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Akunne OO, Mugabo P, Argent AC. Pharmacokinetics of Vancomycin in Critically Ill Children: A Systematic Review. Eur J Drug Metab Pharmacokinet 2021; 47:31-48. [PMID: 34750740 PMCID: PMC8574943 DOI: 10.1007/s13318-021-00730-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 11/26/2022]
Abstract
Background and Objective Vancomycin is often used in the ICU for the treatment of Gram-positive bacterial infection. In critically ill children, there are pathophysiologic changes that affect the pharmacokinetics of vancomycin. A systematic review of vancomycin pharmacokinetics and pharmacodynamics in critically ill children was performed. Methods Pharmacokinetic studies of vancomycin in critically ill children published up to May 2021 were included in the review provided they included children aged > 1 month. Studies including neonates were excluded. A search was performed using the PubMed, Scopus, and Google Scholar databases. The Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) was used to check for quality and reduce bias. Data on study characteristics, patient demographics, clinical parameters, pharmacokinetic parameters, outcomes, and study limitations were collected. Results Thirteen studies were included in this review. A wide variety of dosing and sampling strategies were used in the studies. Methods for estimating vancomycin pharmacokinetics, especially the area under the curve over 24 h, varied. Vancomycin doses of 20–60 mg/kg were given daily. This resulted in high variability in pharmacokinetic parameters. Vancomycin trough level was less than 15 μg/mL in most of the studies. Vancomycin clearance ranged from 0.05 to 0.38 L/h/kg. Volume of distribution ranged from 0.1 to 1.16 L/kg. Half-life was between 2.4 and 23.6 h. Patients in the study receiving continuous vancomycin infusion had AUC24 < 400 µg·h/mL. Conclusion There is large variability in the pharmacokinetics of vancomycin among critically ill patients. Studies to assess the factors responsible for this variability in vancomycin pharmacokinetics are needed.
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Affiliation(s)
- Onyinye Onyeka Akunne
- Discipline of Pharmacology, School of Pharmacy, University of the Western Cape, Bellville, Cape Town, 7535 South Africa
| | - Pierre Mugabo
- Discipline of Pharmacology, School of Pharmacy, University of the Western Cape, Bellville, Cape Town, 7535 South Africa
| | - Andrew C Argent
- Paediatrics and Child Health, University of Cape Town, Rondebosch, Cape Town, 7700 South Africa
- Paediatric Intensive Care Unit, Red Cross War Memorial Children Hospital, Rondebosch, Cape Town, 7700 South Africa
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Germovsek E, Osborne L, Gunaratnam F, Lounis SA, Busquets FB, Standing JF, Sinha AK. Development and external evaluation of a population pharmacokinetic model for continuous and intermittent administration of vancomycin in neonates and infants using prospectively collected data. J Antimicrob Chemother 2020; 74:1003-1011. [PMID: 30668696 DOI: 10.1093/jac/dky525] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/05/2018] [Accepted: 11/16/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Vancomycin is commonly used for nosocomial bacterial pathogens causing late-onset septicaemia in preterm infants. We prospectively collected pharmacokinetic data aiming to describe pharmacokinetics and determine covariates contributing to the variability in neonatal vancomycin pharmacokinetics. Further, we aimed to use the model to compare the ratio of AUC24 at steady-state to the MIC (AUC24,ss/MIC) of several intermittent and continuous dosing regimens. METHODS Newborns receiving vancomycin for suspected or confirmed late-onset sepsis were included. Peak and trough concentrations for intermittent vancomycin dosing and steady-state concentrations for continuous vancomycin dosing were measured. NONMEM 7.3 was used for population pharmacokinetic analysis. Monte Carlo simulations were performed to compare dosing schemes. RESULTS Data from 54 infants were used for model development and from 34 infants for the model evaluation {corrected gestational age [median (range)] = 29 (23.7-41.9) weeks and 28 (23.4-41.7) weeks, respectively}. The final model was a one-compartment model. Weight and postmenstrual age were included a priori, and then no additional covariate significantly improved the model fit. Final model parameter estimates [mean (SEM)]: CL = 5.7 (0.3) L/h/70 kg and V = 39.3 (3.7) L/70 kg. Visual predictive check of the evaluation dataset confirmed the model can predict external data. Simulations using MIC of 1 mg/L showed that for neonates with gestational age ≤25 weeks and postnatal age ≤2 weeks AUC24,ss/MIC was lower with the intermittent regimen (median 482 versus 663). CONCLUSIONS A population pharmacokinetic model for continuous and intermittent vancomycin administration in infants was developed. Continuous administration might be favourable for treating infections caused by resistant microorganisms in very young and immature infants.
