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Rodríguez-Báez AS, Jiménez-Meseguer M, Milán-Segovia RDC, Romano-Moreno S, Barcia E, Ortiz-Álvarez A, García-Díaz B, Medellín-Garibay SE. Comparison of pharmacokinetics software for therapeutic drug monitoring of piperacillin in patients with severe infections. Eur J Hosp Pharm 2024; 31:201-206. [PMID: 36126967 PMCID: PMC11042351 DOI: 10.1136/ejhpharm-2022-003367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/05/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the predictive performance of population pharmacokinetic models for piperacillin (PIP) available in the software MwPharm, TDMx and ID-ODs for initial dosing selection and therapeutic drug monitoring (TDM) purposes. METHODS This is a prospective observational study in adult patients with severe infections receiving PIP treatment. Plasma concentrations were quantified by ultra-high performance liquid chromatography coupled to tandem mass spectrometry. The differences between predicted and observed PIP concentrations were evaluated with Bland-Altman plots; additionally, the relative and absolute bias and precision of the models were determined. RESULTS A total of 145 PIP plasma concentrations from 42 patients were analysed. For population prediction, MwPharm showed the best predictive performance with a mean relative difference of 34.68% (95% CI -197% to 266%) and a root mean square error (RMSE) of 60.42 µg/mL; meanwhile TDMx and ID-ODs under-predicted PIP concentrations. For individual prediction, the TDMx model was found to be the most precise with a mean relative difference of 7.61% (95% CI -57.63 to 72.86%), and RMSE of 17.86 µg/mL. CONCLUSION Current software for TDM is a valuable tool, but it may also include different population pharmacokinetic models in patients with severe infections, and should be evaluated before performing a model-based TDM in clinical practice. Considering the heterogeneous characteristics of patients with severe infections, this study demonstrates the need for therapy personalisation for PIP to improve pharmacokinetic/pharmacodynamic target attainment.
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Affiliation(s)
| | | | | | - Silvia Romano-Moreno
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, San Luis Potosi, SLP, Mexico
| | - Emilia Barcia
- Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Comunidad de Madrid, Spain
| | | | - Benito García-Díaz
- Servicio de Farmacia, Hospital Universitario Severo Ochoa, Leganés, Spain
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Herrera-Pérez IG, Rodríguez-Báez AS, Ortiz-Álvarez A, Velarde-Salcedo R, Arriaga-García FJ, Rodríguez-Pinal CJ, Romano-Moreno S, Milán-Segovia RDC, Medellín-Garibay SE. Standardization and validation of a novel UPLC-MS/MS method to quantify first line anti-tuberculosis drugs in plasma and dried blood spots. J Chromatogr B Analyt Technol Biomed Life Sci 2023; 1228:123801. [PMID: 37453389 DOI: 10.1016/j.jchromb.2023.123801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/09/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023]
Abstract
Tuberculosis (TB) is a high-burden infectious disease with high prevalence and mortality rates. The first-line anti-TB drugs include isoniazid (INH), rifampicin (RMP), pyrazinamide (PZA), and ethambutol (EMB). At present, the standard method of blood sampling for therapeutic drug monitoring (TDM) analysis is venipuncture. Dried blood spots (DBS) are a minimally invasive method for collecting small quantities of whole blood from fingertips. The aim of the current study was to develop an ultrahigh-performance liquid chromatography technique coupled to tandem mass spectrometry (UPLC-MS/MS) for simultaneous quantification of the first-line anti-TB drugs in human plasma and DBS as a sampling alternative. The separation and detection conditions were optimized to quantify INH, RMP, PZA, and EMB in both matrices in an ACQUITY UPLC H Class system coupled to a XEVO TQD detector. Chromatographic separation was performed through an Acquity HSS T3 column (2.1 × 100 mm, 1.8 μm) with 0.1% formic acid in water and acetonitrile as the mobile phase. The total run time was 7 min for both methods, with retention time in plasma of 0.85, 1.22, 3.16, and 4.04 min and 0.74, 0.87, 0.97, and 4.16 min for EMB, INH, PZA, and RMP in DBS, respectively. The bioanalytical methods developed were proved selective, linear, precise, and accurate (inter- and intra-assay); the matrix effect was demonstrated to be within the established limits. Short- and long-term stability, freeze-thaw cycles for plasma, and short-term stability for DBS were established. A total of 15 patients with 46 ± 17 (mean ± SD) years old were included, and anti-TB drug concentrations were quantified on plasma and DBS as proof of concept. Based on RMP and INH plasma concentrations (Cp), and Bayesian estimation of individual pharmacokinetic parameters, a dose adjustment was necessary for 93% of patients. The slopes of the correlation lines between plasma and DBS concentrations of RMP, EMB, INH, and PZA were 0.5321, 0.8125, 0.5680, and 0.6791, respectively. Finally, significant correlations (p < 0.05) were observed between DBS and plasma concentrations for RMP (r2 = 0.6961), EMB (r2 = 0.4369), INH (r2 = 0.8675) and PZA (r2 = 0.7363). A simple, fast, and reliable UPLC-MS/MS method was developed to quantify first-line anti-TB drugs in plasma and DBS, which provides an easy sampling and storage to be applied as a new strategy for TDM in patients with TB.
