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Collignon C, de Marcellus C, Oualha M, Neuranter V, Heilbronner C, Hirt D. Pharmacokinetic profile of acyclovir in a child receiving continuous kidney replacement therapy for acute liver failure. Pediatr Nephrol 2023; 38:3493-3497. [PMID: 36702934 PMCID: PMC9880359 DOI: 10.1007/s00467-023-05881-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND Continuous venovenous hemodiafiltration (CVVHDF) is one of the treatments of critically ill children presenting severe acute liver failure. This affliction might be induced by HSV infection requiring a treatment by acyclovir. Continuous kidney replacement therapy (CKRT) can alter its pharmacokinetics, according to its physicochemical properties and CVVHDF settings. CASE-DIAGNOSIS/TREATMENT The patient was a 21-month-old female presenting liver failure with hyperammonemia treated by acyclovir with presumed HSV infection. CKRT was initiated on day 1 with substantial replacement and dialysate flow rates (respectively 75 and 220 mL/kg/h). Acyclovir was intravenously administered every 8 h with a 1-h infusion of 500 mg/m2. Plasma and effluent concentrations were measured by liquid chromatography-tandem mass spectrometry assay to estimate the area under a curve (AUC) and CKRT clearance by 2 methods (one based on pre- and post-filter concentrations and the other one on dialysate flow rates). Clearance was estimated between 19.2 and 26.3 mL/min with the first method and between 27.6 and 44.3 mL/min with the second one. Concentrations were highly above the therapeutic index (peak concentration was measured at 28 mg/L), but AUC was appropriate. CONCLUSIONS This case describes acyclovir pharmacokinetics during CKRT in a pediatric patient treated by acyclovir. The patient was treated with adapted exposure with the usual dosing, but lower dosing should be investigated with complementary studies. TRIAL REGISTRATION ClinicalTrials.gov NCT02539407.
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Affiliation(s)
- Charlotte Collignon
- Pediatric Intensive Care Unit, APHP University Hospital Necker-Enfants Malades, 149 Rue de Sèvres, 75015, Paris, France.
| | - Charles de Marcellus
- Pediatric Intensive Care Unit, APHP University Hospital Necker-Enfants Malades, 149 Rue de Sèvres, 75015, Paris, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, APHP University Hospital Necker-Enfants Malades, 149 Rue de Sèvres, 75015, Paris, France
- Université de Paris, Paris, France
| | - Valentin Neuranter
- Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Paris Descartes University, Paris, France
- Department of Clinical Pharmacology, Cochin Hospital, Paris, France
| | - Claire Heilbronner
- Pediatric Intensive Care Unit, APHP University Hospital Necker-Enfants Malades, 149 Rue de Sèvres, 75015, Paris, France
| | - Déborah Hirt
- Université de Paris, Paris, France
- Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Paris Descartes University, Paris, France
- Department of Clinical Pharmacology, Cochin Hospital, Paris, France
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Olanrewaju AO, Sullivan BP, Gim AH, Craig CA, Sevenler D, Bender AT, Drain PK, Posner JD. REverSe TRanscrIptase chain termination (RESTRICT) for selective measurement of nucleotide analogs used in HIV care and prevention. Bioeng Transl Med 2023; 8:e10369. [PMID: 36684094 PMCID: PMC9842053 DOI: 10.1002/btm2.10369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 01/25/2023] Open
Abstract
Sufficient drug concentrations are required for efficacy of antiretroviral drugs used in HIV care and prevention. Measurement of nucleotide analogs, included in most HIV medication regimens, enables monitoring of short- and long-term adherence and the risk of treatment failure. The REverSe TRanscrIptase Chain Termination (RESTRICT) assay rapidly infers the concentration of intracellular nucleotide analogs based on the inhibition of DNA synthesis by HIV reverse transcriptase enzyme. Here, we introduce a probabilistic model for RESTRICT and demonstrate selective measurement of multiple nucleotide analogs using DNA templates designed according to the chemical structure of each drug. We measure clinically relevant concentrations of tenofovir diphosphate, emtricitabine triphosphate, lamivudine triphosphate, and azidothymidine triphosphate with agreement between experiment and theory. RESTRICT represents a new class of activity-based assays for therapeutic drug monitoring in HIV care and could be extended to other diseases treated with nucleotide analogs.
