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Yi JM, Kim KM, Lee HJ, Hong SK, Choi BM. External Validation of a Pharmacokinetic Model Developed for Vancomycin Administration via Target-Controlled Infusion. Drug Des Devel Ther 2025; 19:2229-2241. [PMID: 40160968 PMCID: PMC11952145 DOI: 10.2147/dddt.s507377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2024] [Accepted: 03/14/2025] [Indexed: 04/02/2025] Open
Abstract
Purpose Target-controlled infusion (TCI) could provide a patient-tailored approach for vancomycin dosing. This study aimed to externally evaluate the predictive performance of a previously constructed pharmacokinetic model of vancomycin (Choi model) specifically optimized for TCI administration of vancomycin differing from the existing model, and to assess the feasibility of administering vancomycin via TCI in clinical practice. Additionally, clinical outcomes were exploratively compared between the TCI and intermittent infusion (standard) methods for vancomycin administration. Patients and Methods Clinically ill patients were randomly assigned in a 1:1 ratio to either the TCI or standard group. In the TCI group, vancomycin was administered using the Choi model, targeting an initial concentration of 25 mg/L, adjusted to maintain therapeutic levels (20-30 mg/L). The standard group received a loading dose of 25 mg/kg, then 15 mg/kg every 12 hours. Vancomycin concentrations for analysis were obtained from three blood samples per patient at set times, along with routine therapeutic drug monitoring data. Predictive performance was assessed using four parameters: inaccuracy, divergence, bias, and wobble. The occurrence of acute kidney injury (AKI) during and up to 7 days after vancomycin was investigated. Results The study was terminated early due to challenges in enrolling subjects (TCI: n=12, standard: n=13). Thirty-seven serum concentration measurements from the TCI group were analyzed. Pooled median bias and inaccuracy (95% confidence interval) were -2.7 (-7.3 to 1.9) and 17.0 (13.9 to 20.2), respectively. AKI incidence was similar between groups (TCI: n=0, standard: n=1) in this exploratory analysis, but caution is warranted in interpreting these outcomes as the planned sample size was not met. Conclusion The predictive performance of the TCI system integrated with the Choi model was suitable for clinical use. Further studies with a large cohort should be performed to determine the clinical effectiveness of vancomycin administered via the TCI method. Trial Registration This study was registered at the Clinical Research Information Service of the Korean National Institute of Health (CRIS, http://cris.nih.go.kr), with registration number KCT0003462, on January 31, 2019).
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Affiliation(s)
- Jung-Min Yi
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University International St. Mary’s Hospital, Incheon, South Korea
| | - Kyung Mi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hak-Jae Lee
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Ben Romdhane H, Woillard JB, Ben Fadhel N, Chadli Z, Chaabane A, Boughattas N, Ben Fredj N, Aouam K. Population Pharmacokinetic of Vancomycin Administered by Continuous Infusion in Critically Ill Patients. Pharmacology 2024; 110:65-76. [PMID: 39154639 DOI: 10.1159/000539866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 06/13/2024] [Indexed: 08/20/2024]
Abstract
INTRODUCTION Administration of vancomycin dose by continuous infusion (CI) according to population pharmacokinetic (Pop Pk) models is highly recommended in critically ill patients who exhibit pathophysiological changes. OBJECTIVE The objective of this study was to develop and validate a Pop Pk model of vancomycin administered by CI in critically ill patients with normal and impaired renal functions. METHODS The Pop Pk study was performed using a nonparametric approach (Pmetrics*). The influence of covariates (gender, age, weight, height, and creatinine clearance [Cr-Cl]) was tested on the model's Pk parameters. The performance of the final model was assessed using an external dataset. RESULTS A one-compartment model (volume of distribution [Vd], elimination from compartment [Ke]) was found to show a good prediction performance. The influence of covariates has shown that age and Cr-Cl affected significantly Vd and Ke, respectively. The distribution of simulated vancomycin clearance (CLv) according to different renal function levels showed a negative correlation between CLv and the severity of the renal impairment. The internal validation of the final model showed that the plot of individual-predicted concentration versus observed concentration resulted in r2 = 0.86 in the final model. The external validation of the final model showed an acceptable predictive performance. CONCLUSION We developed a Pop Pk model for vancomycin administered by CI in critically ill patients. A significant impact of Cr-Cl and different stages of renal failure on CLv has been demonstrated. The establishment of an individualized proposal dose based on this model may be helpful to achieve the target range which is critical in optimizing the efficacy and safety of this antibiotic.