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Affiliation(s)
| | | | - Arturo Ortiz-Álvarez
- Servicio de Infectología, Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí, S.L.P, Mexico
| | | | | | | | - Silvia Romano-Moreno
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, S.L.P, Mexico
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3
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Espiricueta-Zavala LA, Sanchez-Durán D, Ortiz-Álvarez A, Huerta-García AP, Rodríguez-Pinal CJ, Milán-Segovia RC, Romano-Moreno S, Medellín-Garibay S. 1449. Therapeutic Drug Monitoring of Isoniazid and Rifampicin and Clinical Outcomes in Adults with Tuberculosis. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Directly Observed Treatment Short Course for Tuberculosis (TB) (DOTS) treatment currently produces a cure rate of 80%. Rifampicin (RMP) and isoniazid (INH) are the main bactericides; both show wide inter-individual pharmacokinetics and narrow therapeutic range. Therapeutic drug monitoring (TDM) of antiTB drugs is a strategy to improve the response to treatment.
The aim of this work was to optimize and individualize antiTB treatment based on plasma concentrations of RMP and INH, NAT2 genotyping and the Bayesian estimation of PK parameters.
Methods
A prospective and analytical study including TB patients under DOTS scheme was performed. Venous blood samples were drawn 2 and 4 hours after last dose; INH and RMP were quantified by liquid chromatography coupled to tandem mass spectrometry. Anthropometric and clinical information was retrieved from medical records. Acetylator phenotype was determined based on NAT2 genotyping by real-time PCR.
Bayesian estimation of the PK parameters was performed using NONMEM and dosing scheme was proposed to achieve therapeutic concentrations of RIF and INH.
Results
A total 62 patients were included from 18 to 80 years and 35 to 117 kg of total body weight. The most frequent was pulmonary infection (40%), 25% of patients had type 2 diabetes mellitus and 58.5% were slow acetylators for the NAT2 gene. Lower INH and RMP plasma concentrations were related to adverse clinical outcome, compared to those patients classified with early clinical success [1.9 vs 3.7 mg/L and 16.9 vs 10.0 mg/L (p< 0.05)]. Results indicate the need to adjust anti-TB drugs dose to more than 50% of the patients who show plasma concentrations outside the range for both drugs. Bayesian dosing performed was validated after individualization by quantification and interpretation of INH and RMP plasma concentrations followed by a narrow medical follow up.