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Affiliation(s)
- Ayokunle O. Olanrewaju
- Department of Mechanical EngineeringUniversity of WashingtonSeattleWashingtonUSA
- Department of BioengineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Benjamin P. Sullivan
- Department of Mechanical EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Alicia H. Gim
- Department of Chemical EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Cosette A. Craig
- Department of Mechanical EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Derin Sevenler
- Center for Engineering in Medicine and SurgeryMassachusetts General HospitalBostonMassachusettsUSA
| | - Andrew T. Bender
- Department of Mechanical EngineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Paul K. Drain
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Jonathan D. Posner
- Department of Mechanical EngineeringUniversity of WashingtonSeattleWashingtonUSA
- Department of Chemical EngineeringUniversity of WashingtonSeattleWashingtonUSA
- Department of Family MedicineUniversity of WashingtonSeattleWashingtonUSA
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3
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Therapeutic monitoring of serum concentrations of acyclovir and its metabolite 9-(carboxymethoxymethyl) guanine in routine clinical practice. Biomed Pharmacother 2022; 156:113852. [DOI: 10.1016/j.biopha.2022.113852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/23/2022] Open
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Maillard M, Gong L, Nishii R, Yang JJ, Whirl-Carrillo M, Klein TE. PharmGKB summary: acyclovir/ganciclovir pathway. Pharmacogenet Genomics 2022; 32:201-208. [PMID: 35665708 PMCID: PMC9179945 DOI: 10.1097/fpc.0000000000000474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Maud Maillard
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Li Gong
- Departments of Biomedical Data Science
| | - Rina Nishii
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Teri E Klein
- Departments of Biomedical Data Science
- Medicine (BMIR), Stanford University, Stanford, California, USA
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Minotti C, Barbieri E, Doni D, Impieri C, Giaquinto C, Donà D. Anti-infective Medicines Use in Children and Neonates With Pre-existing Kidney Dysfunction: A Systematic Review. Front Pediatr 2022; 10:868513. [PMID: 35558367 PMCID: PMC9087830 DOI: 10.3389/fped.2022.868513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Dosing recommendations for anti-infective medicines in children with pre-existing kidney dysfunction are derived from adult pharmacokinetics studies and adjusted to kidney function. Due to neonatal/pediatric age and kidney impairment, modifications in renal clearance and drug metabolism make standard anti-infective dosing for children and neonates inappropriate, with a risk of drug toxicity or significant underdosing. The aim of this study was the systematic description of the use of anti-infective medicines in pediatric patients with pre-existing kidney impairment. Methods A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The EMBASE, Medline and Cochrane databases were searched on September 21st, 2021. Studies in all languages reporting data on pre-defined outcomes (pharmacokinetics-PK, kidney function, safety and efficacy) regarding the administration of anti-infective drugs in children up to 18 years with pre-existing kidney dysfunction were included. Results 29 of 1,792 articles were eligible for inclusion. There were 13 case reports, six retrospective studies, nine prospective studies and one randomized controlled trial (RCT), reporting data on 2,168 pediatric patients. The most represented anti-infective class was glycopeptides, with seven studies on vancomycin, followed by carbapenems, with five studies, mostly on meropenem. Antivirals, aminoglycosides and antifungals counted three articles, followed by combined antibiotic therapy, cephalosporins, lipopeptides with two studies, respectively. Penicillins and polymixins counted one study each. Nine studies reported data on patients with a decreased kidney function, while 20 studies included data on kidney replacement therapy (KRT). Twenty-one studies reported data on PK. In 23 studies, clinical outcomes were reported. Clinical cure was achieved in 229/242 patients. There were four cases of underdosing, one case of overdosing and 13 reported deaths. Conclusion This is the first systematic review providing evidence of the use of anti-infective medicines in pediatric patients with impaired kidney function or requiring KRT. Dosing size or interval adjustments in pediatric patients with kidney impairment vary according to age, critical illness status, decreased kidney function and dialysis type. Our findings underline the relevance of population PK in clinical practice and the need of developing predictive specific models for critical pediatric patients.
