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Gul S, Gallo R, Bertolino L, Patauner F, Buono S, De Rosa R, Esposito C, Galdieri N, Karruli A, Iossa D, Piscitelli E, Andini R, Corcione A, Durante-Mangoni E. Pharmacokinetic parameters of CAZ-AVI in the normal lung and in models of pneumonia: lessons for treatment optimization in critical care. J Chemother 2024; 36:465-473. [PMID: 38288996 DOI: 10.1080/1120009x.2024.2308977] [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: 07/16/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 09/20/2024]
Abstract
The spread of multidrug-resistant Gram-negative bacterial infections is a significant issue for worldwide public health. Gram-negative organisms regularly develop resistance to antibiotics, especially to β-lactam antimicrobials, which can drastically restrict the number of therapies. A third-generation cephalosporin and the non-β-lactam β-lactamase inhibitor avibactam, which exhibits broad-spectrum β-lactamase inhibition in vitro, are combined to form ceftazidime-avibactam (CAZ-AVI). In this narrative review, we summarize data on pharmacokinetic (PK) parameters for CAZ-AVI in both animal and human models of pneumonia, as well as in healthy individuals. We assessed current literature performing an extensive search of the literature, using as search words 'CAZ-AVI', 'pharmacokinetics', 'pneumonia', 'lung', and 'epithelial lining fluid'. Overall, lung exposure studies of CAZ-AVI revealed that the epithelial lining fluid penetration ranges between 30% and 35% of plasma concentration. Despite the fair lung penetration of CAZ-AVI, this antimicrobial agent has a pivotal role in managing patients with multi-drug resistant Gram-negative pneumonia, however further studies are needed to better assess its PK profile.
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Affiliation(s)
- Sabiha Gul
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Raffaella Gallo
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Lorenzo Bertolino
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Fabian Patauner
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Salvatore Buono
- Department of Critical Care Medicine, AORN Ospedali dei Colli, Naples, Italy
| | - Rosanna De Rosa
- Department of Critical Care Medicine, AORN Ospedali dei Colli, Naples, Italy
| | - Clelia Esposito
- Department of Critical Care Medicine, AORN Ospedali dei Colli, Naples, Italy
| | - Nicola Galdieri
- Department of Critical Care Medicine, AORN Ospedali dei Colli, Naples, Italy
| | - Arta Karruli
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Napoli, Italy
| | - Domenico Iossa
- Unit of Infectious & Transplant Medicine, A.O.R.N. Ospedali dei Colli - Ospedale Monaldi, Napoli, Italy
| | - Eugenio Piscitelli
- Department of Critical Care Medicine, AORN Ospedali dei Colli, Naples, Italy
| | - Roberto Andini
- Unit of Infectious & Transplant Medicine, A.O.R.N. Ospedali dei Colli - Ospedale Monaldi, Napoli, Italy
| | - Antonio Corcione
- Department of Critical Care Medicine, AORN Ospedali dei Colli, Naples, Italy
| | - Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Napoli, Italy
- Unit of Infectious & Transplant Medicine, A.O.R.N. Ospedali dei Colli - Ospedale Monaldi, Napoli, Italy
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Bhandari RK, Rohilla R, Shafiq N, Pandey AK, Malhotra S. Clinical pharmacokinetics of antimicrobials in critical care: a narrative review. Expert Rev Anti Infect Ther 2024:1-14. [PMID: 39297805 DOI: 10.1080/14787210.2024.2406466] [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: 06/06/2024] [Revised: 08/25/2024] [Accepted: 09/16/2024] [Indexed: 09/25/2024]
Abstract
INTRODUCTION The management of critically ill septic patients presents considerable challenges due to multifaceted physiological alterations. Rapid changes such as fluid shifts, hyperdynamic states, and altered renal clearance often require special attention for better clinical outcomes. Vital organ dysfunction, with or without MODS, often necessitates supportive management like RRT, ventilatory support, and ECMO. These interventions can significantly affect the PK/PD of administered antimicrobials, complicating effective treatment. AREA COVERED Patient-specific parameters such as age, weight, and comorbid illnesses (e.g. cystic fibrosis, burns, and immunocompromised states) are critical determinants of antimicrobial pharmacokinetics. Understanding PK/PD determinants is crucial for developing optimized dosing regimens that enhance therapeutic efficacy and minimize toxicity in critically ill patients. EXPERT OPINION Incorporating pharmacometrics approaches in dose optimization can significantly improve patient outcomes. This review focuses on the nuances of PK/PD for optimized antimicrobial dosing in critically ill septic patients, emphasizing the importance of individualized treatment plans to address the complex and dynamic needs of this patient population. The adoption of these advanced pharmacokinetic and pharmacodynamic principles into clinical practice is essential for advancing patient care and optimizing therapeutic outcomes in critically ill patients.
