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Tang Girdwood S, Tang P, Fenchel M, Dong M, Stoneman E, Jones R, Ostermeier A, Curry C, Forton M, Hail T, Mullaney R, Diseroad E, Punt N, Kaplan J, Vinks AA. Pharmacokinetic parameters over time during sepsis and the association of target attainment and outcomes in critically ill children and young adults receiving ceftriaxone. Pharmacotherapy 2023. [PMID: 36727212 PMCID: PMC10363190 DOI: 10.1002/phar.2774] [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: 07/15/2022] [Revised: 12/16/2022] [Accepted: 01/21/2023] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Early sepsis results in pharmacokinetic (PK) changes due to physiologic alterations. PK changes can lead to suboptimal drug target attainment, risking inadequate coverage from antibiotics like ceftriaxone. Little is known about how ceftriaxone PK and target attainment quantitatively change over time in patients with sepsis or the association between target attainment and outcomes in critically ill children and young adults. METHODS A retrospective analysis of a prospective study was conducted in a single-center pediatric intensive care unit. Septic patients given at least one ceftriaxone dose (commonly as 50 mg/kg every 12 h) and who had blood obtained in both the first 48 h of therapy (early) and afterwards (late) were included. Normalized clearance and central volume were estimated and compared in both sepsis phases. We evaluated target attainment, defined as concentrations above 1× or 4× the minimum inhibitory concentration (MIC) for 100% of dosing intervals, and investigated the association between target attainment and clinical outcomes. RESULTS Fifty-five septic patients (median age: 7.5 years) were included. Normalized clearance and central volume were similar in both phases (6.18 ± 1.48 L/h/70 kg early vs. 6.10 ± 1.61 L/h/70 kg late, p = 0.60; 26.6 [IQR 22.3, 31.3] L/70 kg early vs. 24.5 [IQR 22.0, 29.4] L/70 kg late, p = 0.18). Individual percent differences in normalized clearance and central volume between sepsis phases ranged from -39% to 276% and -51% to 212% (reference, late sepsis), respectively. Fewer patients attained the 1× MIC target in late sepsis (82% late vs. 96% early, p = 0.013), which was associated with transition to once daily dosing, typically done due to transfer from the pediatric intensive care unit (PICU) to a lower acuity unit. Failure to attain either target in late sepsis was associated with antibiotic broadening. CONCLUSION Ceftriaxone PK parameters were similar between early and late sepsis, but there were large individual differences. Fewer patients attained MIC targets in late sepsis and all who did not attain the less stringent target received once daily dosing during this period. The failure to attain targets in late sepsis was associated with antibiotic broadening and could be an area for antibiotic stewardship intervention.
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Affiliation(s)
- Sonya Tang Girdwood
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Peter Tang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pathology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Matthew Fenchel
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Min Dong
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Erin Stoneman
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rhonda Jones
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Austin Ostermeier
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Calise Curry
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Melissa Forton
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Traci Hail
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Randi Mullaney
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Emily Diseroad
- Department of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nieko Punt
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Medimatics, Maastricht, The Netherlands
| | - Jennifer Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Tang Girdwood S, Pavia K, Paice K, Hambrick HR, Kaplan J, Vinks AA. β-lactam precision dosing in critically ill children: Current state and knowledge gaps. Front Pharmacol 2022; 13:1044683. [PMID: 36532752 PMCID: PMC9752101 DOI: 10.3389/fphar.2022.1044683] [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: 09/14/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
There has been emerging interest in implementing therapeutic drug monitoring and model-informed precision dosing of β-lactam antibiotics in critically ill patients, including children. Despite a position paper endorsed by multiple international societies that support these efforts in critically ill adults, implementation of β-lactam precision dosing has not been widely adopted. In this review, we highlight what is known about β-lactam antibiotic pharmacokinetics and pharmacodynamics in critically ill children. We also define the knowledge gaps that present barriers to acceptance and implementation of precision dosing of β-lactam antibiotics in critically ill children: a lack of consensus on which subpopulations would benefit most from precision dosing and the uncertainty of how precision dosing changes outcomes. We conclude with opportunities for further research to close these knowledge gaps.