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Affiliation(s)
- Eva Germovsek
- Inflammation, Infection and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, UK.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Leanne Osborne
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, Whitechapel, London, UK
| | - Flora Gunaratnam
- Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, UK
| | - Shehrazed A Lounis
- Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, UK
| | - Ferran Bossacoma Busquets
- Inflammation, Infection and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, UK.,Hospital Sant Joan de Deu, Passeig Hospital Sant Joan de Deu 2, Barcelona, Spain
| | - Joseph F Standing
- Inflammation, Infection and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, UK
| | - Ajay K Sinha
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, Whitechapel, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London, UK
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Sridharan K, Al Daylami A. Clinical audit of gentamicin use by Bayesian pharmacokinetic approach in critically ill children. J Infect Chemother 2020; 26:540-548. [DOI: 10.1016/j.jiac.2020.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 02/09/2023]
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Smits A, De Cock P, Vermeulen A, Allegaert K. Physiologically based pharmacokinetic (PBPK) modeling and simulation in neonatal drug development: how clinicians can contribute. Expert Opin Drug Metab Toxicol 2018; 15:25-34. [PMID: 30554542 DOI: 10.1080/17425255.2019.1558205] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Legal initiatives to stimulate neonatal drug development should be accompanied by development of valid research tools. Physiologically based (PB)-pharmacokinetic (PK) modeling and simulation are established tools, accepted by regulatory authorities. Consequently, PBPK holds promise to be a strong research tool to support neonatal drug development. Area covered: The currently available PBPK models still have poor predictive performance in neonates. Using an illustrative approach on distinct PK processes of absorption, distribution, metabolism, excretion, and real-world data in neonates, we provide evidence on the need to further refine available PBPK system parameters through generation and integration of new knowledge. This necessitates cross talk between clinicians and modelers to integrate knowledge (PK datasets, system knowledge, maturational physiology) or test and refine PBPK models. Expert opinion: Besides refining these models for 'small molecules', PBPK model development should also be more widely applied for therapeutic proteins and to determine exposure through breastfeeding. Researchers should also be aware that PBPK modeling in combination with clinical observations can also be used to elucidate age-related changes that are almost impossible to study based on in vivo or in vitro data. This approach has been explored for hepatic biliary excretion, renal tubular activity, and central nervous system exposure.
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Affiliation(s)
- Anne Smits
- a Neonatal Intensive Care Unit , University Hospitals Leuven , Leuven , Belgium.,b Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Pieter De Cock
- c Department of Pharmacy , Ghent University Hospital , Ghent , Belgium.,d Heymans Institute of Pharmacology , Ghent University , Ghent , Belgium.,e Department of Pediatric Intensive Care , Ghent University , Ghent , Belgium
| | - An Vermeulen
- f Laboratory of Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences , Ghent University , Ghent , Belgium
| | - Karel Allegaert
- b Department of Development and Regeneration , KU Leuven , Leuven , Belgium.,g Department of Pediatrics, Division of Neonatology , Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam , Rotterdam , The Netherlands
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van Donge T, Bielicki JA, van den Anker J, Pfister M. Key Components for Antibiotic Dose Optimization of Sepsis in Neonates and Infants. Front Pediatr 2018; 6:325. [PMID: 30420947 PMCID: PMC6215831 DOI: 10.3389/fped.2018.00325] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 10/11/2018] [Indexed: 12/21/2022] Open
Abstract
Sepsis in neonates and infants remains a major cause of death despite a decline in child mortality and morbidity over the last decades. A key factor in further reducing poor clinical outcomes is the optimal use of antibiotics in sepsis management. Developmental changes such as maturation of organ function and capacity of drug metabolizing enzymes can affect the pharmacokinetic profile and therefore the antibiotic exposure and response in neonates and infants. Optimal antibiotic treatment of sepsis in neonates and young infants is dependent on several key components such as the determination of treatment phase, the administered dose and the resulted drug exposure and microbiological response. During the initial phase of suspected sepsis, the primary focus of empirical treatment is to assure efficacy. Once bacterial infection as the cause of sepsis is confirmed the focus shifts toward a targeted treatment, ensuring an optimal balance between efficacy and safety. Interpretation of antibiotic exposure and microbiological response in neonates and infants is multifaceted. The response or treatment effect can be determined by the microbiological parameters (MIC) together with the characteristics of the pathogen (time- or concentration dependent). The antibiotic response is influenced by the properties of the causative pathogen and the unique characteristics of the vulnerable patient population such as reduced humoral response or reduced skin barrier function. Therapeutic drug monitoring (TDM) of antibiotics may be used to increase effectiveness while maximizing safety and minimizing the toxicity, but requires expertise in different fields and requires collaborations between physicians, lab technicians, and quantitative clinical pharmacologists. Understanding these clinical, pharmacological, and microbiological components and their underlying relationship can provide a scientific basic for proper antibiotic use and reduction of antibiotic resistance in neonates and infants. This highlights the necessity of a close multidisciplinary collaboration between physicians, pharmacists, clinical pharmacologists and microbiologist to assure the optimal utilization of antibiotics in neonates and young infants.
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Affiliation(s)
- Tamara van Donge
- Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Julia A Bielicki
- Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
| | - John van den Anker
- Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland.,Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, United States
| | - Marc Pfister
- Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland.,Certara LP, Princeton, NJ, United States
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