Conclusion
Even with standard anti-TB treatment, great proportion of patients show subtherapeutic concentrations of RMP and INH which is associated with overall therapeutic failure. TDM is a useful tool to individualize antimicrobials dose and improve clinical outcomes at early stages of active TB.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | - Diego Sanchez-Durán
- Hospital Central "Dr. Ignacio Morones Prieto" , San Luis Potosi, San Luis Potosi , Mexico
| | - Arturo Ortiz-Álvarez
- Hospital Central “Dr. Ignacio Morones Prieto” , San Luis Potosi, San Luis Potosi , Mexico
| | - Ana P Huerta-García
- Universidad Autónoma de San Luis Potosí , San Luis Potosi, San Luis Potosi , Mexico
| | | | - Rosa C Milán-Segovia
- Universidad Autónoma de San Luis Potosí , San Luis Potosi, San Luis Potosi , Mexico
| | - Silvia Romano-Moreno
- Universidad Autónoma de San Luis Potosí , San Luis Potosi, San Luis Potosi , Mexico
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Rodríguez-Báez AS, Ortiz-Álvarez A, Romano-Aguilar M, Martínez-Gutiérrez F, Romano-Moreno S, Milán-Segovia RC, Medellín-Garibay S. 612. Pharmacokinetics of Piperacillin-Tazobactam in Patients with Severe Infections. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Abstract
Background
Piperacillin-Tazobactam (PIP/TAZ) is a combination of a β-lactam antibiotic with a β-lactamase inhibitor, used to treat moderate to severe infections due to its broad-spectrum antibacterial activity. Its bactericidal effect is time-dependent. Therefore, the free-drug concentration should remain above the minimum inhibitory concentration during at least 50% of the dosing interval. Patients with severe infections develop pathophysiological changes that alter drugs pharmacokinetics (PK), leading to only 30% of probability of target attainment in clinical setting.
Methods
A prospective observational study was performed in patients with severe infections from Hospital Central “Dr. Ignacio Morones Prieto”. The protocol was approved by the Research and Ethics Committee (register 05-20) and patients signed written informed consent. Samples were collected at steady-state and plasma concentrations were quantified by liquid chromatography coupled to mass spectrometry. Data were analyzed by a population approach using NONMEM® software.
Results
A total of 52 patients were included (52% male) with a mean age of 46 ± 17 years and a body mass index of 25 ± 5 Kg/m2. According to the Akaike information criterion and visual inspection, a one-compartment open model was chosen to describe the concentration vs time data (n=156) for both drugs. Typical values (relative standard error) of PK parameters obtained were Clearance [CLPIP (L/h)] = 8.79 (12%) and Volume of distribution [VPIP (L)] = 17.6 (13%); and CLTAZ (L/h) = 12.6 (14%), VTAZ (L) = 32.8 (13%). Interindividual variability (IIV) of each parameter was modeled by exponential error and reported as coefficient of variation as follows: 75.3% and 88.7% for CL; 67.2% and 68.8% for V of PIP and TAZ, respectively. Finally, residual error was modeled as additive and presented a standard deviation (SD) of 7.28 µg/mL for PIP, and for TAZ was modeled as a combined with a SD of 0.22 µg/mL and a coefficient of variation of 17.32%.
Conclusion
Individualization and optimization of β-lactam dosing are essential in drugs with wide IIV as PIP/TAZ; hence, development of a population PK model will provide a valuable aid in explaining and quantifying some of this variability to allow a priori predictions to design initial regimens to reach pharmacotherapeutic targets.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
- Ana S Rodríguez-Báez
- Universidad Autónoma de San Luis Potosí , San Luis Potosi, San Luis Potosi , Mexico
| | - Arturo Ortiz-Álvarez
- Hospital Central “Dr. Ignacio Morones Prieto” , San Luis Potosi, San Luis Potosi , Mexico
| | | | | | - Silvia Romano-Moreno
- Universidad Autónoma de San Luis Potosí , San Luis Potosí, San Luis Potosi , Mexico
| | - Rosa C Milán-Segovia
- Universidad Autónoma de San Luis Potosí , San Luis Potosí, San Luis Potosi , Mexico
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Romano-Aguilar M, Ortiz-Álvarez A, Medellín-Garibay S, Martínez-Gutiérrez F, Jung-Cook H, Milán-Segovia RC, Romano-Moreno S. 611. Meropenem Dosage Optimization in Critically Ill Patients Based on a Population Pharmacokinetic Approach. Open Forum Infect Dis 2022. [PMCID: PMC9752118 DOI: 10.1093/ofid/ofac492.663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Meropenem (MRP) is commonly used to treat serious infections and displays wide variability in plasma concentrations after administration of the same dose in critically ill patients due to factors that affect MRP volume of distribution (V) and clearance (CL) (e.g. edema, sepsis, kidney failure). These alterations could lead to not achieve the pharmacokinetic/pharmacodinamic (PK/PD) target with the consequent failure of antibacterial therapy. The aim of this study was to describe MRP pharmacokinetic parameters in critically ill patients in order to establish safe and effective initial dosing regimens adapted to patients characteristics. Methods This prospective observational study enrolled 78 critically ill patients receiving MRP based on the clinical, biochemical and microbiological findings. Blood sampling occurred at pre-dose, 1, 3 and 6h post-dose. MRP plasma concentrations were determined by high-performance liquid chromatography. Population pharmacokinetic modelling and Monte Carlo simulations were executed with NONMEM. Several regimen dosages of MRP under different scenarios were simulated in order to achieve high probability of target attainment (PTA > 90%) for PK/PD targets of %t > CMI 50% and 100%.
