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Kontou A, Agakidou E, Chatziioannidis I, Chotas W, Thomaidou E, Sarafidis K. Antibiotics, Analgesic Sedatives, and Antiseizure Medications Frequently Used in Critically Ill Neonates: A Narrative Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:871. [PMID: 39062320 PMCID: PMC11275925 DOI: 10.3390/children11070871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024]
Abstract
Antibiotic, analgesic sedative, and antiseizure medications are among the most commonly used medications in preterm/sick neonates, who are at high risk of nosocomial infections, central nervous system complications, and are exposed to numerous painful/stressful procedures. These severe and potentially life-threatening complications may have serious short- and long-term consequences and should be prevented and/or promptly treated. The reported variability in the medications used in neonates indicates the lack of adequate neonatal studies regarding their effectiveness and safety. Important obstacles contributing to inadequate studies in preterm/sick infants include difficulties in obtaining parental consent, physicians' unwillingness to recruit preterm infants, the off-label use of many medications in neonates, and other scientific and ethical concerns. This review is an update on the use of antimicrobials (antifungals), analgesics (sedatives), and antiseizure medications in neonates, focusing on current evidence or knowledge gaps regarding their pharmacokinetics, indications, safety, dosage, and evidence-based guidelines for their optimal use in neonates. We also address the effects of early antibiotic use on the intestinal microbiome and its association with long-term immune-related diseases, obesity, and neurodevelopment (ND). Recommendations for empirical treatment and the emergence of pathogen resistance to antimicrobials and antifungals are also presented. Finally, future perspectives on the prevention, modification, or reversal of antibiotic resistance are discussed.
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Affiliation(s)
- Angeliki Kontou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - Eleni Agakidou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - Ilias Chatziioannidis
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA
| | - Evanthia Thomaidou
- Department of Anesthesia and Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, AHEPA University General Hospital of Thessaloniki, 54621 Thessaloniki, Greece;
| | - Kosmas Sarafidis
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
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[Clinical practice guidelines for meropenem therapy in neonatal sepsis (2024)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2024; 26:107-117. [PMID: 38436306 PMCID: PMC10921874 DOI: 10.7499/j.issn.1008-8830.2309059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/29/2023] [Indexed: 03/05/2024]
Abstract
Meropenem is one of the most widely used special-grade antimicrobial agents in the treatment of neonatal sepsis. However, its irrational use has led to an increasingly severe problem of bacterial multidrug resistance. The guideline was developed following standardized methods and procedures, and provides 12 recommendations specifically addressing 9 clinical issues. The recommendations cover various aspects of meropenem use in neonates, including timing of administration, recommended dosage, extended infusion, monitoring and assessment, antimicrobial adjustment strategies, treatment duration, and treatment strategies for carbapenem-resistant Enterobacteriaceae infections. The aim of the guideline is to provide evidence-based recommendations and guidance for the rational use of meropenem in neonates with sepsis.
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Budai KA, Tímár ÁE, Obeidat M, Máté V, Nagy R, Harnos A, Kiss-Dala S, Hegyi P, Garami M, Hankó B, Lódi C. Extended infusion of β-lactams significantly reduces mortality and enhances microbiological eradication in paediatric patients: a systematic review and meta-analysis. EClinicalMedicine 2023; 65:102293. [PMID: 38021371 PMCID: PMC10651452 DOI: 10.1016/j.eclinm.2023.102293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Background Paediatric patients are often exposed to subtherapeutic levels or treatment failure of β-lactams, and prolonged infusion may be beneficial. We aimed to investigate the efficacy and safety of extended infusion (EI; defined as ≥3 h) or continuous infusion vs. short, intermittent infusion (SI; defined as ≤60 min) of β-lactams in patients <21 years of age. Methods A systematic review and meta-analysis was conducted to compare EI and continuous infusion with SI of β-lactams in children. A systematic search was performed in MEDLINE (via PubMed), Embase, CENTRAL, and Scopus databases for randomised controlled trials (RCTs) and observational studies published from database inception up to August 22, 2023. Any comparative study concerned with mortality, clinical efficacy, adverse events, or plasma concentrations of β-lactams for any infection was eligible. Case reports, case series, and patients aged >21 years were excluded. Odds ratios (OR) and median differences with 95% confidence intervals (CI) were calculated using a random-effects model. Risk of bias (ROB) was assessed using ROB2 and ROBINS-I tools. The protocol was registered with PROSPERO, CRD42022375397. Findings In total, 19,980 articles were screened, out of which 19 studies (4195 patients) were included in the meta-analysis. EI administration was associated with a significantly lower all-cause mortality in both RCTs and non-RCTs [OR 0.74; CI 0.55-0.99; I2 = 0%; CI 0-58%]. Early microbiological eradication was higher with EI [OR 3.18; CI 2.24-4.51; I2 = 0%; CI 0-90%], but the clinical cure did not differ significantly between the two groups [OR 1.20; CI 0.17-8.71; I2 = 79%; CI 32-93%]. Achieving the optimal plasma level (50-100% fT > MIC) appeared favourable in the EI group compared to the SI. No significant differences were observed in the adverse events. The overall ROB was high because of the small sample sizes and clinically heterogeneous populations. Interpretation Our findings suggest that extended infusion of β-lactams was associated with lower mortality and increased microbiological eradication and was considered safe compared to short-term infusion. Funding None.
