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Association between Vancomycin Pharmacokinetic Parameters and Clinical and Microbiological Efficacy in a Cohort of Neonatal Patients. Antimicrob Agents Chemother 2022; 66:e0110922. [PMID: 36222533 PMCID: PMC9664865 DOI: 10.1128/aac.01109-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Vancomycin pharmacokinetic/pharmacodynamic (PK/PD) targets have not been validated in the neonatal population as no specifically designed studies are available. The main goal of this study was to analyze the therapeutic vancomycin regimen, the 24-h area under the curve (AUC24), and the trough plasma concentration (Ct) obtained that achieved clinical and microbiological effectiveness in a cohort of neonates. This was an observational, prospective, single-center study covering a period of 2 years. Eligible patients were neonates and young infants who were undergoing treatment with intravenous vancomycin for ≥72 h with ≥1 Ct available. The primary outcome was the association of Ct and AUC24 with clinical and microbiological efficacy at the beginning (early clinical evolution [ECE]) and the end (late clinical evolution [LCE]) of treatment with vancomycin. A total of 43 patients were included, 88.4% of whom were cured. In ECE, the cutoff points of the receiver operating characteristic (ROC) curve were 238 mg · h/L (sensitivity of 61% and specificity of 88%) for AUC24 and 6.8 μg/mL (sensitivity of 61% and specificity of 92%) for Ct. In LCE, the Ct value was 11 μg/mL, with a sensitivity of 80% and a specificity of 92%. In this analysis, AUC24 was not considered a good predictor. Logistic regression showed that a vancomycin Ct of ≤6.8 μg/mL was associated with an unfavorable ECE (P = 0.001), being 18 times more likely to progress poorly compared to those with higher levels. AUC24 and Ct are good predictors of ECE in this population. Concentrations close to 7 μg/mL and an AUC24 of around 240 mg · h/L 48 h after antibiotic initiation seem to be sufficient to achieve clinical cure in most cases.
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Ponthier L, Ensuque P, Destere A, Marquet P, Labriffe M, Jacqz-Aigrain E, Woillard JB. Optimization of Vancomycin Initial Dose in Term and Preterm Neonates by Machine Learning. Pharm Res 2022; 39:2497-2506. [PMID: 35918452 DOI: 10.1007/s11095-022-03351-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/23/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Vancomycin is one of the antibiotics most used in neonates. Continuous infusion has many advantages over intermittent infusions, but no consensus has been achieved regarding the optimal initial dose. The objectives of this study were: to develop a Machine learning (ML) algorithm based on pharmacokinetic profiles obtained by Monte Carlo simulations using a population pharmacokinetic model (POPPK) from the literature, in order to derive the best vancomycin initial dose in preterm and term neonates, and to compare ML performances with those of an literature equation (LE) derived from a POPPK previously published. MATERIALS AND METHODS The parameters of a previously published POPPK model of vancomycin in children and neonates were used in the mrgsolve R package to simulate 1900 PK profiles. ML algorithms were developed from these simulations using Xgboost, GLMNET and MARS in parallel, benchmarked and used to calculate the ML first dose. Performances were evaluated in a second simulation set and in an external set of 82 real patients and compared to those of a LE. RESULTS The Xgboost algorithm yielded numerically best performances and target attainment rates: 46.9% in the second simulation set of 400-600 AUC/MIC ratio vs. 41.4% for the LE model (p = 0.0018); and 35.3% vs. 28% in real patients (p = 0.401), respectively). The Xgboost model resulted in less AUC/MIC > 600, thus decreasing the risk of nephrotoxicity. CONCLUSION The Xgboost algorithm developed to estimate the initial dose of vancomycin in term or preterm infants has better performances than a previous validated LE and should be evaluated prospectively.
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Affiliation(s)
- Laure Ponthier
- Pharmacology & Transplantation, University Limoges, INSERM U1248 P&T, 2 rue du Pr Descottes, F-87000, Limoges, France.,Department of Pediatrics, University Hospital of Limoges, Limoges, France
| | - Pauline Ensuque
- Department of Pediatrics, University Hospital of Limoges, Limoges, France
| | - Alexandre Destere
- Pharmacology & Transplantation, University Limoges, INSERM U1248 P&T, 2 rue du Pr Descottes, F-87000, Limoges, France.,Department of Pharmacology and Toxicology, University Hospital of Nice, Nice, France
| | - Pierre Marquet
- Pharmacology & Transplantation, University Limoges, INSERM U1248 P&T, 2 rue du Pr Descottes, F-87000, Limoges, France.,Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, Limoges, France
| | - Marc Labriffe
- Pharmacology & Transplantation, University Limoges, INSERM U1248 P&T, 2 rue du Pr Descottes, F-87000, Limoges, France.,Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, Limoges, France
| | - Evelyne Jacqz-Aigrain
- Pediatric Pharmacology, Department of Biological Pharmacology, Saint-Louis University Hospital, Assistance Publique - Hôpitaux de Paris, Saint-Louis, France
| | - Jean-Baptiste Woillard
- Pharmacology & Transplantation, University Limoges, INSERM U1248 P&T, 2 rue du Pr Descottes, F-87000, Limoges, France. .,Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, Limoges, France.