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Affiliation(s)
- Chiara Minotti
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Elisa Barbieri
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Denis Doni
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Cristina Impieri
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Carlo Giaquinto
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
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Maximova N, Nisticò D, Luci G, Simeone R, Piscianz E, Segat L, Barbi E, Di Paolo A. Population Pharmacokinetics of Intravenous Acyclovir in Oncologic Pediatric Patients. Front Pharmacol 2022; 13:865871. [PMID: 35496277 PMCID: PMC9050193 DOI: 10.3389/fphar.2022.865871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/29/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Acyclovir represents the first-line prophylaxis and therapy for herpes virus infections. However, its pharmacokinetics in children exposes them to the risk of ineffective or toxic concentrations. The study was aimed at investigating the population pharmacokinetics (POP/PK) of intravenous (IV) acyclovir in oncologic children. Methods: Patients (age, 8.6 ± 5.0 years, 73 males and 47 females) received IV acyclovir for prophylaxis (n = 94) and therapy (n = 26) under a therapeutic drug monitoring (i.e., minimum and maximal plasma concentrations, >0.5 and <25 mg/L, respectively). Plasma concentrations were fitted by nonlinear mixed effect modeling and a simulation of dosing regimens was performed. Findings were stratified according to an estimated glomerular filtration rate (eGFR) threshold of 250 ml/min/1.73 m2. Results: The final 1-compartment POP/PK model showed that eGFR had a significant effect on drug clearance, while allometric body weight influenced both clearance and volume of distribution. The population clearance (14.0 ± 5.5 L/h) was consistent across occasions. Simulation of standard 1-h IV infusion showed that a 10-mg/kg dose every 6 h achieved target concentrations in children with normal eGFR (i.e., ≤250 ml/min/1.73 m2). Increased eGFR values required higher doses that led to an augmented risk of toxic peak concentrations. On the contrary, simulated prolonged (i.e., 2 and 3-h) or continuous IV infusions at lower doses increased the probability of target attainment while reducing the risk of toxicities. Conclusion: Due to the variable pharmacokinetics of acyclovir, standard dosing regimens may not be effective in some patients. Prospective trials should confirm the therapeutic advantage of prolonged and continuous IV infusions
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Affiliation(s)
- Natalia Maximova
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS Burlo Garofolo, Trieste, Italy
- *Correspondence: Natalia Maximova,
| | - Daniela Nisticò
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giacomo Luci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto Simeone
- Transfusion Medicine Department, Azienda Sanitaria Universitaria “Giuliano Isontina”, Trieste, Italy
| | - Elisa Piscianz
- Laboratory for Hygiene and Public Health, University Hospital of Trieste, Trieste, Italy
| | - Ludovica Segat
- Laboratory for Hygiene and Public Health, University Hospital of Trieste, Trieste, Italy
| | - Egidio Barbi
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Dubinsky S, Watt K, Saleeb S, Ahmed B, Carter C, Yeung CH, Edginton A. Pharmacokinetics of Commonly Used Medications in Children Receiving Continuous Renal Replacement Therapy: A Systematic Review of Current Literature. Clin Pharmacokinet 2022; 61:189-229. [PMID: 34846703 PMCID: PMC8816883 DOI: 10.1007/s40262-021-01085-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVE The use of continuous renal replacement therapy (CRRT) for renal support has increased substantially in critically ill children compared with intermittent modalities owing to its preferential effects on hemodynamic stability. With the expanding role of CRRT, the quantification of extracorporeal clearance and the effect on primary pharmacokinetic parameters is of the utmost importance. Within this review, we aimed to summarize the current state of the literature and compare published pharmacokinetic analyses of commonly used medications in children receiving CRRT to those who are not. METHODS A systematic search of the literature within electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science was conducted. Published studies that were included contained relevant information on the use of commonly administered medications to children, from neonates to adolescents, receiving CRRT. Pharmacokinetic parameters that were analyzed included volume of distribution, total clearance, extracorporeal clearance, area under the curve, and elimination half-life. Information regarding CRRT circuit, flow rates, and membrane components was analyzed to investigate differences in pharmacokinetics between each modality. RESULTS Forty-five studies met the final inclusion criteria within this systematic review, totaling 833 pediatric patients, with 586 receiving CRRT. Antimicrobials were the most common pharmacological class represented within the literature, representing 81% (35/43) of studies analyzed. Children receiving CRRT largely had similar volume of distribution and total clearance to critically ill children not receiving CRRT, suggesting reno-protective dose adjustments may lead to subtherapeutic dosing regimens in these patients. Overall, there was a tendency for hydrophilic agents, with a low protein binding to undergo elevated total clearance in these children. However, results should be interpreted with caution because of the large variability amongst patient populations and heterogeneity with CRRT modalities, flow rates, and use of extracorporeal membrane oxygenation within studies. This review was able to identify that variation in solute removal, or CRRT modalities, properties (i.e., flow rates), and membrane composition, may have differing effects on the pharmacokinetics of commonly administered medications. CONCLUSIONS The current state of the literature regarding medications administered to children receiving CRRT largely focuses on antimicrobials. Significant gaps remain with other commonly used medications such as sedatives and analgesics. Overall reporting of patient clinical characteristics, CRRT settings, and circuit composition was poor, with only 10% of articles including all relevant information to assess the impact of CRRT on total clearance. Changes in pharmacokinetics because of CRRT often required higher than labeled doses, suggesting renally adjusted or reno-protective doses may lead to subtherapeutic dosing regimens. A thorough understanding of the interplay between patient, drug, and CRRT-circuit factors are required to ensure adequate delivery of dosing regimens to this vulnerable population.