![]() Results In critically-ill Mexican patients, MRP PK were best described by a one compartment model. The final population model was: CL (L/h) = 11.9 ∗ (CLCr/102.23) and V (L) = 25.2. Final model was internally validated proving that it was stable and showed an adequate estimation of variability. Precision and bias fit were assessed through external validation comparing the predictive performance of the base and final models. Different initial dosage regimens were found for CLCr values in which the clinician can choose between a lower dose, a longer dosage interval or a shorter infusion time. However, for patients with augmented renal clearance or PK/PD target 100%t > MIC it was observed that no regimen complied PTA > 90%, suggesting a continuous infusion would be more appropriate.
![]() ![]() ![]() Conclusion This study demonstrates the wide variability in MRP pharmacokinetics and enhances the need to include therapeutic drug monitoring as part of stewardships interventions in critically ill patients to maximize bacteriological and clinical responses. Disclosures All Authors: No reported disclosures.
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Affiliation(s)
| | - Arturo Ortiz-Álvarez
- Hospital Central “Dr. Ignacio Morones Prieto”, San Luis Potosi, San Luis Potosi, Mexico
| | | | | | - Helgi Jung-Cook
- Universidad Nacional Autónoma de México, Mexico city, Distrito Federal, Mexico
| | - Rosa C Milán-Segovia
- Universidad Autónoma de San Luis Potosí, San Luis Potosi, San Luis Potosi, Mexico
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Alvarado-Alvarado JA, Vidal-Morales G, Velázquez-Silva RI, Ortiz-Álvarez A, Torres-Velázquez R, Velázquez-Orta JD, Magaña-Aquino M, Martínez-Martínez MU. Surgical procedure versus medical treatment for infective endocarditis associated to mortality in Mexican population. Arch Cardiol Mex 2021; 91:458-464. [PMID: 33471785 PMCID: PMC8641446 DOI: 10.24875/acm.200004011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Early surgical procedures on patients with infective endocarditis (IE) have shown a clearly benefit to reduce embolization at the central nervous system. We conducted a retrospective cohort in Mexican population to evaluate mortality and clinical outcomes in patients with IE with or without surgical intervention. Objectives: Our aim was to evaluate factors associated with mortality in patients with IE and compare both groups with and without a surgical intervention. Methods: We evaluated a retrospective cohort of patients who had been diagnosed with IE according to the Duke’s criteria at our Institution in SLP, Mexico, from January 2001 to September 2016. We compared the risk factors associated to mortality of patients with or without surgery. Our primary outcome was mortality within 6 months of follow-up after the diagnosis. Results: We included 105 patients, 51 (48.6%) were men, median age 46 [Q1 30, Q3 59] years, 36 patients (34.3%) received surgical treatment (STG), and 69 (65.7%) only medical treatment (MTG) group; 41 patients (39%) died during the study period; in the surgery group eight patients died (22%); and 33 in the MT group (47%) p = 0.049. Adjusted for APACHE II, surgery, creatinine levels and the size of vegetation, the surgery group had lower mortality than patients on MTG (HR 0.36, p = 0.047). Conclusion: As previously described in the literature, patients who underwent surgery had lower mortality than the patients who only received medical treatment; however, the Mexican population is different to other populations group, due to higher risk of diabetes mellitus (28%) versus (10%) in global risk of DM in the world and its complications and other chronic diseases as arterial systemic hypertension. Thus, surgical treatment must be elected as goal standard treatment in patient’s whit IE and presence of vegetation.
