampling Strategy. Ther Drug Monit 2024; 46:537-542. [PMID: 38666474 DOI: 10.1097/ftd.0000000000001211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/28/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Daptomycin is a cyclic lipopeptide antibiotic used to treat serious infectious endocarditis caused by Staphylococcus aureus . The pharmacodynamic parameter correlating best with efficacy is the ratio of the estimated area under the concentration (AUC 0-24 )-time curve to the minimum inhibitory concentration. The aim of the study is to develop a limited sampling strategy to estimate AUC 0-24 using a reduced number of samples. METHODS Sixty-eight daptomycin AUC 0-24 values were calculated for 50 White patients who underwent treatment for at least 5 consecutive days. Plasma concentrations were detected using a validated high-performance liquid chromatography-tandem mass spectrometry analytical method, with daptomycin-d5 as an internal standard. Multiple regression was used to evaluate the ability of 2 concentration-time points to predict the AUC 0-24 calculated from the entire pharmacokinetic profile. Prediction bias was calculated as the mean prediction error, whereas prediction precision was estimated as the mean absolute prediction error. The development and validation datasets comprised 40 and 10 randomly selected patients, respectively. RESULTS The AUC 0-24 (mg*h/L) was best estimated using the daptomycin trough concentration and plasma concentrations detected 2 hours after dosing. We calculated a mean prediction error of 1.6 (95% confidence interval, -10.7 to 10.9) and a mean absolute prediction error of 11.8 (95% confidence interval, 5.3-18.3), with 73% of prediction errors within ±15%. CONCLUSIONS An equation was developed to estimate daptomycin exposure (AUC 0-24 ), offering clinical applicability and utility in generating personalized dosing regimens, especially for individuals at high risk of treatment failure or delayed response.
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Affiliation(s)
- Simona De Gregori
- Department of Diagnostic Medicine and Services: Laboratory Medicine-Clinical and Experimental Pharmacokinetics Unit, Fondazione IRCCS Policlinico, San Matteo, Pavia, Italy
| | - Elena Seminari
- Division of Infectious Diseases I, Fondazione IRCCS Policlinico, San Matteo, Pavia, Italy; and
| | - Mara Capone
- Department of Diagnostic Medicine and Services: Laboratory Medicine-Clinical and Experimental Pharmacokinetics Unit, Fondazione IRCCS Policlinico, San Matteo, Pavia, Italy
| | - Paola Giordani
- Division of Infectious Diseases I, Fondazione IRCCS Policlinico, San Matteo, Pavia, Italy; and
| | - Raffaele Bruno
- Division of Infectious Diseases I, Fondazione IRCCS Policlinico, San Matteo, Pavia, Italy; and
| | - Annalisa De Silvestri
- SSD Biostatistics and Clinical Trial Center, Fondazione IRCCS Policlinico, San Matteo, Pavia, Italy
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Liu Q, Zhou J, Zheng Y, Xu B, Li D, Liu M, Zhang X, Wu X. Three methods to optimise polymyxin B dosing using estimated AUC after first dose: validation with the data generated by Monte Carlo simulation. Xenobiotica 2024:1-9. [PMID: 38884560 DOI: 10.1080/00498254.2024.2370051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 06/16/2024] [Indexed: 06/18/2024]
Abstract
To achieve the AUC-guided dosing, we proposed three methods to estimate polymyxin B AUC across 24 h at steady state (AUCSS,24h) using limited concentrations after its first dose.Monte Carlo simulation based on a well-established population PK model was performed to generate the PK profiles of 1000 patients with normal or abnormal renal function. Polymyxin B AUCSS,24h was estimated for each subject using three methods (two-point PK approach, three-point PK approach, and four-point PK approach) based on limited concentration data in its first dose and compared with the actual AUC at steady state calculated using the linear-trapezoidal formula.In patients with normal renal function, the mean bias of two-point PK approach, three-point PK approach, and four-point PK approach was -8.73%, 1.37%, and -0.48%, respectively. The corresponding value was -11.15%, 1.99%, and -0.28% in patients with renal impairment, respectively. The largest mean bias of two-point PK approach, three-point PK approach, and four-point PK approach was -12.63%, -6.47%, and -0.54% when the sampling time shifted.The Excel calculators designed based on the three methods can be potentially used to optimise the dosing regimen of polymyxin B in the clinic.
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Affiliation(s)
- Qingxia Liu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jianxing Zhou
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - You Zheng
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Baohua Xu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Dandan Li
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Maobai Liu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xiaohan Zhang
- College of Arts and Sciences, University of Virginia, Charlottesville, VA, USA
| | - Xuemei Wu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
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3
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Wang X, Xiong W, Zhong M, Liu Y, Xiong Y, Yi X, Wang X, Zhang H. Pharmacokinetics of polymyxin B in different populations: a systematic review. Eur J Clin Pharmacol 2024; 80:813-826. [PMID: 38483544 DOI: 10.1007/s00228-024-03666-w] [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: 12/08/2023] [Accepted: 03/04/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND AND OBJECTIVES Despite being clinically utilized for the treatment of infections, the limited therapeutic range of polymyxin B (PMB), along with considerable interpatient variability in its pharmacokinetics and frequent occurrence of acute kidney injury, has significantly hindered its widespread utilization. Recent research on the population pharmacokinetics of PMB has provided valuable insights. This study aims to review relevant literature to establish a theoretical foundation for individualized clinical management. METHODS Follow PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, Pop-PK studies of PMB were searched in PubMed and EMBASE database systems from the inception of the database until March 2023. RESULT To date, a total of 22 population-based studies have been conducted, encompassing 756 subjects across six different countries. The recruited population in these studies consisted of critically infected individuals with multidrug-resistant bacteria, patients with varying renal functions, those with cystic fibrosis, kidney or lung transplant recipients, patients undergoing extracorporeal membrane oxygenation (ECMO) or continuous renal replacement therapy (CRRT), as well as individuals with obesity or pediatric populations. Among these studies, seven employed a one-compartmental model, with the range of typical clearance (CL) and volume (Vc) being 1.18-2.5L /h and 12.09-47.2 L, respectively. Fifteen studies employed a two-compartmental model, with the ranges of the clearance (CL) and volume of the central compartment (Vc), the volume of the peripheral compartment (Vp), and the intercompartment clearance (Q) were 1.27-8.65 L/h, 5.47-38.6 L, 4.52-174.69 L, and 1.34-24.3 L/h, respectively. Primary covariates identified in these studies included creatinine clearance and body weight, while other covariates considered were CRRT, albumin, age, and SOFA scores. Internal evaluation was conducted in 19 studies, with only one study being externally validated using an independent external dataset. CONCLUSION We conclude that small sample sizes, lack of multicentre collaboration, and patient homogeneity are the primary reasons for the discrepancies in the results of the current studies. In addition, most of the studies limited in the internal evaluation, which confined the implementation of model-informed precision dosing strategies.
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Affiliation(s)
- Xing Wang
- School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Wenqiang Xiong
- School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Maolian Zhong
- School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Yan Liu
- School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Yuqing Xiong
- School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Xiaoyi Yi
- Clinical Medicine Research Center, Jiangxi Cancer Hospital, Jiangxi Cancer Hospital of Nanchang University, Nanchang, 330029, China
| | - Xiaosong Wang
- Clinical Medicine Research Center, Jiangxi Cancer Hospital, Jiangxi Cancer Hospital of Nanchang University, Nanchang, 330029, China
| | - Hong Zhang
- Clinical Medicine Research Center, Jiangxi Cancer Hospital, Jiangxi Cancer Hospital of Nanchang University, Nanchang, 330029, China.
- Jiangxi Clinical Research Center for Cancer, Nanchang, 330029, China.
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4
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Li X, Cheng Y, Zhang B, Chen B, Chen Y, Huang Y, Lin H, Zhou L, Zhang H, Liu M, Que W, Qiu H. A systematic evaluation of population pharmacokinetic models for polymyxin B in patients with liver and/or kidney dysfunction. J Pharmacokinet Pharmacodyn 2024:10.1007/s10928-024-09916-9. [PMID: 38625507 DOI: 10.1007/s10928-024-09916-9] [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: 11/23/2023] [Accepted: 03/21/2024] [Indexed: 04/17/2024]
Abstract
Polymyxin B (PMB) is considered a last-line treatment for multidrug-resistant (MDR) gram-negative bacterial infections. Model-informed precision dosing with population pharmacokinetics (PopPK) models could help to individualize PMB dosing regimens and improve therapy. However, the external prediction ability of the established PopPK models has not been fully elaborated. This study aimed to systemically evaluate eleven PMB PopPK models from ten published literature based on a new independent population, which was divided into four different populations, patients with liver dysfunction, kidney dysfunction, liver and kidney dysfunction, and normal liver and kidney function. The whole data set consisted of 146 patients with 391 PMB concentrations. The prediction- and simulation-based diagnostics and Bayesian forecasting were conducted to evaluate model predictability. In the overall evaluation process, none of the models exhibited satisfactory predictive ability in both prediction- and simulation-based diagnostic simultaneously. However, the evaluation of the models in the subgroup of patients with normal liver and kidney function revealed improved predictive performance compared to those with liver and/or kidney dysfunction. Bayesian forecasting demonstrated enhanced predictability with the incorporation of two to three prior observations. The external evaluation highlighted a lack of consistency between the prediction results of published models and the external validation dataset. Nonetheless, Bayesian forecasting holds promise in improving the predictive performance of the models, and feedback from therapeutic drug monitoring is crucial in optimizing individual dosing regimens.
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Affiliation(s)
- Xueyong Li
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China
| | - Yu Cheng
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China
| | - Bingqing Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China
| | - Bo Chen
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China
| | - Yiying Chen
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China
| | - Yingbing Huang
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China
| | - Hailing Lin
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China
| | - Lili Zhou
- Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China
| | - Hui Zhang
- Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China
| | - Wancai Que
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China.
| | - Hongqiang Qiu
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China.