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Affiliation(s)
- Samuel Dubinsky
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
| | - Kevin Watt
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada;,Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | | | - Caitlin Carter
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
| | - Cindy H.T. Yeung
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
| | - Andrea Edginton
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
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Scott BL, Bonadonna D, Ozment CP, Rehder KJ. Extracorporeal membrane oxygenation in critically ill neonatal and pediatric patients with acute respiratory failure: a guide for the clinician. Expert Rev Respir Med 2021; 15:1281-1291. [PMID: 34010072 DOI: 10.1080/17476348.2021.1932469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Intro: Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure continues to demonstrate improving outcomes, largely due to advances in technology along with refined management strategies despite mounting patient acuity and complexity. Successful use of ECMO requires thoughtful initiation and candidacy strategies, along with reducing the risk of ventilator induced lung injury and the progression to multiorgan failure.Areas Covered: This review describes current ECMO management strategies for neonatal and pediatric patients with acute refractory respiratory failure and summarizes relevant published literature. ECMO initiation and candidacy, along with ventilator and sedation management, are highlighted. Additionally, rapidly expanding areas of interest such as anticoagulation strategies, transfusion thresholds, rehabilitation on ECMO, and drug pharmacokinetics are described.Expert Opinion: Over the last few decades, published studies supporting ECMO use for acute refractory respiratory failure, along with institutional experience, have resulted in increased utilization although more randomized-controlled trials are needed. Future research should focus on filling the knowledge gaps that remain regarding anticoagulation, transfusion thresholds, ventilator strategies, sedation, and approaches to rehabilitation to subsequently implement into clinical practice. Additionally, efforts should focus on well-designed trials, including population pharmacokinetic studies, to develop dosing recommendations.
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Affiliation(s)
- Briana L Scott
- Division of Pediatric Critical Care Medicine, Duke University Health System, Durham, NC, USA
| | | | - Caroline P Ozment
- Division of Pediatric Critical Care Medicine, Duke University Health System, Durham, NC, USA
| | - Kyle J Rehder
- Division of Pediatric Critical Care Medicine, Duke University Health System, Durham, NC, USA
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Gurgel Assis MS, Fernandes Pedrosa TC, de Moraes FS, Caldeira TG, Pereira GR, de Souza J, Ruela ALM. Novel Insights to Enhance Therapeutics With Acyclovir in the Management of Herpes Simplex Encephalitis. J Pharm Sci 2021; 110:1557-1571. [PMID: 33450220 DOI: 10.1016/j.xphs.2021.01.003] [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: 12/04/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 11/17/2022]
Abstract
Acyclovir is an antiviral drug poorly absorbed in the gastrointestinal tract due to its hydrophilicity, with low oral bioavailability (~20%). Although acyclovir is prescribed in the management of herpes simplex encephalitis (HSE), the disease has a poor prognosis, particularly if the treatment is delayed, reaching mortality rates of 70% if left untreated. Thus, high acyclovir doses are administered by intravenous (IV) infusion, usually at a dosage of 10 mg kg-1 8-hourly in adults with normal renal function. However, the mortality related to HSE treated with acyclovir remains high (~20%) and permanent sequelae are commonly reported after 1 year (~50%). This review analyzed clinical trials following IV acyclovir administration. Novel insights aiming to improve drug bioavailability were reviewed, including acyclovir or its prodrugs, leading to the systemic distribution of the drug or drug targeting. Much research effort has been made to improve antiviral therapy, searching for delivery systems increasing acyclovir bioavailability by non-invasive pathways, such as oral and nasal pathways, or parenterally administered nanotechnology-based systems leading to drug targeting. Nanocarriers administered by non-invasive pathways represent feasible alternatives to treat HSE, even though not be industrially manufactured yet.
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Affiliation(s)
- Maria Silvia Gurgel Assis
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil
| | | | - Fernanda Segurasse de Moraes
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil
| | - Tamires Guedes Caldeira
- Graduate Program in Pharmaceutical Sciences-CiPharma, School of Pharmacy, UFOP, Minas Gerais, Brazil
| | - Gislaine Ribeiro Pereira
- Faculty of Pharmaceutical Sciences, Federal University of Alfenas (UNIFAL-MG), Alfenas, Minas Gerais, Brazil
| | - Jacqueline de Souza
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil
| | - André Luís Morais Ruela
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil.
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De Rose DU, Cairoli S, Dionisi M, Santisi A, Massenzi L, Goffredo BM, Dionisi-Vici C, Dotta A, Auriti C. Therapeutic Drug Monitoring Is a Feasible Tool to Personalize Drug Administration in Neonates Using New Techniques: An Overview on the Pharmacokinetics and Pharmacodynamics in Neonatal Age. Int J Mol Sci 2020; 21:E5898. [PMID: 32824472 PMCID: PMC7460644 DOI: 10.3390/ijms21165898] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023] Open
Abstract
Therapeutic drug monitoring (TDM) should be adopted in all neonatal intensive care units (NICUs), where the most preterm and fragile babies are hospitalized and treated with many drugs, considering that organs and metabolic pathways undergo deep and progressive maturation processes after birth. Different developmental changes are involved in interindividual variability in response to drugs. A crucial point of TDM is the choice of the bioanalytical method and of the sample to use. TDM in neonates is primarily used for antibiotics, antifungals, and antiepileptic drugs in clinical practice. TDM appears to be particularly promising in specific populations: neonates who undergo therapeutic hypothermia or extracorporeal life support, preterm infants, infants who need a tailored dose of anticancer drugs. This review provides an overview of the latest advances in this field, showing options for a personalized therapy in newborns and infants.