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Affiliation(s)
- Sonya Tang Girdwood
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States,*Correspondence: Sonya Tang Girdwood,
| | - Kathryn Pavia
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Kelli Paice
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - H. Rhodes Hambrick
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Jennifer Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States,Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Alexander A. Vinks
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Tang Girdwood SC, Tang PH, Murphy ME, Chamberlain AR, Benken LA, Jones RL, Stoneman EM, Kaplan JM, Vinks AA. Demonstrating Feasibility of an Opportunistic Sampling Approach for Pharmacokinetic Studies of β-Lactam Antibiotics in Critically Ill Children. J Clin Pharmacol 2020; 61:565-573. [PMID: 33111331 DOI: 10.1002/jcph.1773] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/06/2020] [Indexed: 12/23/2022]
Abstract
There has been increasing interest in incorporating β-lactam precision dosing into routine clinical care, but robust population pharmacokinetic models in critically ill children are needed for these purposes. The objective of this study was to demonstrate the feasibility of an opportunistic sampling approach that utilizes scavenged residual blood for future pharmacokinetic studies of cefepime, meropenem, and piperacillin. We aimed to show that opportunistic samples would cover the full concentration-versus-time profiles and to evaluate stability of the antibiotics in whole blood and plasma to optimize future use of the opportunistic sampling approach. A prospective observational study was conducted in a single-center pediatric intensive care unit, where pediatric patients administered at least 1 dose of cefepime, meropenem, or piperacillin/tazobactam and who had residual blood scavenged from samples obtained for routine clinical care were enrolled. A total of 138 samples from 22 pediatric patients were collected in a 2-week period. For all 3 antibiotics, the samples collected covered the entire dosing intervals and were not clustered around specific times. There was high variability in the free concentrations and in the percentage of drug bound to protein. There was less than 15% degradation for meropenem or piperacillin when stored in whole blood or plasma at 4°C after 6 days. Cefepime degraded by more than 15% after 3 days. The opportunistic sampling approach is a powerful and feasible method to obtain sufficient samples to study the variability of drug concentrations and protein binding for future pharmacokinetic studies in the pediatric critical care population.
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Affiliation(s)
- Sonya C Tang Girdwood
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Peter H Tang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pathology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Mark E Murphy
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrea R Chamberlain
- Department of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Laura A Benken
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rhonda L Jones
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Erin M Stoneman
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer M Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Santana GMFD, Santana DCASD, Santana FJMD. Diabetes as a risk factor of acute kidney injury in vancomycin users: an observational and prospective study. BRAZ J PHARM SCI 2020. [DOI: 10.1590/s2175-97902020000118401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Corey GR, Wilcox MH, Gonzalez J, Jandourek A, Wilson DJ, Friedland HD, Das S, Iaconis J, Dryden M. Ceftaroline fosamil therapy in patients with acute bacterial skin and skin-structure infections with systemic inflammatory signs: A retrospective dose comparison across three pivotal trials. Int J Antimicrob Agents 2019; 53:830-837. [PMID: 30716446 DOI: 10.1016/j.ijantimicag.2019.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 01/09/2019] [Accepted: 01/27/2019] [Indexed: 12/23/2022]
Abstract
This post-hoc analysis compared the pharmacokinetics and clinical outcomes of ceftaroline fosamil 600 mg every 12 (q12h) versus every 8 hours (q8h) in patients with acute bacterial skin and skin-structure infection (ABSSSI) and signs of sepsis. Clinical outcomes at test-of-cure in patients with ABSSSI and systemic inflammatory signs/systemic inflammatory response syndrome (SIRS) as well as ceftaroline minimum inhibitory concentrations (MICs) against baseline pathogens were compared between the COVERS trial (ceftaroline fosamil 600 mg q8h, 2-h infusion) and the CANVAS 1 and 2 trials (ceftaroline fosamil 600 mg q12h, 1-h infusion). Ceftaroline exposure among patients in COVERS with or without markers of sepsis was compared using population pharmacokinetic modelling. In COVERS, 62% (312/506) and 41% (208/506) of ceftaroline fosamil-treated patients had ≥1 systemic inflammatory sign or SIRS, respectively, compared with 55% (378/693) and 22% (155/693), respectively, in the CANVAS trials. Clinical cure rates for the modified intent-to-treat population in COVERS and CANVAS were similar for ceftaroline fosamil-treated patients with ≥1 sign of sepsis [82% (255/312) and 85% (335/394)] and for those with SIRS [84% (168/199) and 85% (131/155)]. Ceftaroline MIC distributions were similar across trials. Sepsis did not affect predicted individual steady-state ceftaroline exposure. Clinical cure rates in patients with ≥1 systemic inflammatory sign or SIRS were comparable for both ceftaroline fosamil dosage regimens. Pathogen susceptibilities to ceftaroline were similar across trials. Ceftaroline exposure was not affected by disease severity. Ceftaroline fosamil 600 mg q12h is a robust dosage regimen for most ABSSSI patients with sepsis [ClinicalTrials.gov ID: NCT01499277, NCT00424190, NCT00423657].
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Affiliation(s)
- G Ralph Corey
- Department of Medicine, Duke University School of Medicine, 310 Trent Drive, Durham, NC 27710, USA
| | - Mark H Wilcox
- Department of Medical Microbiology, Leeds Teaching Hospitals & University of Leeds, Leeds, UK
| | | | | | | | | | | | | | - Matthew Dryden
- Hampshire Hospitals NHS Foundation Trust, Winchester, UK.