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Affiliation(s)
- Ritika Kondel Bhandari
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rachna Rohilla
- Department of Pharmacology, All India Institute of Medical Sciences, Bathinda, India
| | - Nusrat Shafiq
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Avaneesh Kumar Pandey
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Samir Malhotra
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Xu Y, Tang J, Yuan B, Luo X, Liang P, Liu N, Dong D, Jin L, Ge W, Gu Q. A descriptive pharmacokinetic/pharmacodynamic analysis of ceftazidime-avibactam in a case series of critically ill patients with augmented renal clearance. Pharmacol Res Perspect 2024; 12:e01163. [PMID: 38149723 PMCID: PMC10751856 DOI: 10.1002/prp2.1163] [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: 08/22/2023] [Revised: 11/11/2023] [Accepted: 12/05/2023] [Indexed: 12/28/2023] Open
Abstract
To describe the pharmacokinetics/pharmacodynamics (PK/PD) of a 2 h infusion of ceftazidime-avibactam (CAZ-AVI) in critically ill patients with augmented renal clearance (ARC). A retrospective review of all critically ill patients with ARC who were treated with CAZ-AVI between August 2020 and May 2023 was conducted. Patients whose 12-h creatinine clearance prior to CAZ-AVI treatment and steady-state concentration (Css) of CAZ-AVI were both monitored were enrolled. The free fraction (fCss) of CAZ-AVI was calculated from Css. The joint PK/PD targets of CAZ-AVI were considered optimal when a Css/minimum inhibitory concentration (MIC) ratio for CAZ ≥4 (equivalent to 100% fT > 4 MIC) and a Css/CT ratio of AVI >1 (equivalent to 100% fT > CT 4.0 mg/L) were reached simultaneously, quasioptimal when only one of the two targets was reached, and suboptimal when neither target was reached. The relationship between PK/PD goal achievement, microbial eradication and the clinical efficacy of CAZ-AVI was evaluated. Four patients were included. Only one patient achieved optimal joint PK/PD targets, while the other three reached suboptimal targets. The patient with optimal PK/PD targets achieved microbiological eradication, while the other three patients did not, but all four patients achieved good clinical efficacy. Standard dosages may not enable most critically ill patients with ARC to reach the optimal joint PK/PD targets of CAZ-AVI. Optimal drug dose adjustment of CAZ-AVI in ARC patients requires dynamic drug concentration monitoring.
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Affiliation(s)
- Ying Xu
- Intensive Care UnitDrum Tower Hospital Affiliated to Nanjing University School of MedicineNanjingJiangsuChina
| | - Jian Tang
- Intensive Care UnitDrum Tower Hospital Affiliated to Nanjing University School of MedicineNanjingJiangsuChina
| | - Binbin Yuan
- Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese MedicineNanjingChina
| | - Xuemei Luo
- Department of PharmacyDrum Tower Hospital Affiliated to Nanjing University School of MedicineNanjingChina
| | - Pei Liang
- Department of PharmacyDrum Tower Hospital Affiliated to Nanjing University School of MedicineNanjingChina
| | - Ning Liu
- Intensive Care UnitDrum Tower Hospital Affiliated to Nanjing University School of MedicineNanjingJiangsuChina
| | - Danjiang Dong
- Intensive Care UnitDrum Tower Hospital Affiliated to Nanjing University School of MedicineNanjingJiangsuChina
| | - Lu Jin
- Department of PharmacyDrum Tower Hospital Affiliated to Nanjing University School of MedicineNanjingChina
| | - Weihong Ge
- Department of PharmacyDrum Tower Hospital Affiliated to Nanjing University School of MedicineNanjingChina
| | - Qin Gu
- Intensive Care UnitDrum Tower Hospital Affiliated to Nanjing University School of MedicineNanjingJiangsuChina
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Shi Y, Wu J, Mi W, Zhang X, Ren X, Shen C, Lu C. Ceftazidime-avibactam induced renal disorders: past and present. Front Pharmacol 2024; 15:1329307. [PMID: 38318141 PMCID: PMC10838962 DOI: 10.3389/fphar.2024.1329307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/16/2024] [Indexed: 02/07/2024] Open
Abstract
With the increasing prevalence of multidrug-resistant Gram-negative bacterial pathogens worldwide, antimicrobial resistance has become a significant public health concern. Ceftazidime-avibactam (CAZ-AVI) exhibited excellent in vitro activity against many carbapenemase-producing pathogens, and was widely used for the treatment of various complicated infections. CAZ-AVI is well tolerated across all dosing regimens, and its associated acute kidney injury (AKI) in phase II/III clinical trials is rare. However, recent real-world studies have demonstrated that CAZ-AVI associated AKI was more frequent in real-world than in phase II and III clinical trials, particularly in patients receiving concomitant nephrotoxic agents, with critically ill patients being at a higher risk. Herein, we reviewed the safety data related to renal impairment of CAZ-AVI, and discussed its pharmacokinetic/pharmacodynamic targets and dosage adjustment in patients with impaired renal function. This review aimed to emphasize the importance for healthcare professionals to be aware of this adverse event of CAZ-AVI and provide practical insights into the dosage optimization in critically ill patients with renal dysfunction.