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Affiliation(s)
- Haifa Ben Romdhane
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Jean Baptiste Woillard
- Department of Pharmacology and Toxicology, Centre Hospitalier Universitaire à Limoges, Limoges, France
| | - Najah Ben Fadhel
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Zohra Chadli
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Amel Chaabane
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Naceur Boughattas
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Nadia Ben Fredj
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Karim Aouam
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
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Bidkar PU, Dey A, Chatterjee P, Ramadurai R, Joy JJ. Target-controlled infusion - Past, present, and future. J Anaesthesiol Clin Pharmacol 2024; 40:371-380. [PMID: 39391641 PMCID: PMC11463930 DOI: 10.4103/joacp.joacp_64_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 10/12/2024] Open
Abstract
Target-controlled infusion (TCI) is a novel drug delivery system wherein a microprocessor calculates the rate of drug to be infused based upon the target plasma or effect site concentration set by the operator. It has found its place in the operation theaters and intensive care units (ICUs) for safe administration of intravenous anesthesia and analgosedation using drugs like propofol, dexmedetomidine, opioids, and so on. Operating a TCI device requires the user to have a primitive understanding of drug pharmacokinetics and pharmacodynamics and an awareness of the practical problems that can arise during its administration. Ongoing research supports their usage in other clinical settings and for various other drugs such as antibiotics, vasopressors, and so on. In this article, we review the underlying principles and commonly used drugs for TCI, the practical aspects of its implementation, and the scope of this technology in future. TCI technology is increasingly being used in the field of anesthesiology and critical care due to the myriad advantages it offers when compared to manual infusions. It is, therefore, essential for the reader to understand the relevant principles and practical aspects related to TCI technology, as well as to be aware of the commonly used TCI models.
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Affiliation(s)
- Prasanna Udupi Bidkar
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Ankita Dey
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Bathinda, Punjab, India
| | - Protiti Chatterjee
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Rajasekar Ramadurai
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Jerry Jame Joy
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Ribba B, Bräm DS, Baverel PG, Peck RW. Model enhanced reinforcement learning to enable precision dosing: A theoretical case study with dosing of propofol. CPT Pharmacometrics Syst Pharmacol 2022; 11:1497-1510. [PMID: 36177959 PMCID: PMC9662205 DOI: 10.1002/psp4.12858] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/09/2022] [Indexed: 11/24/2022] Open
Abstract
Extending the potential of precision dosing requires evaluating methodologies offering more flexibility and higher degree of personalization. Reinforcement learning (RL) holds promise in its ability to integrate multidimensional data in an adaptive process built toward efficient decision making centered on sustainable value creation. For general anesthesia in intensive care units, RL is applied and automatically adjusts dosing through monitoring of patient's consciousness. We further explore the problem of optimal control of anesthesia with propofol by combining RL with state-of-the-art tools used to inform dosing in drug development. In particular, we used pharmacokinetic-pharmacodynamic (PK-PD) modeling as a simulation engine to generate experience from dosing scenarios, which cannot be tested experimentally. Through simulations, we show that, when learning from retrospective trial data, more than 100 patients are needed to reach an accuracy within the range of what is achieved with a standard dosing solution. However, embedding a model of drug effect within the RL algorithm improves accuracy by reducing errors to target by 90% through learning to take dosing actions maximizing long-term benefit. Data residual variability impacts accuracy while the algorithm efficiently coped with up to 50% interindividual variability in the PK and 25% in the PD model's parameters. We illustrate how extending the state definition of the RL agent with meaningful variables is key to achieve high accuracy of optimal dosing policy. These results suggest that RL constitutes an attractive approach for precision dosing when rich data are available or when complemented with synthetic data from model-based tools used in model-informed drug development.