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China.
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5
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Wang P, Liu S, Sun T, Yang J. Daily fluid intake as a novel covariate affecting the population pharmacokinetics of polymyxin B in patients with sepsis. Int J Antimicrob Agents 2024; 63:107099. [PMID: 38280575 DOI: 10.1016/j.ijantimicag.2024.107099] [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: 07/31/2023] [Revised: 12/08/2023] [Accepted: 01/18/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Polymyxin B dosing in patients with sepsis is difficult because pathophysiological changes and supportive therapies alter drug pharmacokinetics (PK). This study aimed to investigate the impact of fluid management and renal function on the PK of polymyxin B and to propose alternative dosing regimens. METHODS Patients (aged ≥ 18 y) with sepsis and receiving intravenous polymyxin B for ≥ 96 h were enrolled. Blood samples were collected at steady state. Plasma concentrations were measured by liquid chromatography-tandem mass spectrometry and subjected to population PK modelling. Monte Carlo simulations were used to optimise dosage regimens. RESULTS Eighty-three patients with a median (range) daily fluid intake of 4.2 (1.3-8.4) L and a creatinine clearance (CrCL) of 87.5 (17.3-309.7) mL/min were included. Polymyxin B PK was adequately characterised by a two-compartment model. The PK covariate analysis revealed daily fluid intake statistically significantly affected central volume of distribution and central compartment clearance (CL), and CrCL influenced CL. Simulation indicated that a decreased dosing would be suitable for patients with renal dysfunction (CrCL < 40 mL/min), and therapeutic drug monitoring is recommended to avoid exposure fluctuation when patients have fluid overload. CONCLUSIONS Fluid management as well as renal function are essential factors affecting polymyxin B PK for patients with sepsis, which can help optimise dosage regimens.
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Affiliation(s)
- Peile Wang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China; Henan Engineering Research Center for Application & Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Shaohua Liu
- Department of General Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- Department of General Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Jing Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China; Henan Engineering Research Center for Application & Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China.
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6
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Zeng J, Leng B, Guan X, Jiang S, Xie M, Zhu W, Tang Y, Zhang L, Sha J, Wang T, Ding M, Guo N, Jiang J. Comparative pharmacokinetics of polymyxin B in critically ill elderly patients with extensively drug-resistant gram-negative bacteria infections. Front Pharmacol 2024; 15:1347130. [PMID: 38362145 PMCID: PMC10867212 DOI: 10.3389/fphar.2024.1347130] [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: 11/30/2023] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction: Elderly patients are more prone to develop acute kidney injury during infections and polymyxin B (PMB)-associated nephrotoxicity than young patients. The differential response to PMB between the elderly and young critically ill patients is unknown. We aimed to assess PMB exposure in elderly patients compared with young critically ill patients, and to determine the covariates of PMB pharmacokinetics in critically ill patients. Methods: Seventeen elderly patients (age ≥ 65 years) and six young critically ill patients (age < 65 years) were enrolled. Six to eight blood samples were collected during the 12 h intervals after at least six doses of intravenous PMB in each patient. PMB plasma concentrations were quantified by high-performance liquid chromatography-tandem mass spectrometry. The primary outcome was PMB exposure as assessed by the area under the concentration-time curve over 24 h at steady state (AUCss, 0-24 h). Results and Discussion: The elderly group had lower total body weight (TBW) and higher Charlson comorbidity scores than young group. Neither AUCss, 0-24 h nor normalized AUCss, 0-24 h (adjusting AUC for the daily dose in mg/kg of TBW) was significantly different between the elderly group and young group. The half-life time was longer in the elderly patients than in young patients (11.21 vs 6.56 h respectively, p = 0.003). Age and TBW were the covariates of half-life time (r = 0.415, p = 0.049 and r = -0.489, p = 0.018, respectively). TBW was the covariate of clearance (r = 0.527, p = 0.010) and AUCss, 0-24 h (r = -0.414, p = 0.049). Patients with AUCss, 0-24 h ≥ 100 mg·h/L had higher baseline serum creatinine levels and lower TBW than patients with AUCss, 0-24 h < 50 mg·h/L or patients with AUCss, 0-24 h 50-100 mg·h/L. The PMB exposures were comparable in elderly and young critically ill patients. High baseline serum creatinine levels and low TBW was associated with PMB overdose. Trial registration: ChiCTR2300073896 retrospectively registered on 25 July 2023.
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Affiliation(s)
- Juan Zeng
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Bing Leng
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xiaoyan Guan
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Shuangyan Jiang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Maoyu Xie
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Wenying Zhu
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Yue Tang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Lin Zhang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Jing Sha
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Tengfei Wang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Min Ding
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Nan Guo
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Jinjiao Jiang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
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Wang J, Li Y, Huang S, Wang M, Jin L, Luo X, Cheng X, Yang N, Zhu H. Mid-dosing interval concentration is important for polymyxin B exposure and acute kidney injury in critically ill patients. CPT Pharmacometrics Syst Pharmacol 2023; 12:1911-1921. [PMID: 37655610 PMCID: PMC10725268 DOI: 10.1002/psp4.13040] [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: 05/12/2023] [Revised: 08/10/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023] Open
Abstract
This study aimed to evaluate the association between polymyxin B (PMB) exposure and acute kidney injury (AKI) and analyze the risk factors for PMB-induced AKI in critically ill patients. Plasma concentrations of PMB were determined using an ultraperformance liquid chromatography-tandem mass spectrometer in intensive care unit patients who were administered PMB. Univariate and multivariate analyses were conducted to identify risk factors. A receiver operating characteristic curve was constructed to assess the discriminant power of the factors and to identify the cutoff value for AKI. The white blood cell count and estimated area under the concentration-time curve (AUC) of patients administered PMB were independent risk factors for PMB-induced AKI, where AUC were calculated using a first-order pharmacokinetic equation based on the mid-dosing interval concentration (C1/2t ) and peak concentration. The area under the receiver operating characteristic curve of the final model was 0.805 (95% confidence interval, 0.690-0.921). The cutoff value for the combined predictor was 0.57. Alternatively, when using C1/2t , which was strongly correlated with AUC, as the only independent risk factor, the analysis showed that the 3.47 μg/ml threshold provides favorable differentiation between the AKI and non-AKI groups. These results provide insightful information for therapeutic drug monitoring-guiding PMB dosing in clinical practice.
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Affiliation(s)
- Jing Wang
- Department of PharmacyNanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
| | - Yuanchen Li
- Department of PharmacyChina Pharmaceutical University Nanjing Drum Tower HospitalNanjingChina
| | - Siqi Huang
- Department of PharmacyNanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese MedicineNanjingChina
| | - Min Wang
- Department of PharmacyNanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
- Nanjing Medical Center for Clinical PharmacyNanjingChina
| | - Lu Jin
- Department of PharmacyNanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
- Nanjing Medical Center for Clinical PharmacyNanjingChina
| | - Xuemei Luo
- Department of PharmacyNanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
- Nanjing Medical Center for Clinical PharmacyNanjingChina
| | - Xiaoliang Cheng
- Jiangsu Qlife Medical Technology Group Co., Ltd.NanjingChina
| | - Na Yang
- Department of PharmacyNanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
- Nanjing Medical Center for Clinical PharmacyNanjingChina
| | - Huaijun Zhu
- Department of PharmacyNanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese MedicineNanjingChina
- Nanjing Medical Center for Clinical PharmacyNanjingChina
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Li X, Cheng Y, Chen B, Chen Y, Huang Y, Zhang B, Que W, Liu M, Zhang H, Qiu H. Population pharmacokinetics of polymyxin B in patients with liver dysfunction. Br J Clin Pharmacol 2023; 89:3561-3572. [PMID: 37461291 DOI: 10.1111/bcp.15855] [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: 05/22/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 08/10/2023] Open
Abstract
AIMS Polymyxin B (PMB) is widely used to treat infections caused by multidrug-resistant Gram-negative pathogens. Currently, the pharmacokinetic data of PMB in patients with liver dysfunction are limited. This study aimed to develop a population pharmacokinetic (PopPK) model of PMB in patients with liver dysfunction and identify the factors affecting PMB pharmacokinetics. METHODS We conducted a retrospective pharmacokinetic study involving 136 adults with different levels of liver function. Nonlinear mixed effects modelling was used to develop a PopPK model of PMB. Monte Carlo simulation was used to design PMB dosage schedules across various liver and renal functions. RESULTS PMB pharmacokinetic analyses included 401 steady-state concentrations in 136 adult patients. A one-compartment pharmacokinetic model with first-order absorption and elimination was used to describe the data. The typical population value of PMB clearance was 2.43 L/h and the volume of distribution was 23.11 L. This study revealed that creatinine clearance (CrCL) and Child-Pugh class were significantly associated with PMB pharmacokinetic parameters; however, clinically relevant variations of dose-normalized drug exposure were not significant. For patients with a minimum inhibitory concentration of ≤0.5 mg/L, the appropriate dose was 40-75 mg/12-h. When the dose exceeded 100 mg/12-h, the risk of nephrotoxicity increased significantly. CONCLUSIONS This study provided PMB pharmacokinetic information for patients with liver dysfunction. Patients with renal and liver dysfunctions may not require an initial dose adjustment. Rather than PopPK-guided dose adjustment, therapeutic drug monitoring of PMB plays a more direct role in optimizing dosing regimens based on its therapeutic window.