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Affiliation(s)
- Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Sara Cairoli
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Marco Dionisi
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Alessandra Santisi
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Luca Massenzi
- Neonatal Intensive Care Unit and Neonatal Pathology, Fatebenefratelli Hospital, 00186 Rome, Italy;
| | - Bianca Maria Goffredo
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Carlo Dionisi-Vici
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Cinzia Auriti
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
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Li L, Li X, Xia Y, Chu Y, Zhong H, Li J, Liang P, Bu Y, Zhao R, Liao Y, Yang P, Lu X, Jiang S. Recommendation of Antimicrobial Dosing Optimization During Continuous Renal Replacement Therapy. Front Pharmacol 2020; 11:786. [PMID: 32547394 PMCID: PMC7273837 DOI: 10.3389/fphar.2020.00786] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/12/2020] [Indexed: 12/13/2022] Open
Abstract
Continuous Renal Replacement Therapy (CRRT) is more and more widely used in patients for various indications recent years. It is still intricate for clinicians to decide a suitable empiric antimicrobial dosing for patients receiving CRRT. Inappropriate doses of antimicrobial agents may lead to treatment failure or drug resistance of pathogens. CRRT factors, patient individual conditions and drug pharmacokinetics/pharmacodynamics are the main elements effecting the antimicrobial dosing adjustment. With the development of CRRT techniques, some antimicrobial dosing recommendations in earlier studies were no longer appropriate for clinical use now. Here, we reviewed the literatures involving in new progresses of antimicrobial dosages, and complied the updated empirical dosing strategies based on CRRT modalities and effluent flow rates. The following antimicrobial agents were included for review: flucloxacillin, piperacillin/tazobactam, ceftriaxone, ceftazidime/avibactam, cefepime, ceftolozane/tazobactam, sulbactam, meropenem, imipenem, panipenem, biapenem, ertapenem, doripenem, amikacin, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, azithromycin, tigecycline, polymyxin B, colistin, vancomycin, teicoplanin, linezolid, daptomycin, sulfamethoxazole/trimethoprim, fluconazole, voriconazole, posaconzole, caspofungin, micafungin, amphotericin B, acyclovir, ganciclovir, oseltamivir, and peramivir.
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Affiliation(s)
- Lu Li
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xin Li
- Department of Pharmacy, Second Hospital of Jilin University, Changchun, China
| | - Yanzhe Xia
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanqi Chu
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haili Zhong
- Department of Pharmacy, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jia Li
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pei Liang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing, China
| | - Yishan Bu
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
| | - Rui Zhao
- School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Yun Liao
- Department of Pharmacy, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Yang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xiaoyang Lu
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Saiping Jiang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
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Cies JJ, Moore WS, Enache A, Chopra A. Peramivir for Influenza A and B Viral Infections: A Pharmacokinetic Case Series. Pharmacotherapy 2019; 39:1060-1065. [PMID: 31514223 PMCID: PMC7167779 DOI: 10.1002/phar.2330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective To describe the peramivir (PRV) pharmacokinetics in critically ill children treated for influenza A or B viral infections. Design Retrospective electronic medical record review of prospectively collected data from critically ill children receiving peramivir for influenza A or B viral infections in the pediatric intensive care unit (PICU). Setting A 189‐bed, freestanding children's tertiary care teaching hospital in Philadelphia, PA. Patients Critically ill children admitted to the PICU who were infected with influenza between January 1, 2016 and March 31, 2018. Interventions None. Results Eleven patients, two females (18%) and nine males (82%), accounted for 24 peramivir samples for therapeutic drug management. The median age was 5 years (interquartile range 1.5–6.5 yrs) with a median weight of 16.4 kg (interquartile range 14–24 kg). Ten (91%) patients demonstrated a larger volume of distribution, 11 (100%) patients demonstrated an increase in clearance, and 11 (100%) patients demonstrated a shorter half‐life estimate as compared with the package insert and previous pediatric trial data for peramivir. Eight (73%) patients tested positive for a strain of influenza A and 3 (27%) patients tested positive for influenza B; 4 of 11 (36%) patients tested positive for multiple viruses. All patients had adjustments made to their dosing interval to a more frequent interval. Ten (91%) patients were adjusted to an every‐12‐hour regimen and 1 (9%) patient was adjusted to an every‐8‐hour regimen. No adverse events were associated with peramivir treatment. Conclusion The pharmacokinetics of PRV demonstrated in this PICU cohort differs in comparison to healthy pediatric and adult patients, and alterations to dosing regimens may be needed in PICU patients to achieve pharmacodynamic exposures. Additional investigations in the PICU population are needed to confirm these findings.