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Affiliation(s)
- Benjamin Ribba
- Roche Pharma Research and Early Development (pRED)F. Hoffmann La Roche Ltd.BaselSwitzerland
| | - Dominic Stefan Bräm
- Roche Pharma Research and Early Development (pRED)F. Hoffmann La Roche Ltd.BaselSwitzerland,Present address:
University Children’s Hospital BaselSpitalstrasse 33, 4056BaselSwitzerland.
| | - Paul Gabriel Baverel
- Roche Pharma Research and Early Development (pRED)F. Hoffmann La Roche Ltd.BaselSwitzerland,Present address:
Molecular Partners AGWagistrasse 14, 8952SchlierenSwitzerland.
| | - Richard Wilson Peck
- Roche Pharma Research and Early Development (pRED)F. Hoffmann La Roche Ltd.BaselSwitzerland,Present address:
Department of Pharmacology & TherapeuticsUniversity of LiverpoolUK.
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Kim KM, Jung J, Lee JM, Yang HS, Bang J, Lee E, Choi B, Noh G. The expected advantage of administering prophylactic antibiotics using target‐ concentration controlled infusion: Development of a new pharmacokinetic model of cefazolin. Clin Exp Pharmacol Physiol 2022; 49:731-739. [DOI: 10.1111/1440-1681.13648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/29/2022] [Accepted: 04/07/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Kyung Mi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Jong Min Lee
- Department of Anesthesiology and Pain Medicine Daejeon Eulji University Hospital Eulji University School of Medicine Daejeon Korea
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine Daejeon Eulji University Hospital Eulji University School of Medicine Daejeon Korea
| | - Ji‐Yeon Bang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Eun‐Kyung Lee
- Department of Statistics Ewha Womans University Seoul South Korea
| | - Byung‐Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Gyu‐Jeong Noh
- Departments of Anesthesiology and Pain Medicine, Clinical Pharmacology and Therapeutics, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
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Target Controlled Infusion: An Anaesthetic Technique Brought in ICU. J Crit Care Med (Targu Mures) 2022; 8:3-5. [PMID: 35274049 PMCID: PMC8852287 DOI: 10.2478/jccm-2022-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 11/20/2022] Open
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A personalised approach to antibiotic pharmacokinetics and pharmacodynamics in critically ill patients. Anaesth Crit Care Pain Med 2021; 40:100970. [PMID: 34728411 DOI: 10.1016/j.accpm.2021.100970] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/26/2021] [Accepted: 08/14/2021] [Indexed: 01/01/2023]
Abstract
Critically ill patients admitted to intensive care unit (ICU) with severe infections, or those who develop nosocomial infections, have poor outcomes with substantial morbidity and mortality. Such patients commonly have suboptimal antibiotic exposures at routinely used antibiotic doses related to an increased volume of distribution and altered clearance due to their underlying altered physiology. Furthermore, the use of extracorporeal devices such as renal replacement therapy and extracorporeal membrane oxygenation in these group of patients also has the potential to alter in vivo drug concentrations. Moreover, ICU patients are likely to be infected with less-susceptible pathogens. Therefore, one potential contributing cause to the poor outcomes observed in critically ill patients may be related to subtherapeutic antibiotic exposures. Newer concepts include the clinician considering optimised dosing based on a blood antibiotic exposure defined by pharmacokinetic modelling and therapeutic drug monitoring, combined with a knowledge of the antibiotic penetration into the site of infection, thereby achieving optimal bacterial killing. Such optimised dosing is likely to improve patient outcomes. The aim of this review is to highlight key aspects of antibiotic pharmacokinetics and pharmacodynamics (PK/PD) in critically ill patients and provide a PK/PD approach to tailor antibiotic dosing to the individual patient.