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Alonso-Moreno M, Mejías-Trueba M, Herrera-Hidalgo L, Goycochea-Valdivia WA, Gil-Navarro MV. Efficacy and Safety of Continuous Infusion of Vancomycin in Children: A Systematic Review. Antibiotics (Basel) 2021; 10:antibiotics10080912. [PMID: 34438962 PMCID: PMC8388768 DOI: 10.3390/antibiotics10080912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022] Open
Abstract
Vancomycin is used to treat a wide variety of infections within the pediatric population. In adults, continuous infusion of vancomycin (CIV) has been evaluated as an alternative to intermittent infusion of vancomycin (IIV) with potential advantages. In children, the use of CIV is increasing; however, data is currently limited. The objective is to provide efficacy and safety evidence for CIV within this population. The review was carried out following PRISMA guidelines. A bibliographic search was performed for studies on PubMed and EMBASE. Clinical trials and observational studies that reported clinical efficacy and/or target attainment of CIV in pediatrics were included. Articles were reviewed to assess their design and target population, characteristics of vancomycin treatment and the main findings in terms of safety and efficacy. A total of 359 articles were identified, of which seven met the inclusion criteria. All of them evaluated the target attainment, six assessed safety but only three assessed clinical efficacy. The best administration method for this antibiotic within the pediatric population is still unknown due to limited evidence. However, studies conducted thus far suggest pharmacokinetic advantages for CIV. Further investigation is required, in particular for studies comparing IIV with CIV for clinical efficacy and toxicity outcomes.
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Affiliation(s)
- Marta Alonso-Moreno
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.A.-M.); (M.M.-T.)
| | - Marta Mejías-Trueba
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.A.-M.); (M.M.-T.)
| | - Laura Herrera-Hidalgo
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
- Correspondence: ; Tel.: +34-955-012-095
| | - Walter Alfredo Goycochea-Valdivia
- Unidad de Pediatría de Enfermedades Infecciosas, Reumatología e Inmunología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
| | - María Victoria Gil-Navarro
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
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Vancomycin dosing and therapeutic drug monitoring practices: guidelines versus real-life. Int J Clin Pharm 2021; 43:1394-1403. [PMID: 33913087 DOI: 10.1007/s11096-021-01266-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/05/2021] [Indexed: 02/07/2023]
Abstract
Background Correct dosing and therapeutic drug monitoring (TDM) practices are essential when aiming for optimal vancomycin treatment. Objective To assess target attainment after initial dosing and dose adjustments, and to determine compliance to dosing and TDM guidelines. Setting Tertiary care university hospital in Belgium. Method A chart review was performed in 150 patients, ranging from preterm infants to adults, treated intravenously with vancomycin. Patient characteristics, dosing and TDM data were compared to evidence-based hospital guidelines. Main outcome measures Target attainment of vancomycin after initial dosing and dose adjustments. Results Subtherapeutic concentrations were measured in 68% of adults, in 76% of children and in 52% of neonates after treatment initiation. Multiple dose adaptations (median 2, Q1 1-Q3 2) were required for target attainment, whilst more than 20% of children and neonates never reached targeted concentrations. Regarding compliance to the hospital guideline, some points of improvement were identified: omitted dose adjustment in adults with decreased renal function (53%), delayed sampling (16% in adults, 31% in children) and redundant sampling (34% of all samples in adults, 12% in children, 13% in neonates). Conclusion Target attainment for vancomycin with current dosing regimens and TDM is poor in all age groups. Besides, human factors should not be ignored when aiming for optimal treatment. This study reflects an ongoing challenge in clinical practice and highlights the need for optimization of vancomycin dosing strategies and improvement of awareness of all health care professionals involved.
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Mejías-Trueba M, Alonso-Moreno M, Herrera-Hidalgo L, Gil-Navarro MV. Target Attainment and Clinical Efficacy for Vancomycin in Neonates: Systematic Review. Antibiotics (Basel) 2021; 10:antibiotics10040347. [PMID: 33805874 PMCID: PMC8064372 DOI: 10.3390/antibiotics10040347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/14/2021] [Accepted: 03/21/2021] [Indexed: 01/22/2023] Open
Abstract
Vancomycin is commonly used as a treatment for neonatal infections. However, there is a lack of consensus establishing the optimal vancomycin therapeutic regimen and defining the most appropriate PK/PD parameter correlated with the efficacy. A recent guideline recommends AUC–guided therapeutic dosing in treating serious infections in neonates. However, in clinical practice, trough serum concentrations are commonly used as a surrogate PKPD index for AUC24. Despite this, target serum concentrations in a neonatal population remain poorly defined. The objective is to describe the relationship between therapeutic regimens and the achievement of clinical or pharmacokinetic outcomes in the neonatal population. The review was carried out following PRISMA guidelines. A bibliographic search was manually performed for studies published on PubMed and EMBASE. Clinical efficacy and/or target attainment and the safety of vancomycin treatment were evaluated through obtaining serum concentrations. A total of 476 articles were identified, of which 20 met the inclusion criteria. All of them evaluated the target attainment, but only two assessed the clinical efficacy. The enormous variability concerning target serum concentrations is noteworthy, which translates into a difficulty in determining which therapeutic regimen achieves the best results. Moreover, there are few studies that analyze clinical efficacy results obtained after reaching predefined trough serum concentrations, this information being essential for clinical practice.
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Affiliation(s)
- Marta Mejías-Trueba
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.M.-T.); (M.A.-M.)
| | - Marta Alonso-Moreno
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.M.-T.); (M.A.-M.)
| | - Laura Herrera-Hidalgo
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
- Correspondence: ; Tel.: +34-955–012–095
| | - Maria Victoria Gil-Navarro
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
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