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Affiliation(s)
- Yanrong Shi
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jichao Wu
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Wei Mi
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xusheng Zhang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xiuli Ren
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chengwu Shen
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Cuicui Lu
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Shi AX, Qu Q, Zhuang HH, Teng XQ, Xu WX, Liu YP, Xiao YW, Qu J. Individualized antibiotic dosage regimens for patients with augmented renal clearance. Front Pharmacol 2023; 14:1137975. [PMID: 37564179 PMCID: PMC10410082 DOI: 10.3389/fphar.2023.1137975] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 07/12/2023] [Indexed: 08/12/2023] Open
Abstract
Objectives: Augmented renal clearance (ARC) is a state of enhanced renal function commonly observed in 30%-65% of critically ill patients despite normal serum creatinine levels. Using unadjusted standard dosing regimens of renally eliminated drugs in ARC patients often leads to subtherapeutic concentrations, poor clinical outcomes, and the emergence of multidrug-resistant bacteria. We summarized pharmaceutical, pharmacokinetic, and pharmacodynamic research on the definition, underlying mechanisms, and risk factors of ARC to guide individualized dosing of antibiotics and various strategies for optimizing outcomes. Methods: We searched for articles between 2010 and 2022 in the MEDLINE database about ARC patients and antibiotics and further provided individualized antibiotic dosage regimens for patients with ARC. Results: 25 antibiotic dosage regimens for patients with ARC and various strategies for optimization of outcomes, such as extended infusion time, continuous infusion, increased dosage, and combination regimens, were summarized according to previous research. Conclusion: ARC patients, especially critically ill patients, need to make individualized adjustments to antibiotics, including dose, frequency, and method of administration. Further comprehensive research is required to determine ARC staging, expand the range of recommended antibiotics, and establish individualized dosing guidelines for ARC patients.
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Affiliation(s)
- A-Xi Shi
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
- Department of Pharmacy, The First Hospital of Lanzhou University, Lanzhou, China
| | - Qiang Qu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China
| | - Hai-Hui Zhuang
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Xin-Qi Teng
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Wei-Xin Xu
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Yi-Ping Liu
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Yi-Wen Xiao
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Jian Qu
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
- Hunan Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China
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Zhuang HH, Chen Y, Hu Q, Long WM, Wu XL, Wang Q, Xu TT, Qu Q, Liu YP, Xiao YW, Qu J. Efficacy and mortality of ceftazidime/avibactam-based regimens in carbapenem-resistant Gram-negative bacteria infections: A retrospective multicenter observational study. J Infect Public Health 2023; 16:938-947. [PMID: 37087853 DOI: 10.1016/j.jiph.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/20/2023] [Accepted: 04/12/2023] [Indexed: 04/25/2023] Open
Abstract
OBJECTIVES Limited data on clinical and microbiological efficacy, patient mortality, and other associated factors are available for ceftazidime/avibactam (CAZ/AVI)-based regimens for carbapenem-resistant Gram-negative bacteria (CR-GNB). This study aimed to assess these issues retrospectively using multicenter data. METHODS This multicenter study included CR-GNB infected patients treated with CAZ/AVI-based regimens for more than three days. Patient characteristics, bacterial culture reports, drug-sensitivity test results, and antibiotic use, including CAZ/AVI use, were extracted from the patient's clinical records. The clinical and microbiological efficacy of the combined drug regimen and patient mortality were evaluated according to corresponding definitions. Univariate and multivariate logistic regressions were performed to explore the efficacy and mortality-related factors. RESULTS A total of 183 patients with CR-GNB infection were considered for the analysis according to the inclusion and exclusion criteria. After the treatment of CAZ/AVI-based regimens, the clinical efficacy was 75.4 %. The 7-day microbial efficacy and clearance rate after treatment were 43.7 % and 66.0 %, respectively. Moreover, 30-day all-cause and in-hospital mortality were 11.5 % and 14.2 %, respectively. Harboring renal dysfunction (creatinine clearance rate (CCR) of<20 mL/min), cardiovascular diseases, and digestive system diseases were independent risk factors for poor clinical efficacy of CAZ/AVI-based regimens. Bloodstream infection (BSI), patients with the adjusted doses of CAZ/AVI, and