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Affiliation(s)
- Xueyong Li
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Yu Cheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Bo Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Yiying Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Yingbin Huang
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Bingqing Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Wancai Que
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hui Zhang
- Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hongqiang Qiu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
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9
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Hanafin PO, Kwa A, Zavascki AP, Sandri AM, Scheetz MH, Kubin CJ, Shah J, Cherng BPZ, Yin MT, Wang J, Wang L, Calfee DP, Bolon M, Pogue JM, Purcell AW, Nation RL, Li J, Kaye KS, Rao GG. A population pharmacokinetic model of polymyxin B based on prospective clinical data to inform dosing in hospitalized patients. Clin Microbiol Infect 2023; 29:1174-1181. [PMID: 37217076 DOI: 10.1016/j.cmi.2023.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/03/2023] [Accepted: 05/14/2023] [Indexed: 05/24/2023]
Abstract
OBJECTIVES To develop a population pharmacokinetic (PK) model with data from the largest polymyxin B-treated patient population studied to date to optimize its dosing in hospitalized patients. METHODS Hospitalized patients receiving intravenous polymyxin B for ≥48 hours were enrolled. Blood samples were collected at steady state and drug concentrations were analysed by liquid chromotography tandem mass spectrometry (LC-MS/MS). Population PK analysis and Monte Carlo simulations were performed to determine the probability of target attainment (PTA). RESULTS One hundred and forty-two patients received intravenous polymyxin B (1.33-6 mg/kg/day), providing 681 plasma samples. Twenty-four patients were on renal replacement therapy, including 13 on continuous veno-venous hemodiafiltration (CVVHDF). A 2-compartment model adequately described the PK with body weight as a covariate on the volume of distribution that affected Cmax, but it did not impact clearance or exposure. Creatinine clearance was a statistically significant covariate on clearance, although clinically relevant variations of dose-normalized drug exposure were not observed across a wide creatinine clearance range. The model described higher clearance in CVVHDF patients than in non-CVVHDF patients. Maintenance doses of ≥2.5 mg/kg/day or ≥150 mg/day had a PTA ≥90% (for non-pulmonary infections target) at a steady state for minimum inhibitory concentrations ≤2 mg/L. The PTA at a steady state for CVVHDF patients was lower. DISCUSSION Fixed loading and maintenance doses of polymyxin B seemed to be more appropriate than weight-based dosing regimens in patients weighing 45-90 kg. Higher doses may be needed in patients on CVVHDF. Substantial variability in polymyxin B clearance and volume of distribution was found, suggesting that therapeutic drug monitoring may be indicated.
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Affiliation(s)
- Patrick O Hanafin
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrea Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore; Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore
| | - Alexandre P Zavascki
- Infectious Diseases Service, Hospital Moinhos de Vento, Porto Alegre, Brazil; Department of Internal Medicine, Medical School, Universidade Federal, Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Ana Maria Sandri
- Infection Control Department, Hospital São Lucas da Pontifícia Universidade Católica Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Marc H Scheetz
- Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA
| | - Christine J Kubin
- New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Jayesh Shah
- Division of Infectious Diseases, Department of Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Benjamin P Z Cherng
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | - Michael T Yin
- Division of Infectious Diseases, Department of Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Jiping Wang
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Lu Wang
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - David P Calfee
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Maureen Bolon
- Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, IL, USA; Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Anthony W Purcell
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia; Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Jian Li
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Keith S Kaye
- Division of Allergy, Immunology and Infectious Diseases, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Gauri G Rao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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10
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Zheng Y, Xu B, Chen S, Liu M, Huang H, Wang J, Wu X. Population Pharmacokinetic Modeling Using Polymyxin B Free Plasma Concentrations From Published Reports and Evaluation of Dosage Regimens Based on Monte Carlo Simulation in Critically Ill Patients. J Clin Pharmacol 2023; 63:1036-1044. [PMID: 37125471 DOI: 10.1002/jcph.2261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/02/2023]
Abstract
A population pharmacokinetic (pop PK) model of polymyxin B was developed using nonlinear mixed-effects (NONMEM) modeling based on free plasma concentrations to determine whether dose adjustment is required in critically ill patients. One thousand pharmacokinetic profiles for virtual patients with a body weight of 70 kg were simulated using Monte Carlo simulation at different dose scenarios, and area under the concentration-time curve of free drug (fAUC) was computed. The probability of target attainment (PTA) at each minimum inhibitory concentration (MIC) was calculated using fAUC/MIC as a pharmacokinetic/pharmacodynamic (PK/PD) index. The final population PK model was a 2-compartment model. PTA showed that 3.5 mg/kg/day regimens of polymyxin B effectively achieved the fAUC/MIC target of 10 (one log10 kill) against Pseudomonas aeruginosa strains with MIC of 1 mg/L or less (PTA, 90.7% or greater), while the dose regimen were ineffective against strains with an MIC of 2 mg/L or greater (PTA, 56.9% or less). For Klebsiella pneumoniae, the fAUC/MIC target of 17.4 (one log10 kill) was achieved in more than 90.4% of cases for MIC of 0.5 mg/L or less with 3 mg/kg/day regimens. However, the PTA decreased dramatically as MICs increased above 1 mg/L (PTA, 56.1% or less). The polymyxin B dosage regimen of 3.5 mg/kg/day and 3 mg/kg/day are sufficient to treat P. aeruginosa infections with an MIC of 1 mg/L or less and K. pneumoniae infections with an MIC of 0.5 mg/L or less, respectively. The current recommended dose (1.5-3 mg/kg/day) of polymyxin B appears inadequate to attain the PK/PD target for therapeutic efficacy against infections caused by P. aeruginosa and K. pneumoniae isolates when MIC is above the values.
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Affiliation(s)
- You Zheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Baohua Xu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Shengyang Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Huiping Huang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Jingting Wang
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Xuemei Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
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11
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Wang P, Liu S, Qi G, Xu M, Sun T, Yang J. Evaluation of polymyxin B AUC/MIC ratio for dose optimization in patients with carbapenem-resistant Klebsiella pneumoniae infection. Front Microbiol 2023; 14:1226981. [PMID: 37675417 PMCID: PMC10477696 DOI: 10.3389/fmicb.2023.1226981] [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: 05/22/2023] [Accepted: 07/31/2023] [Indexed: 09/08/2023] Open
Abstract
Polymyxin B has been used as a last-line therapy for the treatment of carbapenem-resistant gram-negative bacterial infection. The pharmacokinetic/pharmacodynamic index (AUC/MIC) of polymyxin B has not been clinically evaluated, given that the broth microdilution method for polymyxin susceptibility testing is rarely used in hospitals. This study analyzed data from 77 patients with carbapenem-resistant Klebsiella pneumoniae infections. Among the samples, 63 K. pneumoniae isolates had MIC values of 1.0 mg/L as measured by broth microdilution but 0.5 mg/L as measured using the Vitek 2 system. Polymyxin B AUC/MIC was significantly associated with clinical response (p = 0.002) but not with 30-day all-cause mortality (p = 0.054). With a target AUC/MIC value of 50, Monte Carlo simulations showed that a fixed dose of 100 mg/12 h and three weight-based regimens (1.25 mg/kg/12 h for 80 kg and 1.5 mg/kg/12 h for 70 kg/80 kg) achieved a cumulative fraction of response >90% regardless of renal function, but the risk of nephrotoxicity was high. For patients with carbapenem-resistant K. pneumoniae infections, the underestimation of polymyxin resistance in automated systems need to be taken into account when optimizing polymyxin B dosing based on pharmacokinetic/pharmacodynamic principles.
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Affiliation(s)
- Peile Wang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Application and Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Shaohua Liu
- Department of General Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guangzhao Qi
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Min Xu
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- Department of General Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
- Henan Engineering Research Center for Application and Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
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12
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Liu S, Wu Y, Qi S, Shao H, Feng M, Xing L, Liu H, Gao Y, Zhu Z, Zhang S, Du Y, Lu Y, Yang J, Chen P, Sun T. Polymyxin B therapy based on therapeutic drug monitoring in carbapenem-resistant organisms sepsis: the PMB-CROS randomized clinical trial. Crit Care 2023; 27:232. [PMID: 37312218 PMCID: PMC10262552 DOI: 10.1186/s13054-023-04522-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/04/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND The appropriate administration regimen of polymyxin B is yet controversial. The present study aimed to explore the optimal dose of polymyxin B under therapeutic drug monitoring (TDM) guidance. METHODS In China's Henan province, 26 hospitals participated in a randomized controlled trial. We included patients with sepsis caused by carbapenem-resistant Gram-negative bacteria (CR-GNB) susceptible to polymyxin B. The patients were randomly divided into a high-dose (HD) group or a low-dose (LD) group and received 150 mg loading dose, 75 mg every 12 h and 100 mg loading dose, 50 mg every 12 h, respectively. TDM was employed to determine if the dose of polymyxin B needs adjustment based on the area under the concentration-time curve across 24 h at a steady state (ssAUC0-24) of 50-100 mg h/L. The primary outcome was the 14-day clinical response, and the secondary outcomes included 28- and 14-day mortality. RESULTS This trial included 311 patients, with 152 assigned to the HD group and 159 assigned to the LD group. Intention-to-treat analysis showed that the 14-day clinical response was non-significant (p = 0.527): 95/152 (62.5%) in the HD group and 95/159 (59.7%) in the LD group. Kaplan-Meier's 180-day survival curve showed survival advantage in the HD group than in the LD group (p = 0.037). More patients achieved the target ssAUC0-24 in the HD than in the LD group (63.8% vs. 38.9%; p = 0.005) and in the septic shock subgroup compared to all subjects (HD group: 71.4% vs. 63.8%, p = 0.037; LD group: 58.3% vs. 38.9%, p = 0.0005). Also, the target AUC compliance was not correlated with clinical outcomes but with acute kidney injury (AKI) (p = 0.019). Adverse events did not differ between the HD and LD groups. CONCLUSION A fixed polymyxin B loading dose of 150 mg and a maintenance dose of 75 mg every 12 h was safe for patients with sepsis caused by CR-GNB and improves long-term survival. The increased AUC was associated with increased incidence of AKI, and TDM results were valued to prevent AKI. Trial registration Trial registration ClinicalTrials.gov: ChiCTR2100043208, Registration date: January 26, 2021.