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Affiliation(s)
- Kinga Anna Budai
- University Pharmacy, Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Ágnes Eszter Tímár
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Mahmoud Obeidat
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Vanda Máté
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Rita Nagy
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Andrea Harnos
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biostatistics at the University of Veterinary Medicine, Budapest, Hungary
| | - Szilvia Kiss-Dala
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Miklós Garami
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Balázs Hankó
- University Pharmacy, Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Csaba Lódi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
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Tian X, Dong L, Jiang TT, Tang BH, Wang ZM, Wu YE, You DP, Bi J, Qian SY, Qi H, Shen AD. Meropenem for children with severe pneumonia: Protocol for a randomized controlled trial. Front Pharmacol 2022; 13:1021661. [DOI: 10.3389/fphar.2022.1021661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/02/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Pneumonia, caused by infection or other factors, seriously endangers the health of children. Meropenem is an effective broad-spectrum antibiotic using in the treatment of infectious diseases. In the therapy of pneumonia, meropenem is mostly employed for the treatment of moderate to severe pneumonia. Previously, we established a population pharmacokinetics (PPK) model for meropenem in pediatric severe infection and simulated the control rate of the time during which the free plasma concentration of meropenem exceeds the minimum inhibitory concentration (MIC) is 70% of the dosing interval (70% fT > MIC). Therefore, we plan to conduct a multicenter randomized controlled trial (RCT) to compare the efficacy and safety between conventional regimen and model regimen for meropenem in pediatric severe pneumonia.Methods: One hundred patients (aged 3 months to 15 years) will be recruited in this RCT. They will be assigned randomly (at a 1:1 ratio) to a conventional treatment group (20 mg/kg, q8h, with 0.5–1 h infusion) and a model treatment group (20 mg/kg, q8 h, with 4 h infusion). The primary outcome will be 70% fT > MIC. Secondary outcomes will be the prevalence of meropenem therapy failure, duration of antibiotic therapy, changes in levels of inflammatory indicators, changes in imaging examination results, and prevalence of adverse events. Ethical approval of our clinical trial has been granted by the ethics committee of Beijing Children’s Hospital ([2022]-E-133-Y). This trial has been registered in the Chinese Clinical Trial Registry (ChiCTR2200061207).Discussion: Based on our previous PPK data, we have designed this RCT. It is hoped that it will promote rational use of antibacterial drugs in children suffering from severe pneumonia.Clinical Trial Registration: http://www.chictr.org.cn identifier, ChiCTR2200061207.