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Affiliation(s)
- Jeffrey J Cies
- The Center for Pediatric Pharmacotherapy LLC, Pottstown, Philadelphia, Pennsylvania.,St. Christopher's Hospital for Children, Philadelphia, Pennsylvania.,Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Wayne S Moore
- The Center for Pediatric Pharmacotherapy LLC, Pottstown, Philadelphia, Pennsylvania
| | - Adela Enache
- Atlantic Diagnostic Laboratories, Bensalem, Pennsylvania
| | - Arun Chopra
- The Center for Pediatric Pharmacotherapy LLC, Pottstown, Philadelphia, Pennsylvania.,NYU Langone Medical Center, New York, New York.,NYU School of Medicine, New York, New York
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Cies JJ, Moore WS, Enache A, Chopra A. Ceftaroline for Suspected or Confirmed Invasive Methicillin-Resistant Staphylococcus aureus: A Pharmacokinetic Case Series. Pediatr Crit Care Med 2018; 19:e292-e299. [PMID: 29419605 DOI: 10.1097/pcc.0000000000001497] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To describe the ceftaroline pharmacokinetics in critically ill children treated for suspected or confirmed methicillin-resistant Staphylococcus aureus infections, including blood stream infection and describe the microbiological and clinical outcomes. DESIGN Retrospective electronic medical record review. SETTINGS Free-standing tertiary/quaternary pediatric children's hospital. PATIENTS Critically ill children receiving ceftaroline monotherapy or combination therapy for suspected or confirmed methicillin-resistant S. aureus infections in the PICU. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Seven patients, three females (43%), and four males (57%), accounted for 33 ceftaroline samples for therapeutic drug management. A median of four samples for therapeutic drug management was collected per patient (range, 2-9 samples). The median age was 7 years (range, 1-13 yr) with a median weight of 25.5 kg (range, 12.6-40.1 kg). Six of seven patients (86%) demonstrated an increase in volume of distribution, five of seven patients (71%) demonstrated an increase in clearance, and 100% of patients demonstrated a shorter half-life estimate as compared with the package insert estimate. Six of seven patients (85.7%) had documented methicillin-resistant S. aureus growth from a normally sterile site with five of six (83.3%) having documented BSI, allowing six total patients to be evaluated for the secondary objective of microbiological and clinical response. All six patients achieved a positive microbiological and clinical response for a response rate of 100%. CONCLUSIONS These data suggest the pharmacokinetics of ceftaroline in PICU patients is different than healthy pediatric and adult patients, most notably a faster clearance and larger volume of distribution. A higher mg/kg dose and a more frequent dosing interval for ceftaroline may be needed in PICU patients to provide appropriate pharmacodynamic exposures. Larger pharmacokinetic, pharmacodynamic, and interventional treatment trials in the PICU population are warranted.
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Affiliation(s)
| | - Wayne S Moore
- The Center for Pediatric Pharmacotherapy LLC, Pottstown, PA
| | | | - Arun Chopra
- The Center for Pediatric Pharmacotherapy LLC, Pottstown, PA
- NYU Langone Medical Center, New York, NY
- NYU School of Medicine, New York, NY
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Cies JJ, LaCoursiere RJ, Moore WS, Chopra A. Therapeutic Drug Monitoring of Prolonged Infusion Aztreonam for Multi-Drug Resistant Pseudomonas aeruginosa: A Case Report. J Pediatr Pharmacol Ther 2017; 22:467-470. [PMID: 29290748 DOI: 10.5863/1551-6776-22.6.467] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Aztreonam, a broad-spectrum monobactam, is typically reserved for multidrug resistant (MDR) infections. Pharmacokinetic (PK) data to guide dosing in children, however, are limited to healthy volunteers or nonintensive care unit (ICU) patients. Impaired antibiotic delivery into tissue remains a major concern and may explain the high morbidity and mortality associated with MDR infections. Therefore, evaluating the PK changes in pediatric ICU patients is necessary to elucidate the most appropriate antimicrobial regimen. We describe the PK of prolonged infusion aztreonam in a patient with MDR Pseudomonas aeruginosa empyema. The 16-year-old tetraplegic male with a cervical spinal cord injury, chronic respiratory failure, and tracheostomy was admitted with a 2-day history of fever and hypoxemia. Chest x-ray revealed a left lower lobe infiltrate. On hospital day 2, computed tomography scan noted a massive collapse of the left lung with bronchiectasis and hepatization with a pneumatocele. He underwent bronchoscopy on days 2, 6, and 10 and the cultures subsequently grew P aeruginosa only sensitive to aztreonam (minimum inhibitory concentration [MIC] of 2-6 mg/L). A regimen of aztreonam 2 grams intravenously (IV) every 6 hours (each dose infused over 4 hours) and polymyxin B 1,000,000 units IV every 12 hours (each dose infused over 30 minutes) was initiated on day 3. On day 8, the aztreonam serum plateau concentration was 71 mg/L. Repeat respiratory and bronchoscopy cultures from days 19 to 37 remained negative. Aztreonam clearance was 2.3 mL/kg/min, which was significantly increased when compared with the 1.3 mL/kg/min suggested in the prescribing information based on adult data. A prolonged infusion of 2 grams of aztreonam every 6 hours (each dose infused over 4 hours) successfully attained 100% of the target serum and lung concentrations above the MIC for at least 40% of the dosing interval, and was associated with successful treatment of MDR P aeruginosa empyema.