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Affiliation(s)
- Shaohua Liu
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, 450052, People's Republic of China
| | - Ying Wu
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Shaoyan Qi
- Department of ICU, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People's Republic of China
| | - Huanzhang Shao
- Department of ICU, Henan Provincial People's Hospital, Zhengzhou, 450052, People's Republic of China
| | - Min Feng
- Department of Surgery ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People's Republic of China
| | - Lihua Xing
- Department of Respiratory ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People's Republic of China
| | - Hongmei Liu
- Department of Respiratory ICU, Henan Provincial People's Hospital, Zhengzhou, 450052, People's Republic of China
| | - Yanqiu Gao
- Department of Respiratory ICU, Zhengzhou Central Hospital, Zhengzhou, 450052, People's Republic of China
| | - Zhiqiang Zhu
- Department of Emergency ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People's Republic of China
| | - Shuguang Zhang
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, 450052, People's Republic of China
| | - Yuming Du
- Department of Surgery ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People's Republic of China
| | - Yibin Lu
- Department of ICU, Xinyang Central Hospital, Xinyang, 464000, People's Republic of China
| | - Jing Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, People's Republic of China
| | - Pingyan Chen
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Tongwen Sun
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, 450052, People's Republic of China.
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13
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Tang T, Li Y, Xu P, Zhong Y, Yang M, Ma W, Xiang D, Zhang B, Zhou Y. Optimization of polymyxin B regimens for the treatment of carbapenem-resistant organism nosocomial pneumonia: a real-world prospective study. Crit Care 2023; 27:164. [PMID: 37106370 PMCID: PMC10142183 DOI: 10.1186/s13054-023-04448-z] [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: 11/24/2022] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Polymyxin B is the first-line therapy for Carbapenem-resistant organism (CRO) nosocomial pneumonia. However, clinical data for its pharmacokinetic/pharmacodynamic (PK/PD) relationship are limited. This study aimed to investigate the relationship between polymyxin B exposure and efficacy for the treatment of CRO pneumonia in critically ill patients, and to optimize the individual dosing regimens. METHODS Patients treated with polymyxin B for CRO pneumonia were enrolled. Blood samples were assayed using a validated high-performance liquid chromatography-tandem mass spectrometry method. Population PK analysis and Monte Carlo simulation were performed using Phoenix NLME software. Logistic regression analyses and receiver operating characteristic (ROC) curve were employed to identify the significant predictors and PK/PD indices of polymyxin B efficacy. RESULTS A total of 105 patients were included, and the population PK model was developed based on 295 plasma concentrations. AUCss,24 h/MIC (AOR = 0.97, 95% CI 0.95-0.99, p = 0.009), daily dose (AOR = 0.98, 95% CI 0.97-0.99, p = 0.028), and combination of inhaled polymyxin B (AOR = 0.32, 95% CI 0.11-0.94, p = 0.039) were independent risk factors for polymyxin B efficacy. ROC curve showed that AUCss,24 h/MIC is the most predictive PK/PD index of polymyxin B for the treatment of nosocomial pneumonia caused by CRO, and the optimal cutoff point value was 66.9 in patients receiving combination therapy with another antimicrobial. Model-based simulation suggests that the maintaining daily dose of 75 and 100 mg Q12 h could achieve ≥ 90% PTA of this clinical target at MIC values ≤ 0.5 and 1 mg/L, respectively. For patients unable to achieve the target concentration by intravenous administration, adjunctive inhalation of polymyxin B would be beneficial. CONCLUSIONS For CRO pneumonia, daily dose of 75 and 100 mg Q12 h was recommended for clinical efficacy. Inhalation of polymyxin B is beneficial for patients who cannot achieve the target concentration by intravenous administration.
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Affiliation(s)
- Tiantian Tang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
- Hunan Provincial Engineering Research Centre of Translational Medicine and Innovative Drug, Changsha, China
| | - Ying Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Ping Xu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Yanjun Zhong
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Min Yang
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wanjun Ma
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Daxiong Xiang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
- Hunan Provincial Engineering Research Centre of Translational Medicine and Innovative Drug, Changsha, China
| | - Bikui Zhang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Yangang Zhou
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.
- Institute of Clinical Pharmacy, Central South University, Changsha, China.
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14
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Liang D, Liang Z, Deng G, Cen A, Luo D, Zhang C, Ni S. Population pharmacokinetic analysis and dosing optimization of polymyxin B in critically ill patients. Front Pharmacol 2023; 14:1122310. [PMID: 37063299 PMCID: PMC10090446 DOI: 10.3389/fphar.2023.1122310] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/16/2023] [Indexed: 03/31/2023] Open
Abstract
Objectives: Since the global broadcast of multidrug-resistant gram-negative bacteria is accelerating, the use of Polymyxin B is sharply increasing, especially in critically ill patients. Unsatisfactory therapeutic effects were obtained because of the abnormal physiological function in critically ill patients. Therefore, the determination of optimal polymyxin B dosage becomes highly urgent. This study aimed to illustrate the polymyxin B pharmacokinetic characteristics by defining the influencing factors and optimizing the dosing regimens to achieve clinical effectiveness.Methods: Steady-state concentrations of polymyxin B from twenty-two critically ill patients were detected by a verified liquid chromatography-tandem mass spectrometry approach. The information on age, weight, serum creatinine, albumin levels, and Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score was also collected. The population PK parameters were calculated by the non-parametric adaptive grid method in Pmetrics software, and the pharmacokinetic/pharmacodynamics target attainment rate was determined by the Monte Carlo simulation method.Results: The central clearance and apparent volume of distribution for polymyxin B were lower in critically ill patients (1.24 ± 0.38 L h-1 and 16.64 ± 12.74 L, respectively). Moreover, albumin (ALB) levels can be used to explain the variability in clearance, and age can be used to describe the variability in the apparent volume of distribution. For maintaining clinical effectiveness and lowering toxicity, 75 mg q12 h is the recommended dosing regimen for most patients suffering from severe infections.Conclusion: This study has clearly defined that in critically ill patients, age and ALB levels are potentially important factors for the PK parameters of polymyxin B. Since older critically ill patients tend to have lower ALB levels, so higher dosages of polymyxin B are necessary for efficacy.
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Affiliation(s)
- Danhong Liang
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, Guangdong, China
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Zhi Liang
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Guoliang Deng
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, Guangdong, China
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Anfen Cen
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, Guangdong, China
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Dandan Luo
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Chen Zhang
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, Guangdong, China
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
- *Correspondence: Chen Zhang, ; Suiqin Ni,
| | - Suiqin Ni
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou, Guangdong, China
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
- *Correspondence: Chen Zhang, ; Suiqin Ni,
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15
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Pi MY, Cai CJ, Zuo LY, Zheng JT, Zhang ML, Lin XB, Chen X, Zhong GP, Xia YZ. Population pharmacokinetics and limited sampling strategies of polymyxin B in critically ill patients. J Antimicrob Chemother 2023; 78:792-801. [PMID: 36702748 DOI: 10.1093/jac/dkad012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/02/2023] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To characterize the pharmacokinetics (PK) of polymyxin B in Chinese critically ill patients. The factors significantly affecting PK parameters are identified, and a limited sampling strategy for therapeutic drug monitoring of polymyxin B is explored. METHODS Thirty patients (212 samples) were included in a population PK analysis. A limited sampling strategy was developed using Bayesian estimation, multiple linear regression and modified integral equations. Non-linear mixed-effects models were developed using Phoenix NLME software. RESULTS A two-compartment population PK model was used to describe polymyxin B PK. Population estimates of the volumes of central compartment distribution (V) and peripheral compartment distribution (V2), central compartment clearance (CL) and intercompartmental clearance (Q) were 7.857 L, 12.668 L, 1.672 L/h and 7.009 L/h. Continuous renal replacement therapy (CRRT) significantly affected CL, and body weight significantly affected CL and Q. The AUC0-12h of polymyxin B in patients with CRRT was significantly lower than in patients without CRRT. CL and Q increased with increasing body weight. A limited sampling strategy was suggested using a two-sample scheme with plasma at 0.5h and 8h after the end of infusion (C0.5 and C8) for therapeutic drug monitoring in the clinic. CONCLUSIONS A dosing regimen should be based on body weight and the application of CRRT. A two-sample strategy for therapeutic drug monitoring could facilitate individualized treatment with polymyxin B in critically ill patients.