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Affiliation(s)
- José A Alvarado-Alvarado
- Department of Internal Medicine, Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí; México
| | - Gildardo Vidal-Morales
- Department of Cardiology, Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí; México
| | - Ricardo I Velázquez-Silva
- Department of Internal Medicine, Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí; México
| | - Arturo Ortiz-Álvarez
- Department of Infectology. Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí, México
| | - Rodrigo Torres-Velázquez
- Department of Internal Medicine, Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí; México
| | - Jesús D Velázquez-Orta
- Department of Internal Medicine, Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí; México
| | - Martín Magaña-Aquino
- Department of Infectology. Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí, México
| | - Marco U Martínez-Martínez
- Department of Internal Medicine, Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí; Hospital General de Zona No. 1, Instituto Mexicano del Seguro Social, San Luis Potosí, México
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Ortiz-Álvarez A, Delgado-Ramírez MA, Cuevas-Zúñiga M, Hernández-Carrera T, Barrón DM, Zapata DA, Vázquez RRV, Ramírez-Hinojosa JP, Rodríguez-Zulueta AP. Outpatient ertapenem therapy in an ESBL-high-prevalence area: an efficacy, safety, and cost study. Infect Drug Resist 2018; 12:111-117. [PMID: 30643439 PMCID: PMC6312697 DOI: 10.2147/idr.s173468] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Outpatient parenteral antimicrobial therapy is a safe, effective, and convenient way of administering antimicrobials for a wide variety of infections. So far there are no reports on the efficacy of outpatient antimicrobial therapy in Mexico. Our objective was to determine the outcomes, safety, and cost of outpatient ertapenem therapy (OET) in our hospital. Patients and methods A case series of 99 patients that received intravenous OET was conducted. The primary outcomes were clinical cure, relapse, and recurrence of infection. Results Of the 99 patients who received OET the most common diagnosis was urinary tract infection in 56%. Extended-spectrum-β-lactamase-producing Enterobacteriaceae caused 67% of infections in our population. Ninety-seven percent of the patients were cured at the completion of OET. One patient presented relapse 12 days after the end of OET; two patients presented recurrence, one with skin and soft tissue infection and one with pyelonephritis at days 35 and 34, respectively, after the end of OET. Three patients were readmitted after OET, one with an episode of phlebitis, one with recurrence, and one with relapse. A case of non-Clostridium difficile-associated diarrhea was observed. The intravascular line complications observed during OET were phlebitis in two patients. Conclusion In our hospital, the OET was found to be effective, safe, and cost-saving when compared to inpatient care.
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Affiliation(s)
- Arturo Ortiz-Álvarez
- Department of Infectious Disease, Hospital General Dr. Manuel GEA González, Mexico City, Mexico,
| | - Mónica A Delgado-Ramírez
- Department of Infectious Disease, Hospital General Dr. Manuel GEA González, Mexico City, Mexico,
| | - Montserrat Cuevas-Zúñiga
- Department of Infectious Disease, Hospital General Dr. Manuel GEA González, Mexico City, Mexico,
| | - Teresa Hernández-Carrera
- Department of Infectious Disease, Hospital General Dr. Manuel GEA González, Mexico City, Mexico,
| | - David Moncada Barrón
- Microbiology Laboratory, Hospital General Dr. Manuel GEA González, Mexico City, Mexico
| | - Daniel Aguilar Zapata
- Department of Infectious Disease, Hospital General Dr. Manuel GEA González, Mexico City, Mexico,
| | - Rafael R Valdez Vázquez
- Department of Infectious Disease, Hospital General Dr. Manuel GEA González, Mexico City, Mexico,
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