CAZ/AVI co-administration with carbapenem were independently associated factors of bacterial clearance by CAZ/AVI-based regimens. Age, total hospital stays, use of mechanical ventilation, and cumulative CAZ/AVI dose were independent factors associated with all-cause mortality. CONCLUSION CAZ/AVI was an effective drug in treating CR-GNB infection. CAZ/AVI that is mostly excreted by the kidney and is accumulated in renal impairment should be renally adjusted. Renal dysfunction and the adjusted dose of CAZ/AVI were associated with efficacy. Clinicians should individualize CAZ/AVI regimen and dose by the level of renal function to achieve optimal efficacy and survival. The efficacy of CAZ/AVI in the treatment of CR-GNB infection, as well as the implementation of individualized precision drug administration of CAZ/AVI according to patients' different infection sites, renal function, bacterial types, bacterial resistance mechanisms, blood concentration monitoring and other conditions need to be further studied in multicenter.
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Affiliation(s)
- Hai-Hui Zhuang
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, Central South University, Changsha 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha 410011, China
| | - Ying Chen
- Department of Pharmacy, Wuhan University, Renmin Hospital, Wuhan 430060, China
| | - Qin Hu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410078, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410078, China; Institute of Hospital Management, Central South University, Changsha 410078, China
| | - Wen-Ming Long
- Department of Pharmacy, Jingzhou District, Second People's Hospital of Huaihua City, Huaihua 418400, China
| | - Xiao-Li Wu
- Department of Pharmacy, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Qin Wang
- Department of Pharmacy, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Tian-Tian Xu
- Department of Pharmacy, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Qiang Qu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410078, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410078, China; Institute of Hospital Management, Central South University, Changsha 410078, China
| | - Yi-Ping Liu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, Central South University, Changsha 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha 410011, China
| | - Yi-Wen Xiao
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, Central South University, Changsha 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha 410011, China
| | - Jian Qu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, Central South University, Changsha 410011, China; Institute of Clinical Pharmacy, Central South University, Changsha 410011, China; Hunan key laboratory of the research and development of novel pharmaceutical preparations, Changsha Medical University, Changsha 410219, China.
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Gatti M, Pea F. Jumping into the future: overcoming pharmacokinetic/pharmacodynamic hurdles to optimize the treatment of severe difficult to treat-Gram-negative infections with novel beta-lactams. Expert Rev Anti Infect Ther 2023; 21:149-166. [PMID: 36655779 DOI: 10.1080/14787210.2023.2169131] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The choice of best therapeutic strategy for difficult-to-treat resistance (DTR) Gram-negative infections currently represents an unmet clinical need. AREAS COVERED This review provides a critical reappraisal of real-world evidence supporting the role of pharmacokinetic/pharmacodynamic (PK/PD) optimization of novel beta-lactams in the management of DTR Gram-negative infections. The aim was to focus on prolonged and/or continuous infusion administration, penetration rates into deep-seated infections, and maximization of PK/PD targets in special renal patient populations. Retrieved findings were applied to the three most critical clinical scenarios of Gram-negative resistance phenotypes (i.e. carbapenem-resistant Enterobacterales; difficult-to-treat resistant Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii). EXPERT OPINION Several studies supported the role of PK/PD optimization of beta-lactams in the management of DTR Gram-negative infections for both maximizing clinical efficacy and preventing resistance emergence. Optimizing antimicrobial therapy with novel beta-lactams based on the so called 'antimicrobial therapy puzzle' PK/PD concepts may represent a definitive jump into the future toward a personalized patient management of DTR Gram negative infections. Establishing a dedicated and coordinated multidisciplinary team and implementing a real-time TDM-guided personalized antimicrobial exposure optimization of novel beta-lactams based on expert clinical pharmacological interpretation, could represent crucial cornerstones for the proper management of DTR Gram-negative infections.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Italy.,Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Italy.,Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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