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Affiliation(s)
- Meng-Ying Pi
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China.,School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Chang-Jie Cai
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ling-Yun Zuo
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jun-Tao Zheng
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Miao-Lun Zhang
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China.,School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Bin Lin
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Guo-Ping Zhong
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Yan-Zhe Xia
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
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16
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Zhao Y, Chen H, Yu Z. Trough concentration may not be a good target for polymyxin B therapeutic drug monitoring. Crit Care 2023; 27:41. [PMID: 36698153 PMCID: PMC9878747 DOI: 10.1186/s13054-023-04326-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/19/2023] [Indexed: 01/26/2023] Open
Affiliation(s)
- Yuhua Zhao
- grid.410595.c0000 0001 2230 9154Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hanghzou, China
| | - Huadong Chen
- grid.268099.c0000 0001 0348 3990Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, China
| | - Zhenwei Yu
- grid.13402.340000 0004 1759 700XSir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Wang P, Liu D, Sun T, Zhang X, Yang J. Pharmacokinetics and pharmacodynamics of polymyxin B and proposed dosing regimens in elderly patients with multi-drug-resistant Gram-negative bacterial infections. Int J Antimicrob Agents 2022; 60:106693. [PMID: 36375775 DOI: 10.1016/j.ijantimicag.2022.106693] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/30/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
There are limited data on the pharmacokinetics (PK) and pharmacodynamics (PD) of polymyxin B in the elderly population. The objective of this study was to develop a population PK model of polymyxin B in elderly patients, determine factors that affect its PK parameters, and propose alternative dosing regimens. Critically ill elderly patients (age ≥65 years) who received intravenous polymyxin B for multi-drug-resistant Gram-negative bacterial infections were enrolled. A population PK model was developed using Phoenix NLME software. Monte Carlo simulations were performed to optimize regimens attaining the PK/PD target of AUC24h/MIC >50 and target exposure of 50-100 mg‧h/L. Clinical efficacy and nephrotoxicity of polymyxin B treatment were also assessed. A total of 142 polymyxin B concentrations from 23 patients were available. A two-compartment model with first-order elimination was developed, and albumin was the significant covariate of PK parameters. However, albumin had only a slight effect on polymyxin B exposure. Simulation results indicated that two fixed regimens of 50 mg and 75 mg would be sufficient to reach the PK/PD targets when the minimum inhibitory concentrations was ≤0.5 mg/L. With the exception of 1.25 mg/kg for 58 kg, other weight-based regimens (1.25-1.5 mg/kg for 70 kg and 80 kg; twice daily) may result in at least 40% of predicted AUCss,24h >100 mg‧h/L. In conclusion, fixed maintenance dosing of 50 mg and 75 mg for polymyxin B may maximize efficacy while balancing nephrotoxicity concerns for elderly patients.
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Affiliation(s)
- Peile Wang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Dongmei Liu
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- Department of General Intensive Care Unit, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaojian Zhang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China.
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18
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Evaluation and Validation of the Limited Sampling Strategy of Polymyxin B in Patients with Multidrug-Resistant Gram-Negative Infection. Pharmaceutics 2022; 14:pharmaceutics14112323. [PMID: 36365141 PMCID: PMC9698835 DOI: 10.3390/pharmaceutics14112323] [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: 08/31/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 11/30/2022] Open
Abstract
Polymyxin B (PMB) is the final option for treating multidrug-resistant Gram-negative bacterial infections. The acceptable pharmacokinetic/pharmacodynamic target is an area under the concentration–time curve across 24 h at a steady state (AUCss,24h) of 50–100 mg·h/L. The limited sampling strategy (LSS) is useful for predicting AUC values. However, establishing an LSS is a time-consuming process requiring a relatively dense sampling of patients. Further, given the variability among different centers, the predictability of LSSs is frequently questioned when it is extrapolated to other clinical centers. Currently, limited data are available on a reliable PMB LSS for estimating AUCss,24h. This study assessed and validated the practicability of LSSs established in the literature based on data from our center to provide reliable and ready-made PMB LSSs for laboratories performing therapeutic drug monitoring (TDM) of PMB. The influence of infusion and sampling time errors on predictability was also explored to obtain the optimal time points for routine PMB TDM. Using multiple regression analysis, PMB LSSs were generated from a model group of 20 patients. A validation group (10 patients) was used to validate the established LSSs. PMB LSSs from two published studies were validated using a dataset of 30 patients from our center. A population pharmacokinetic model was established to simulate the individual plasma concentration profiles for each infusion and sampling time error regimen. Pharmacokinetic data obtained from the 30 patients were fitted to a two-compartment model. Infusion and sampling time errors observed in real-world clinical practice could considerably affect the predictability of PMB LSSs. Moreover, we identified specific LSSs to be superior in predicting PMB AUCss,24h based on different infusion times. We also discovered that sampling time error should be controlled within −10 to 15 min to obtain better predictability. The present study provides validated PMB LSSs that can more accurately predict PMB AUCss,24h in routine clinical practice, facilitating PMB TDM in other laboratories and pharmacokinetics/pharmacodynamics-based clinical studies in the future.
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Yang J, Liu S, Lu J, Sun T, Wang P, Zhang X. An area under the concentration-time curve threshold as a predictor of efficacy and nephrotoxicity for individualizing polymyxin B dosing in patients with carbapenem-resistant gram-negative bacteria. Crit Care 2022; 26:320. [PMID: 36258197 PMCID: PMC9578216 DOI: 10.1186/s13054-022-04195-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Evidence supports therapeutic drug monitoring of polymyxin B, but clinical data for establishing an area under the concentration-time curve across 24 h at steady state (AUCss,24 h) threshold are still limited. This study aimed to examine exposure-response/toxicity relationship for polymyxin B to establish an AUCss,24 h threshold in a real-world cohort of patients. METHODS Using a validated Bayesian approach to estimate AUCss,24 h from two samples, AUCss,24 h threshold that impacted the risk of polymyxin B-related nephrotoxicity and clinical response were derived by classification and regression tree (CART) analysis and validated by Cox regression analysis and logical regression analysis. RESULTS A total of 393 patients were included; acute kidney injury (AKI) was 29.0%, clinical response was 63.4%, and 30-day all-cause mortality was 35.4%. AUCss,24 h thresholds for AKI of > 99.4 mg h/L and clinical response of > 45.7 mg h/L were derived by CART analysis. Cox and logical regression analyses showed that AUCss,24 h of > 100 mg h/L was a significant predictor of AKI (HR 16.29, 95% CI 8.16-30.25, P < 0.001) and AUCss,24 h of ≥ 50 mg h/L (OR 4.39, 95% CI 2.56-7.47, P < 0.001) was independently associated with clinical response. However, these exposures were not associated with mortality. In addition, the correlation between trough concentration (1.2-2.8 mg/L) with outcomes was similar to AUCss,24 h. CONCLUSIONS For critically ill patients, AUCss,24 h threshold of 50-100 mg h/L was associated with decreased nephrotoxicity while assuring clinical efficacy. Therapeutic drug monitoring is recommended for individualizing polymyxin B dosing.
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Affiliation(s)
- Jing Yang
- grid.412633.10000 0004 1799 0733Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan 45005 People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Engineering Research Center for Application and Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Shaohua Liu
- grid.412633.10000 0004 1799 0733Department of General Intensive Care Unit, First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Jingli Lu
- grid.412633.10000 0004 1799 0733Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan 45005 People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Engineering Research Center for Application and Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Tongwen Sun
- grid.412633.10000 0004 1799 0733Department of General Intensive Care Unit, First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Peile Wang
- grid.412633.10000 0004 1799 0733Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan 45005 People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Engineering Research Center for Application and Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Xiaojian Zhang
- grid.412633.10000 0004 1799 0733Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan 45005 People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Engineering Research Center for Application and Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China
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20
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Cai XJ, Chen Y, Zhang XS, Wang YZ, Zhou WB, Zhang CH, Wu B, Song HZ, Yang H, Yu XB. Population pharmacokinetic analysis, renal safety, and dosing optimization of polymyxin B in lung transplant recipients with pneumonia: A prospective study. Front Pharmacol 2022; 13:1019411. [PMID: 36313312 PMCID: PMC9608142 DOI: 10.3389/fphar.2022.1019411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/03/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives: This study aims to characterize the population pharmacokinetics of polymyxin B in lung transplant recipients and optimize its dosage regimens. Patients and methods: This prospective study involved carbapenem-resistant organisms-infected patients treated with polymyxin B. The population pharmacokinetic model was developed using the NONMEM program. The clinical outcomes including clinical treatment efficacy, microbiological efficacy, nephrotoxicity, and hyperpigmentation were assessed. Monte Carlo simulation was performed to calculate the probability of target attainment in patients with normal or decreased renal function. Results: A total of 34 hospitalized adult patients were included. 29 (85.29%) patients were considered of clinical cure or improvement; 14 (41.18%) patients had successful bacteria elimination at the end of the treatment. Meanwhile, 5 (14.71%) patients developed polymyxin B-induced nephrotoxicity; 19 (55.88%) patients developed skin hyperpigmentation. A total of 164 concentrations with a range of 0.56–11.66 mg/L were obtained for pharmacokinetic modeling. The pharmacokinetic characteristic of polymyxin B was well described by a 1-compartment model with linear elimination, and only creatinine clearance was identified as a covariate on the clearance of polymyxin B. Monte Carlo simulations indicated an adjusted dosage regimen might be needed in patients with renal insufficiency and the currently recommended dose regimens by the label sheet of polymyxin B may likely generate a subtherapeutic exposure for MIC = 2 mg/L. Conclusion: Renal function has a significant effect on the clearance of polymyxin B in lung transplant recipients, and an adjustment of dosage was needed in patients with renal impairments.