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Nurse Influence in Meeting Compliance With the Centers for Medicare and Medicaid Services Quality Measure. Dimens Crit Care Nurs 2019; 38:70-82. [DOI: 10.1097/dcc.0000000000000340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Owen EJ, Gibson GA, Buckman SA. Pharmacokinetics and Pharmacodynamics of Antimicrobials in Critically Ill Patients. Surg Infect (Larchmt) 2017; 19:155-162. [PMID: 29272204 DOI: 10.1089/sur.2017.262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Critically ill patients with severe infections often have altered pharmacokinetic and pharmacodynamic variables that lead to challenging treatment decisions. These altered variables can often lead to inadequate dosing and poor treatment outcomes. The pharmacokinetic parameters include absorption, distribution, metabolism, and excretion. Pharmacodynamics is the relationship between drug serum concentrations and pharmacologic and toxicologic properties of the medication. In addition to these altered parameters, these critically ill patients frequently are receiving organ support in the forms of continuous renal replacement therapy or extra-corporeal membrane oxygenation. Altered pharmacodynamics can lead to decreased end-organ perfusion, which can ultimately lead to treatment failure or exposure-related toxicity. The most common antimicrobials utilized in the intensive care unit are classified by the pharmacodynamic principles of time-dependent, concentration-dependent, and concentration dependent with time-dependence. Thus, the aim of this review is to outline pharmacokinetic and pharmacodynamic changes of critically ill patients with severe infections and provide strategies for optimal antibiotic agent dosing in these patients.
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Affiliation(s)
| | | | - Sara A Buckman
- 2 Washington University School of Medicine in St. Louis , St. Louis, Missouri
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Neininger MP, Buchholz P, Frontini R, Kiess W, Siekmeyer W, Bertsche A, Siekmeyer M, Bertsche T. Incompatible intravenous drug combinations and respective physician and nurse knowledge: a study in routine paediatric intensive care. Eur J Hosp Pharm 2017; 26:214-217. [PMID: 31338170 DOI: 10.1136/ejhpharm-2017-001248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 05/26/2017] [Accepted: 06/05/2017] [Indexed: 11/03/2022] Open
Abstract
Objectives To identify incompatible intravenous drug combinations in routine paediatric intensive care and evaluate physician and nurse knowledge. Methods In a university paediatric intensive care unit, intravenous drug incompatibilities were analysed using a database and physician and nurse knowledge of incompatibilities was assessed using a questionnaire. Results We analysed 665 prescriptions in 87 patients. Incompatible drug administration was identified in 9 (10%) of the 87 patients with a median of 3 different incompatibilities per patient (Q25/Q75: 1/3). We found 26 incompatible combinations. The most frequently involved drugs were cefotaxime, pantoprazole and vancomycin. A median of 10 of the 15 drug combinations were correctly assessed as compatible or incompatible (Q25/Q75: 8/11). Pantoprazole had a low number (20%) of correct answers. Conclusions One in 10 patients in paediatric intensive care was affected by drug incompatibility, with knowledge deficits seen in a third of assessed combinations. This indicates quality improvement strategies should be urgently implemented by pharmacists.
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Affiliation(s)
- Martina P Neininger
- Department of Clinical Pharmacy and Drug Safety Center, Leipzig University, Leipzig, Germany
| | - Patricia Buchholz
- Department of Clinical Pharmacy and Drug Safety Center, Leipzig University, Leipzig, Germany.,Pharmacy Department of the University Hospital Leipzig and Drug Safety Center, Leipzig University, Leipzig, Germany
| | - Roberto Frontini
- Department of Clinical Pharmacy and Drug Safety Center, Leipzig University, Leipzig, Germany.,Pharmacy Department of the University Hospital Leipzig and Drug Safety Center, Leipzig University, Leipzig, Germany
| | - Wieland Kiess
- Department of Women and Child Health, Hospital for Children and Adolescents and Center for Pediatric Research, Leipzig University, Leipzig, Germany
| | - Werner Siekmeyer
- Department of Women and Child Health, Hospital for Children and Adolescents and Center for Pediatric Research, Leipzig University, Leipzig, Germany
| | - Astrid Bertsche
- Department of Women and Child Health, Hospital for Children and Adolescents and Center for Pediatric Research, Leipzig University, Leipzig, Germany
| | - Manuaela Siekmeyer
- Department of Women and Child Health, Hospital for Children and Adolescents and Center for Pediatric Research, Leipzig University, Leipzig, Germany
| | - Thilo Bertsche
- Department of Clinical Pharmacy and Drug Safety Center, Leipzig University, Leipzig, Germany
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