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Affiliation(s)
- Jeffrey J Cies
- The Center for Pediatric Pharmacotherapy (JJC, WSM, AC), LLC, Pottstown, Pennsylvania; St. Christopher's Hospital for Children (JJC), Philadelphia, Pennsylvania; Drexel University College of Medicine (JJC), Philadelphia, Pennsylvania; Thomas Jefferson University School of Pharmacy (RJL), Philadelphia, Pennsylvania; NYU Langone Medical Center (AC), New York, New York; NYU School of Medicine (AC), New York, New York
| | - Richard J LaCoursiere
- The Center for Pediatric Pharmacotherapy (JJC, WSM, AC), LLC, Pottstown, Pennsylvania; St. Christopher's Hospital for Children (JJC), Philadelphia, Pennsylvania; Drexel University College of Medicine (JJC), Philadelphia, Pennsylvania; Thomas Jefferson University School of Pharmacy (RJL), Philadelphia, Pennsylvania; NYU Langone Medical Center (AC), New York, New York; NYU School of Medicine (AC), New York, New York
| | - Wayne S Moore
- The Center for Pediatric Pharmacotherapy (JJC, WSM, AC), LLC, Pottstown, Pennsylvania; St. Christopher's Hospital for Children (JJC), Philadelphia, Pennsylvania; Drexel University College of Medicine (JJC), Philadelphia, Pennsylvania; Thomas Jefferson University School of Pharmacy (RJL), Philadelphia, Pennsylvania; NYU Langone Medical Center (AC), New York, New York; NYU School of Medicine (AC), New York, New York
| | - Arun Chopra
- The Center for Pediatric Pharmacotherapy (JJC, WSM, AC), LLC, Pottstown, Pennsylvania; St. Christopher's Hospital for Children (JJC), Philadelphia, Pennsylvania; Drexel University College of Medicine (JJC), Philadelphia, Pennsylvania; Thomas Jefferson University School of Pharmacy (RJL), Philadelphia, Pennsylvania; NYU Langone Medical Center (AC), New York, New York; NYU School of Medicine (AC), New York, New York
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Cies JJ, Moore WS, Enache A, Chopra A. Population Pharmacokinetics and Pharmacodynamic Target Attainment of Meropenem in Critically Ill Young Children. J Pediatr Pharmacol Ther 2017; 22:276-285. [PMID: 28943823 DOI: 10.5863/1551-6776-22.4.276] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This study aims to describe the population pharmacokinetics and pharmacodynamic target attainment of meropenem in critically ill children. METHODS The study involved a retrospective medical record review from a 189-bed, freestanding children's tertiary care teaching hospital of patients ages 1 to 9 years who received meropenem with concurrent therapeutic drug monitoring. RESULTS There were 9 patients ages 1 to 9 years (mean age, 3.1 ± 2.9 years) with a mean weight of 17.1 ± 11.9 kg who met the inclusion/exclusion criteria and were included in the pharmacokinetic analysis. Meropenem concentrations were best described by a 2-compartment model with first-order elimination, with an R2 and bias of 0.91 and 13.2 mg/L, respectively, for the observed versus population predicted concentrations, and an R2, bias, and imprecision of 1, 0.0675, and 1 mg/L, respectively, for the observed versus individual predicted concentrations. The mean total body drug clearance for the population was 6.99 ± 2.5 mL/min/kg, and Vc was 0.57 ± 0.47 L/kg. The calculated population estimate for the total volume of distribution was 0.78 ± 0.73 L/kg. Standard 0.5-hour meropenem infusions did not provide for appropriate pharmacodynamic exposures of 40% free time > minimum inhibitory concentration (40% fT > MIC) for Gram-negative organisms with susceptible MICs. Dosage regimens employing prolonged and continuous infusion regimens did provide appropriate pharmacodynamic exposures of 40% fT > MIC for Gram-negative organisms up to the break point for Pseudomonas aeruginosa of 4 mg/L. CONCLUSION These data suggest the reference dosage regimens for meropenem (20-40 mg/kg per dose every 8 hours) do not meet an appropriate pharmacodynamic target attainment in critically ill children ages 1 to 9 years. Based on these data, only the 3- to 4-hour prolonged infusion and 24-hour continuous infusion regimens were able to achieve an optimal probability of target attainment against all susceptible Gram-negative bacteria in critically ill children for 40% fT > MIC. Dosage regimens of 120 and 160 mg/kg/day as continuous infusion regimens may be necessary to achieve an optimal probability of target attainment against all susceptible Gram-negative bacteria in critically ill children for 80% fT > MIC. Based on these findings, confirmation with a larger, prospective investigation in critically ill children is warranted.