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Affiliation(s)
- Xiao-Jun Cai
- Department of Pharmacy, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Yan Chen
- Division of Pharmacy, Wuxi Higher Health Vocational Technology School, Wuxi, China
| | - Xiao-Shan Zhang
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- School of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Yu-Zhen Wang
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- School of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Wen-Bo Zhou
- Department of Pharmacy, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Chun-Hong Zhang
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bo Wu
- Lung Transplant Center, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Hui-Zhu Song
- Department of Pharmacy, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
- *Correspondence: Hui-Zhu Song, ; Hang Yang, ; Xu-Ben Yu,
| | - Hang Yang
- Lung Transplant Center, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
- *Correspondence: Hui-Zhu Song, ; Hang Yang, ; Xu-Ben Yu,
| | - Xu-Ben Yu
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- School of Pharmacy, Chonnam National University, Gwangju, South Korea
- *Correspondence: Hui-Zhu Song, ; Hang Yang, ; Xu-Ben Yu,
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21
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Xie YL, Jin X, Yan SS, Wu CF, Xiang BX, Wang H, Liang W, Yang BC, Xiao XF, Li ZL, Pei Q, Zuo XC, Peng Y. Population pharmacokinetics of intravenous colistin sulfate and dosage optimization in critically ill patients. Front Pharmacol 2022; 13:967412. [PMID: 36105229 PMCID: PMC9465641 DOI: 10.3389/fphar.2022.967412] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Aims: To explore the population pharmacokinetics of colistin sulfate and to optimize the dosing strategy for critically ill patients.Methods: The study enrolled critically ill adult patients who received colistin sulfate intravenously for more than 72 h with at least one measurement of plasma concentration. Colistin concentrations in plasma or urine samples were measured by ultraperformance liquid chromatography tandem mass spectrometry (LC-MS/MS). The population pharmacokinetics (PPK) model for colistin sulfate was developed using the Phoenix NLME program. Monte Carlo simulation was conducted to evaluate the probability of target attainment (PTA) for optimizing dosing regimens.Results: A total of 98 plasma concentrations from 20 patients were recorded for PPK modeling. The data were adequately described by a two-compartment model with linear elimination. During modeling, creatinine clearance (CrCL) and alanine aminotransferase (ALT) were identified as covariates of the clearance (CL) and volume of peripheral compartment distribution (V2), respectively. In addition, colistin sulfate was predominantly cleared by the nonrenal pathway with a median urinary recovery of 10.05% with large inter-individual variability. Monte Carlo simulations revealed a greater creatinine clearance associated with a higher risk of sub-therapeutic exposure to colistin sulfate. The target PTA (≥90%) of dosage regimens recommended by the label sheet was achievable only in patients infected by pathogens with MIC ≤0.5 mg/L or with renal impairments.Conclusion: Our study showed that the dose of intravenous colistin sulfate was best adjusted by CrCL and ALT. Importantly, the recommended dosing regimen of 1.0–1.5 million units daily was insufficient for patients with normal renal functions (CrCL ≥80 ml/min) or those infected by pathogens with MIC ≥1.0 mg/L. The dosage of colistin sulfate should be adjusted according to renal function and drug exposure.
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Affiliation(s)
- Yue-liang Xie
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
- Department of Pharmacy and Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xin Jin
- Department of ICU, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Shan-shan Yan
- Department of ICU, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Cui-fang Wu
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
- Department of Pharmacy and Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Bi-xiao Xiang
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
- College of Pharmacy, Zunyi Medical University, Guizhou, China
| | - Hui Wang
- Department of ICU, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Wu Liang
- Changsha VALS Technology Co. Ltd., Changsha, China
| | - Bing-chang Yang
- Department of ICU, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Xue-fei Xiao
- Department of ICU, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Zhi-ling Li
- Department of ICU, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Qi Pei
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
- Department of Pharmacy and Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiao-cong Zuo
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
- Department of Pharmacy and Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Xiao-cong Zuo, ; Yue Peng,
| | - Yue Peng
- Department of ICU, The Third Xiangya Hospital of Central South University, Changsha, China
- Sepsis Translational Medicine Key Laboratory of Hunan Province, Central South University, Changsha, China
- *Correspondence: Xiao-cong Zuo, ; Yue Peng,
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22
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Liu J, Shao M, Xu Q, Liu F, Pan X, Wu J, Xiong L, Wu Y, Tian M, Yao J, Huang S, Zhang L, Chen Y, Zhang S, Wen Z, Du H, TaoWang, Liu Y, Li W, Xu Y, Teboul JL, Chen D. Low-dose intravenous plus inhaled versus intravenous polymyxin B for the treatment of extensive drug-resistant Gram-negative ventilator-associated pneumonia in the critical illnesses: a multi-center matched case-control study. Ann Intensive Care 2022; 12:72. [PMID: 35934730 PMCID: PMC9357592 DOI: 10.1186/s13613-022-01033-5] [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] [Received: 04/14/2022] [Accepted: 06/11/2022] [Indexed: 12/14/2022] Open
Abstract
Background The mortality of extensively drug-resistant Gram-negative (XDR GN) bacilli-induced ventilator-associated pneumonia (VAP) is extremely high. The purpose of this study was to compare the efficacy and safety of inhaled (IH) plus intravenous (IV) polymyxin B versus IV polymyxin B in XDR GN bacilli VAP patients. Methods A retrospective multi-center observational cohort study was performed at eight ICUs between January 1st 2018, and January 1st 2020 in China. Data from all patients treated with polymyxin B for a microbiologically confirmed VAP were analyzed. The primary endpoint was the clinical cure of VAP. The favorable clinical outcome, microbiological outcome, VAP-related mortality and all-cause mortality during hospitalization, and side effects related with polymyxin B were secondary endpoints. Favorable clinical outcome included clinical cure or clinical improvement. Results 151 patients and 46 patients were treated with IV polymyxin B and IH plus IV polymyxin B, respectively. XDR Klebsiella pneumoniae was the main isolated pathogen (n = 83, 42.1%). After matching on age (± 5 years), gender, septic shock, and Apache II score (± 4 points) when polymyxin B was started, 132 patients were included. 44 patients received simultaneous IH plus IV polymyxin B and 88 patients received IV polymyxin B. The rates of clinical cure (43.2% vs 27.3%, p = 0.066), bacterial eradication (36.4% vs 23.9%, p = 0.132) as well as VAP-related mortality (27.3% vs 34.1%, p = 0.428), all-cause mortality (34.1% vs 42.0%, p = 0.378) did not show any significant difference between the two groups. However, IH plus IV polymyxin B therapy was associated with improved favorable clinical outcome (77.3% vs 58.0%, p = 0.029). Patients in the different subgroups (admitted with medical etiology, infected with XDR K. pneumoniae, without bacteremia, with immunosuppressive status) were with odd ratios (ORs) in favor of the combined therapy. No patient required polymyxin B discontinuation due to adverse events. Additional use of IH polymyxin B (aOR 2.63, 95% CI 1.06, 6.66, p = 0.037) was an independent factor associated with favorable clinical outcome. Conclusions The addition of low-dose IH polymyxin B to low-dose IV polymyxin B did not provide efficient clinical cure and bacterial eradication in VAP caused by XDR GN bacilli. Keypoints Additional use of IH polymyxin B was the sole independent risk factor of favorable clinical outcome. Patients in the different subgroups were with HRs substantially favoring additional use of IH polymyxin B. No patients required polymyxin B discontinuation due to adverse events. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01033-5.
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Affiliation(s)
- Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - Min Shao
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
| | - Qianghong Xu
- Department of Critical Care Medicine, Zhejiang Hospital, No.12 Lingyin Road, HangZhou, 310015, China
| | - Fen Liu
- Department of Critical Care Medicine, the First Affiliated Hospital of Nanchang University, No.17, YongwaiZheng Street, Nanchang, 330006, Jiangxi, China
| | - Xiaojun Pan
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - Jianfeng Wu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Er Road, Guangzhou, 510010, China
| | - Lihong Xiong
- Department of Intensive Care Unit, The Second People's Hospital of Shenzhen, Futian District, Sungang West Road, Shenzhen, 3002518035, China
| | - Yueming Wu
- Emergency and Critical Care Center, Lishui People's Hospital, No. 15 Dazhong Road, Lishui, 323000, China
| | - Mi Tian
- Department of Intensive Care Unit, Huashan Hospital, Fudan University, No. 12 Middle Urumqi Road, Shanghai, 200040, China
| | - Jianying Yao
- Department of Intensive Care Unit, The First People's Hospital of KunShan, No 91, Qianjin Road, KunShan, 215300, China
| | - Sisi Huang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - Lidi Zhang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - Yizhu Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - Sheng Zhang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - Zhenliang Wen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - Hangxiang Du
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - TaoWang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - Yongan Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - Wenzhe Li
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - Yan Xu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China
| | - Jean-Louis Teboul
- Service de Médecine-Intensive Réanimation, Hôpital Bicêtre, AP-HP. Université Paris-Saclay, Inserm UMR 999, Université Paris-Saclay, 94270, Le Kremlin-Bicêtre, France
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Ruijin 2nd Road, Shanghai, 201801, China.
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23
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Wang PL, Liu P, Zhang QW, Yuan WH, Wang D, Zhang XJ, Yang J. Population pharmacokinetics and clinical outcomes of polymyxin B in paediatric patients with multidrug-resistant Gram-negative bacterial infections. J Antimicrob Chemother 2022; 77:3000-3008. [PMID: 35924405 DOI: 10.1093/jac/dkac265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/15/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Current polymyxin B dosing in children relies on scant data. OBJECTIVES To build a population pharmacokinetic (PK) model for polymyxin B in paediatric patients and assess the likely appropriateness of different dosages. METHODS A total of 19 paediatric patients were enrolled to receive intravenous polymyxin B (1.33-2.53 mg/kg/day), and the median age was 12.5 (range 3.2-17.8) years. Serial plasma samples were collected at steady-state and modelled by population PK analysis. Clinical efficacy and nephrotoxicity of polymyxin B treatment were also assessed. RESULTS PK data were adequately described by a two-compartment model with first-order elimination, and weight was a significant covariate of polymyxin B clearance. Clinical success occurred in 14 of 19 patients (73.7%) and only one patient developed acute kidney injury. The 28 day mortality was 10.5% (2/19). The steady-state polymyxin B exposure was 36.97 ± 9.84 mg·h/L, lower than the therapeutic exposure of 50-100 mg·h/L. With the AUC24h/MIC target of 50, the dosage of 1.5-3.0 mg/kg/day had a probability of target attainments over 90% when MICs were <0.5 mg/L. CONCLUSIONS Dose adjustment of polymyxin B needs to consider the MIC of infecting pathogens. Current polymyxin B dosing for paediatric patients may be acceptable when MICs are <0.5 mg/L.