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Zhou P, Cheng Y, Cao G, Xing Y, Zhai S, Tong X, Yang K. The OBTAINS study: A nationwide cross-sectional survey on the implementation of extended or continuous infusion of β-lactams and vancomycin among neonatal sepsis patients in China. Front Pharmacol 2022; 13:1001924. [PMID: 36299905 PMCID: PMC9589050 DOI: 10.3389/fphar.2022.1001924] [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: 07/24/2022] [Accepted: 09/23/2022] [Indexed: 01/03/2023] Open
Abstract
Background: Dosing strategies of β-lactams and vancomycin should be optimized according to pharmacokinetic/pharmacodynamic principles. However, there is no available data indicating the implementation of extended infusion (EI) or continuous infusion (CI) administration in the management of neonatal sepsis. Methods: A nationwide cross-sectional survey was conducted and the pediatricians from 31 provinces in China were enrolled. A multidisciplinary team created the questionnaire, which had three sections and a total of 21 questions with open- and closed-ended responses. The survey was then conducted using an internet platform in an anonymous way. The data was eventually gathered, compiled, and examined. To identify the risk factors associated with the implementation of EI/CI, logistic regression was carried out. Results: A total of 1501 respondents answered the questionnaires. The implementation of EI/CI of β-lactams and vancomycin were only available to one-third of the respondents, and the prolonged strategy was primarily supported by guidelines (71.25%) and advice from medical specialists (55.18%). A significant fraction (72.94%-94.71%) lacked a strong understanding of the infusions' stability. Additionally, it was discovered that more frequent MDT discussions about antibiotic use and the appropriate time pediatricians worked in the neonatal ward were associated with an increase in the use of the EI/CI strategy. Conclusion: The EI/CI strategy in neonatal sepsis was not well recognized in China, and it is necessary to establish a solid MDT team with regularly collaborates. In the near future, guidelines regarding prolonged infusion management in neonatal sepsis should be developed.
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Affiliation(s)
- Pengxiang Zhou
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China,Department of Pharmacy, Peking University Third Hospital, Beijing, China,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Yinchu Cheng
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Guangna Cao
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Yan Xing
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Xiaomei Tong
- Department of Pediatrics, Peking University Third Hospital, Beijing, China,*Correspondence: Kehu Yang, ; Xiaomei Tong,
| | - Kehu Yang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China,*Correspondence: Kehu Yang, ; Xiaomei Tong,
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Cao G, Zhou P, Zhang H, Sun B, Tong X, Xing Y. Extended Infusion of Meropenem in Neonatal Sepsis: A Historical Cohort Study. Antibiotics (Basel) 2022; 11:antibiotics11030341. [PMID: 35326804 PMCID: PMC8944670 DOI: 10.3390/antibiotics11030341] [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: 01/26/2022] [Revised: 03/02/2022] [Accepted: 03/02/2022] [Indexed: 02/04/2023] Open
Abstract
This single-center historical cohort study investigated the effectiveness and safety of extended infusion (EI) compared with short-term infusion (STI) of meropenem in neonatal sepsis. Patient electronic health records from Peking University Third Hospital (1 December 2011−1 April 2021) were screened. Neonates diagnosed with sepsis and treated with meropenem in the neonatal intensive care unit were included (256 patients) as STI (0.5 h, 129 patients) and EI (2−3 h, 127 patients) groups. Three-day clinical effectiveness and three-day microbial clearance were considered the main outcomes. Univariate and multivariate analyses were performed. Baseline characteristics were similar in both groups. EI of meropenem was associated with a significantly higher 3-day clinical effectiveness rate (0.335 (0.180, 0.623), p = 0.001) and 3-day microbial clearance (4.127 (1.235, 13.784), p = 0.021) than STI, with comparable safety. Subgroup analyses showed that neonates with very low birth weight benefited from EI in terms of 3-day clinical effectiveness rate (75.6% versus 56.6%, p = 0.007), with no significant difference in the 3-day clinical effectiveness (85.1% versus 78.3%, p = 0.325) and microbial clearance (6% versus 5%, p > 0.999) rates between 3 h and 2 h infusions. Thus, EI of meropenem may be associated with better effectiveness and comparable safety in treating neonatal sepsis than STI. Nonetheless, historically analyzed safety evaluation might be biased, and these findings need confirmation in randomized controlled trials of larger sample sizes.
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Affiliation(s)
- Guangna Cao
- Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China;
| | - Pengxiang Zhou
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China;
- Peking University Health Science Center, Institute for Drug Evaluation, Beijing 100191, China
| | - Hua Zhang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing 100191, China;
| | - Bangkai Sun
- Information Management and Big Data Center, Peking University Third Hospital, Beijing 100191, China;
| | - Xiaomei Tong
- Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China;
- Correspondence: (X.T.); (Y.X.); Tel.: +86-010-8226-7671 (X.T.); +86-010-8226-7677 (Y.X.)
| | - Yan Xing
- Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China;
- Correspondence: (X.T.); (Y.X.); Tel.: +86-010-8226-7671 (X.T.); +86-010-8226-7677 (Y.X.)
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