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Harris JB, Holmes AP. Neonatal Herpes Simplex Viral Infections and Acyclovir: An Update. J Pediatr Pharmacol Ther 2017; 22:88-93. [PMID: 28469532 DOI: 10.5863/1551-6776-22.2.88] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Neonatal herpes simplex virus (HSV) infections have high morbidity and mortality rates. Optimization of treatment and prevention strategies are imperative to improve the care and outcomes of neonates infected with HSV. Management of HSV includes reducing neonatal transmission, treating acute infections, and limiting adverse neurodevelopmental outcomes and future cutaneous outbreaks after acute infections. Transmission risk may be affected by route of delivery and maternal suppressive therapy. Neonatal HSV infections are divided into 3 categories: localized skin, eyes, or mouth; localized central nervous system; or disseminated infections. Parenteral acyclovir, the pharmacologic agent of choice, is used when treating each type of infection. However, dosage strategies and durations of therapy may vary based on disease state severity, presentation, and patient characteristics. Oral acyclovir may be used as suppressive therapy after acute treatment completion in specific neonatal populations, reducing long-term adverse neurodevelopmental outcomes and future skin eruptions. The mortality rate remains high even with treatment.
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Management of adult infectious encephalitis in metropolitan France. Med Mal Infect 2017; 47:206-220. [PMID: 28336304 DOI: 10.1016/j.medmal.2017.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/23/2017] [Indexed: 02/06/2023]
Abstract
Infectious encephalitis is a severe disease leading to a high mortality and morbidity. The most frequent causes include Herpes simplex virus, Varicella Zoster virus, Listeria monocytogenes, and Mycobacterium tuberculosis. Urgent treatment is required (anti-infective therapy and nonspecific supportive care). The aim of this study was to define treatment strategy, empirical and after microbiological documentation at 48hours, through a systematic literature review.
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"In Through the Out Door": Led Zeppelin and Drug Administration in Continuous Renal Replacement Therapy. Pediatr Crit Care Med 2016; 17:373-4. [PMID: 27043905 DOI: 10.1097/pcc.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Continuous Infusion Vancomycin Through the Addition of Vancomycin to the Continuous Renal Replacement Therapy Solution in the PICU: A Case Series. Pediatr Crit Care Med 2016; 17:e138-45. [PMID: 26890194 DOI: 10.1097/pcc.0000000000000656] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe our experience with achieving therapeutic serum vancomycin concentrations in pediatric continuous renal replacement therapy by using continuous infusion vancomycin by mixing vancomycin into the continuous renal replacement therapy solution. DESIGN Retrospective chart review. SETTING A 189-bed, freestanding children's tertiary care teaching hospital in Philadelphia, PA. PATIENTS Pediatric patients receiving continuous renal replacement therapy from April 1, 2009, through December 31, 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were a total of 21 patients who received continuous renal replacement therapy during the study period. Of these, 11 (52.3%) received vancomycin in the continuous renal replacement therapy solution. The median (range) concentration of vancomycin added to the continuous renal replacement therapy solution was 25 mg/L (18-35 mg/L). The mean vancomycin plateau level was 22.8 ± 3.3 mg/L. All patients achieved a serum vancomycin plateau level that was greater than 15 mg/L. There were no adverse events related to the addition of vancomycin to the continuous renal replacement therapy solution. CONCLUSIONS The addition of vancomycin to the continuous renal replacement therapy solution(s) is an effective modality that is used for delivering vancomycin continuous infusion and for ensuring therapeutic vancomycin serum plateau levels in the setting of pediatric continuous renal replacement therapy. Further studies are required to evaluate whether this delivery method can lead to improved patient outcomes.
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