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Affiliation(s)
- Pei Le Wang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Peng Liu
- Department of Pediatric Intensive Care Unit, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qi Wen Zhang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Wen Hua Yuan
- Department of Pediatric Intensive Care Unit, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dao Wang
- Department of Pediatrics, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiao Jian Zhang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
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24
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Yu XB, Zhang XS, Wang YX, Wang YZ, Zhou HM, Xu FM, Yu JH, Zhang LW, Dai Y, Zhou ZY, Zhang CH, Lin GY, Pan JY. Population Pharmacokinetics of Colistin Sulfate in Critically Ill Patients: Exposure and Clinical Efficacy. Front Pharmacol 2022; 13:915958. [PMID: 35784679 PMCID: PMC9243584 DOI: 10.3389/fphar.2022.915958] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Presently, colistin is commercially available in two different forms, namely, colistin sulfate and its sulphomethylated derivative, colistimethate sodium (CMS). However, in the currently reported studies, most of the clinical studies on colistin for parenteral use are referred to as CMS. Data on the pharmacokinetics (PK), clinical efficacy, and side effects of colistin sulfate in clinical use have not been reported.Methods: This retrospective study was performed on carbapenem-resistant organism (CRO)-infected patients treated with colistin sulfate for more than 72 h. The population pharmacokinetic model was developed using the NONMEM program. The clinical outcomes including clinical treatment efficacy, microbiological eradication, and nephrotoxicity were assessed. Monte Carlo simulation was utilized to calculate the probability of target attainment (PTA) in patients with normal or decreased renal function.Results: A total of 42 patients were enrolled, of which 25 (59.52%) patients were considered clinical treatment success and 29 (69.06%) patients had successful bacteria elimination at the end of treatment. Remarkably, no patient developed colistin sulfate-related nephrotoxicity. A total of 112 colistin concentrations with a range of 0.28–6.20 mg/L were included for PK modeling. The PK characteristic of colistin was well illustrated by a one-compartment model with linear elimination, and creatinine clearance (CrCL) was identified as a covariate on the clearance of colistin sulfate that significantly explained inter-individual variability. Monte Carlo simulations showed that the recommended dose regimen of colistin sulfate, according to the label sheet, of a daily dose of 1–1.5 million IU/day, given in 2–3 doses, could attain PTA > 90% for MICs ≤ 0.5 μg/mL, and that a daily dose of 1 million IU/day could pose a risk of subtherapeutic exposure for MIC ≥1 μg/ml in renal healthy patients.Conclusion: Renal function significantly affects the clearance of colistin sulfate. A dose of 750,000 U every 12 h was recommended for pathogens with MIC ≤1 μg/ml. The dosage recommended by the label inserts had a risk of subtherapeutic exposure for pathogens with MIC ≥2 μg/ml. Despite higher exposure to colistin in patients with acute renal insufficiency, dose reduction was not recommended.
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Affiliation(s)
- Xu-ben Yu
- Department of Pharmacy, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- School of Pharmacy, Chonnam National University, Gwangju, South Korea
- *Correspondence: Xu-ben Yu, ; Jing-Ye Pan,
| | - Xiao-Shan Zhang
- Department of Pharmacy, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- School of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Ye-Xuan Wang
- Department of Pharmacy, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- School of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Yu-Zhen Wang
- Department of Pharmacy, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- School of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Hong-Min Zhou
- Intensive Care Unit, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Fang-Min Xu
- School of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Jun-Hui Yu
- School of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Li-Wen Zhang
- School of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Ying Dai
- Department of Pharmacy, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zi-Ye Zhou
- Clinical Research Center, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chun-Hong Zhang
- Department of Pharmacy, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guan-Yang Lin
- Department of Pharmacy, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jing-Ye Pan
- Intensive Care Unit, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Xu-ben Yu, ; Jing-Ye Pan,
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Population pharmacokinetics of polymyxin B in critically ill patients receiving continuous venovenous hemofiltration. Int J Antimicrob Agents 2022; 60:106599. [DOI: 10.1016/j.ijantimicag.2022.106599] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/31/2022] [Accepted: 04/28/2022] [Indexed: 11/22/2022]
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26
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Luo X, Zhang Y, Liang P, Zhu H, Li M, Ding X, Zhang J. Population Pharmacokinetics of Polymyxin B and Dosage Strategy in Critically Ill Patients With/without Continuous Renal Replacement Therapy. Eur J Pharm Sci 2022; 175:106214. [DOI: 10.1016/j.ejps.2022.106214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/14/2022] [Accepted: 05/20/2022] [Indexed: 11/03/2022]
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27
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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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28
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Chen N, Guo J, Xie J, Xu M, Hao X, Ma K, Rao Y. Population pharmacokinetics of polymyxin B: a systematic review. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:231. [PMID: 35280373 PMCID: PMC8908148 DOI: 10.21037/atm-22-236] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/18/2022] [Indexed: 12/19/2022]
Abstract
Background Polymyxin B (PMB) is a basic cyclic polypeptide antibiotic produced by Bacillus polymyxa, and is one of the last options for treating multi-drug-resistant negative bacterial infections in clinical practice. In recent years, many population pharmacokinetic studies of PMB have been conducted. This paper sought to comprehensively summarize the characteristics of population pharmacokinetic models of PMB and provide a theoretical basis for the individualized use of PMB. Methods In this review, we systematically searched the PubMed and Embase databases to find articles on population pharmacokinetic models published from database establishment to August 2021. Results A total of 10 studies were included in this review, including studies on various types of severe infections caused by multi-drug-resistant bacteria, hospital-acquired infections with fibrosis and other male and female populations, and a study of 2 continuous renal replacement therapy (CRRT) patients, aged 16–94 years, who received PMB doses of 10–360 mg/day (0.13–3.45 mg/kg/day), at an administration time of 0.5–6 hours. First-order linear elimination was used in all the studies; a 1-compartment model was used in 5 studies, and a 2-compartment model was used in 5 studies. The most common covariates were creatinine clearance (CrCL) and body weight. Discussion Although these studies included several covariates and total clearance (CL) was close, but the external validation of some models was poorly correlated between the actual and predicted value. Novel or potential covariates represent important directions for further study.
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Affiliation(s)
- Na Chen
- Department of Pharmaceutical, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, Hangzhou, China
| | - Jianhao Guo
- Department of Pharmaceutical, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, Hangzhou, China
| | - Jiao Xie
- Department of Pharmaceutical, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Mi Xu
- Intensive Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xing Hao
- Department of Pharmaceutical, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, Hangzhou, China
| | - Kuifen Ma
- Department of Pharmaceutical, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, Hangzhou, China
| | - Yuefeng Rao
- Department of Pharmaceutical, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, Hangzhou, China
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29
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Wang P, Zhang Q, Feng M, Sun T, Yang J, Zhang X. Population Pharmacokinetics of Polymyxin B in Obese Patients for Resistant Gram-Negative Infections. Front Pharmacol 2021; 12:754844. [PMID: 34880755 PMCID: PMC8645997 DOI: 10.3389/fphar.2021.754844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/08/2021] [Indexed: 01/31/2023] Open
Abstract
Polymyxin B is an effective but potentially nephrotoxic antibiotic that is commonly used to treat resistant Gram-negative infections. As a weight-based dosing drug, obese patients may be at a high risk of nephrotoxicity. However, the pharmacokinetics and dosing recommendations for this population are currently lacking. This study aimed to describe the polymyxin B population pharmacokinetics and to evaluate pharmacokinetic/pharmacodynamics (PK/PD) target attainment for obese patients. This study included 26 patients (body mass index, BMI >30) who received polymyxin B for ≥3 days. The total body weight (TBW) ranged from 75 to 125 kg, and the BMI ranged from 30.04 to 40.35. A two-compartment model adequately described the data using Phoenix NLME software. Monte Carlo simulation was used to assess polymyxin B exposure and the probability of target attainment (PTA). As a result, body weight had no significant effect on polymyxin B pharmacokinetics. According to model-based simulation, adjusted body weight (ABW)-based regimens had a high probability of achieving optimal exposure with minimal toxicity risk by comparing TBW and ideal body weight (IBW)-based regimens. The fixed dose of 125 mg or 150 mg q12h had a high toxicity risk. PTA results showed that TBW, IBW, and ABW-based regimens had similar PTA values. Therefore, for obese patients, ABW-based regimens but with a daily dose <250 mg have a high likelihood of achieving an AUCss,24h of 50-100 mg h/L and attaining PK/PD targets with the MIC ≤0.5 mg/L.
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Affiliation(s)
- Peile Wang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Qiwen Zhang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Min Feng
- Department of ICU, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- Department of General ICU, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Xiaojian Zhang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
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30
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Hanafin PO, Nation RL, Scheetz MH, Zavascki AP, Sandri AM, Kwa AL, Cherng BPZ, Kubin CJ, Yin MT, Wang J, Li J, Kaye KS, Rao GG. Assessing the predictive performance of population pharmacokinetic models for intravenous polymyxin B in critically ill patients. CPT Pharmacometrics Syst Pharmacol 2021; 10:1525-1537. [PMID: 34811968 PMCID: PMC8674003 DOI: 10.1002/psp4.12720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 07/29/2021] [Accepted: 08/05/2021] [Indexed: 12/23/2022] Open
Abstract
Polymyxin B (PMB) has reemerged as a last‐line therapy for infections caused by multidrug‐resistant gram‐negative pathogens, but dosing is challenging because of its narrow therapeutic window and pharmacokinetic (PK) variability. Population PK (POPPK) models based on suitably powered clinical studies with appropriate sampling strategies that take variability into consideration can inform PMB dosing to maximize efficacy and minimize toxicity and resistance. Here we reviewed published PMB POPPK models and evaluated them using an external validation data set (EVD) of patients who are critically ill and enrolled in an ongoing clinical study to assess their utility. Seven published POPPK models were employed using the reported model equations, parameter values, covariate relationships, interpatient variability, parameter covariance, and unexplained residual variability in NONMEM (Version 7.4.3). The predictive ability of the models was assessed using prediction‐based and simulation‐based diagnostics. Patient characteristics and treatment information were comparable across studies and with the EVD (n = 40), but the sampling strategy was a main source of PK variability across studies. All models visually and statistically underpredicted EVD plasma concentrations, but the two‐compartment models more accurately described the external data set. As current POPPK models were inadequately predictive of the EVD, creation of a new POPPK model based on an appropriately powered clinical study with an informed PK sampling strategy would be expected to improve characterization of PMB PK and identify covariates to explain interpatient variability. Such a model would support model‐informed precision dosing frameworks, which are urgently needed to improve PMB treatment efficacy, limit resistance, and reduce toxicity in patients who are critically ill.
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Affiliation(s)
- Patrick O Hanafin
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Marc H Scheetz
- Department of Pharmacy Practice and Pharmacometric Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Alexandre P Zavascki
- Department of Internal Medicine, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Infectious Diseases Service, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Ana M Sandri
- Infectious Diseases Service, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrea L Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore.,Emerging Infectious Diseases, Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Benjamin P Z Cherng
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | - Christine J Kubin
- New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Michael T Yin
- Division of Infectious Diseases, Department of Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Jiping Wang
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Jian Li
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Keith S Kaye
- Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Gauri G Rao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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31
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Li Y, Deng Y, Zhu ZY, Liu YP, Xu P, Li X, Xie YL, Yao HC, Yang L, Zhang BK, Zhou YG. Population Pharmacokinetics of Polymyxin B and Dosage Optimization in Renal Transplant Patients. Front Pharmacol 2021; 12:727170. [PMID: 34512352 PMCID: PMC8424097 DOI: 10.3389/fphar.2021.727170] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022] Open
Abstract
Currently, polymyxin B has been widely used in the treatment of multidrug-resistant Gram-negative pathogen infections. Due to the limited pharmacokinetic/pharmacodynamic data, the optimal dosage regimen for the recently proposed therapeutic target of the area under the concentration-time curve over 24 h in steady state divided by the minimum inhibitory concentration 50–100 mg⋅h/L has not yet been established. Moreover, most studies have focused on critically ill patients, yet there have been no studies in the field of renal transplantation. To optimize the dosage strategy and reduce the risk of toxicity, a population pharmacokinetics model of polymyxin B with the Phoenix NLME program was developed in our study. A total of 151 plasma samples from 50 patients were collected in the present study. Polymyxin B plasma concentrations were measured by high-performance liquid chromatography-tandem mass spectrometry. A one-compartment model adequately described the data, and the clearance and volume of distribution were 1.18 L/h and 12.09 L, respectively. A larger creatinine clearance was associated with increased clearance of polymyxin B (p < 0.01). Monte Carlo simulation showed that a regimen of a 75 mg loading dose with a 50 mg maintenance dose was a better option to achieve an optimal therapeutic effect (minimum inhibitory concentration ≤1 mg/L) and to reduce the incidence of side effects for patients with renal impairments. The developed model suggested that dosing adjustment should be based on renal function in renal transplant patients.
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Affiliation(s)
- Ying Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China.,School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Yang Deng
- Department of Pharmacy, Third Hospital of Changsha, Changsha, China
| | - Zhen-Yu Zhu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Yi-Ping Liu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Ping Xu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Xin Li
- Department of Pharmacy, Third Hospital of Changsha, Changsha, China
| | - Yue-Liang Xie
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Heng-Chang Yao
- Department of Urological Organ Transplantation, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Liu Yang
- Hubei Institute of Land Surveying and Mapping, Wuhan, China
| | - Bi-Kui Zhang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China.,School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Yan-Gang Zhou
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
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32
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Li YQ, Chen KF, Ding JJ, Tan HY, Yang N, Lin YQ, Wu CF, Xie YL, Yang GP, Liu JJ, Pei Q. External evaluation of published population pharmacokinetic models of polymyxin B. Eur J Clin Pharmacol 2021; 77:1909-1917. [PMID: 34342716 DOI: 10.1007/s00228-021-03193-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/20/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Several population pharmacokinetics (popPK) models for polymyxin B have been constructed to optimize therapeutic regimens. However, their predictive performance remains unclear when extrapolated to different clinical centers. Therefore, this study aimed to evaluate the predictive ability of polymyxin B popPK models. METHODS A literature search was conducted, and the predictive performance was determined for each selected model using an independent dataset of 20 patients (92 concentrations) from the Third Xiangya Hospital. Prediction- and simulation-based diagnostics were used to evaluate model predictability. The influence of prior information was assessed using Bayesian forecasting. RESULTS Eight published studies were evaluated. In prediction-based diagnostics, the prediction error within ± 30% was over 50% in two models. In simulation-based diagnostics, the prediction- and variability-corrected visual predictive check (pvcVPC) showed satisfactory predictivity in three models, while the normalized prediction distribution error (NPDE) tests indicated model misspecification in all models. Bayesian forecasting demonstrated a substantially improvement in the model predictability even with one prior observation. CONCLUSION Not all published models were satisfactory in prediction- and simulation-based diagnostics; however, Bayesian forecasting improved the predictability considerably with priors, which can be applied to guide polymyxin B dosing recommendations and adjustments for clinicians.
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Affiliation(s)
- Ya-Qian Li
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Kai-Feng Chen
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Jun-Jie Ding
- Center for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Hong-Yi Tan
- Center for Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Nan Yang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Ya-Qi Lin
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Cui-Fang Wu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Yue-Liang Xie
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Guo-Ping Yang
- Center for Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Jing-Jing Liu
- Department of Intensive Medicine, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
| | - Qi Pei
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
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Comparing the Population Pharmacokinetics of and Acute Kidney Injury Due to Polymyxin B in Chinese Patients with or without Renal Insufficiency. Antimicrob Agents Chemother 2021; 65:AAC.01900-20. [PMID: 33168613 DOI: 10.1128/aac.01900-20] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/29/2020] [Indexed: 12/24/2022] Open
Abstract
Despite excellent bactericidal effect, dosing adjustment of polymyxin B for patients with renal insufficiency and polymyxin B-related nephrotoxicity is still a major concern to clinicians. The aim of this study was to compare the population pharmacokinetics (PK) properties of polymyxin B in Chinese patients with different renal functions and to investigate the relationship between PK parameters and polymyxin B-related acute kidney injury (AKI). A total of 37 patients with normal renal function (creatinine clearance ≥ 80 ml/min) and 33 with renal insufficiency (creatinine clearance < 80 ml/min) were included. In the two-compartment population PK models, the central compartment clearance (CL) (2.19 liters/h versus 1.58 liters/h; P < 0.001) and intercompartmental clearance (Q) (13.83 liters/h versus 10.28 liters/h; P < 0.001) values were significantly different between the two groups. The simulated values for AUC across 24 h at steady state (AUCss,24h) for patients with normal renal function were higher than those for patients with renal insufficiency. However, renal dosing adjustment of polymyxin B seemed not to be necessary. In addition, during the treatment, AKI occurred in 23 (32.86%) patients. The polymyxin B AUCss,24h in patients with AKI was significantly higher than that in patients without AKI (108.66 ± 70.10 mg · h/liter versus 66.18 ± 34.79 mg · h/liter; P = 0.001). Both the receiver operating characteristic (ROC) curve and logistic regression analysis showed that an AUCss,24h of >100 mg · h/liter was a good predictor for the probability of nephrotoxicity.
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34
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Zhang J, Hu Y, Shen X, Zhu X, Chen J, Dai H. Risk factors for nephrotoxicity associated with polymyxin B therapy in Chinese patients. Int J Clin Pharm 2021; 43:1109-1115. [PMID: 33439427 DOI: 10.1007/s11096-020-01225-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/28/2020] [Indexed: 01/14/2023]
Abstract
Background The widespread application of Polymyxin B, an active agent against multidrug resistance and extensive drug resistance Gram-negative bacteria, is majorly impeded by nephrotoxicity. Studies on the safety of polymyxin B in Chinese patients have not been widely reported. Objective This study aimed to explore the risk factors for polymyxin B-associated nephrotoxicity and guide its optimal place in therapy. Setting A tertiary care hospital located in eastern China. Methods This being a retrospective cohort study, we evaluated adult patients who received ≥ 72 h of polymyxin B therapy from January 2018 to December 2019. However, patients who received polymyxin B therapy for less than 3 days or received renal replacement therapy at baseline were excluded. Pertinent information was retrieved from medical records. All statistical analysis was performed in SPSS version 22.0. Main outcome measure(s) The main outcome measures included the proportion of patients who developed nephrotoxicity when subjected to polymyxin B treatment and the independent risk factors for nephrotoxicity. Results A total of 119 patients received polymyxin and met the overall inclusion criterion. Of the 119, 46 patients (38.7%) developed nephrotoxicity. Through multiple logistic regression analysis, we found three variables as independent risk factors for nephrotoxicity, including co-morbidities of malignancy (OR 4.55; 95% CI 1.44-14.41; P = 0.010), co-infection with other microorganisms (OR 4.15; 95% CI 1.48-11.63; P = 0.007), and polymyxin B daily dose (OR 1.02; 95% CI 1.00-1.03; P = 0.026). Conclusion This retrospective cohort study identified three risk factors for polymyxin B-associated nephrotoxicity therapy in Chinese patients. These include malignancy, co-infection with other microorganisms, and polymyxin B daily dose.
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Affiliation(s)
- Jiali Zhang
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yanting Hu
- Department of General Intensive Care Unit, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuping Shen
- Department of General Intensive Care Unit, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiuping Zhu
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jie Chen
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haibin Dai
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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