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Bang JY, Kang HI, Lee HJ, Chong YP, Hong SK, Lee EK, Choi BM, Noh GJ. Development of a new pharmacokinetic model for target-concentration controlled infusion of vancomycin in critically ill patients. Clin Exp Pharmacol Physiol 2021; 49:202-211. [PMID: 34596258 DOI: 10.1111/1440-1681.13597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 09/15/2021] [Accepted: 09/27/2021] [Indexed: 11/28/2022]
Abstract
The aim of this prospective study was to construct a new pharmacokinetic model of vancomycin for target-concentration controlled infusion (TCI). As the first loading dose, 25 mg/kg of vancomycin was administered during 60-90 min. Arterial blood samples were obtained at pre-set intervals to measure the serum concentrations of vancomycin. Population pharmacokinetic analysis was performed using the NONMEM software (ICON Development Solutions). In total, 197 serum concentration measurements from 22 patients were used to characterise the pharmacokinetics of vancomycin. A three-compartment mammillary model best described the pharmacokinetics of vancomycin in critically ill patients. The ideal body weight was a significant covariate for the central and slow peripheral volume of distribution. The weight and age converted to categorical variables at a cut-off of 65 years were a significant covariate for the clearance. Based on the results of stochastic simulation, the TCI method maintained the therapeutic concentration range for the longest duration. In addition, assuming that vancomycin was administered by the TCI method for 7 days, the dose was reduced by about 15% compared with the standard administration methods. The daily area under the curve values were maintained between 500 mg·h/L and 600 mg·h/L. TCI has the potential to become a new infusion method for patient-tailored dosing in critically ill patients. To administer vancomycin via TCI in clinical practice, the newly constructed pharmacokinetic model should undergo proper external validation.
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Affiliation(s)
- Ji-Yeon Bang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Il Kang
- University of Ulsan College of Medicine, Seoul, Korea
| | - Hak-Jae Lee
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Kyung Lee
- Department of Statistics, Ewha Womans University, Seoul, Korea
| | - Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Jeong Noh
- Departments of Anesthesiology and Pain Medicine, Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Torumkuney D, Tunger A, Sancak B, Bıçakçıgil A, Altun B, Aktas Z, Kayacan C, Morrissey I. Results from the Survey of Antibiotic Resistance (SOAR) 2015-17 in Turkey: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. J Antimicrob Chemother 2021; 75:i88-i99. [PMID: 32337598 DOI: 10.1093/jac/dkaa086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates from community-acquired respiratory tract infections (CA-RTIs) collected in 2015-17 from Turkey. METHODS MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. RESULTS A total of 179 S. pneumoniae and 239 H. influenzae isolates were collected. Few (27.9%) pneumococci were penicillin susceptible by CLSI oral or EUCAST low-dose breakpoints, but by EUCAST high-dose or CLSI IV breakpoints 84.4% were susceptible. The most active antibiotics (excluding penicillin IV) by CLSI breakpoints were fluoroquinolones (98.9% of isolates susceptible), ceftriaxone (83.2%), amoxicillin (78.8%) and amoxicillin/clavulanic acid (78.8%). Pneumococcal susceptibility to amoxicillin and amoxicillin/clavulanic acid was lower using EUCAST low-dose breakpoints (49.7%), although susceptibility increased when using EUCAST high-dose (57.0%-58.1%) and PK/PD (78.8%-87.7%) breakpoints. Twenty-three H. influenzae isolates were β-lactamase positive, with 11 characterized as β-lactamase negative and ampicillin resistant following EUCAST criteria and 5 by CLSI criteria. Generally antibiotic susceptibility was high using CLSI breakpoints: ≥92.9% for all antibiotics except ampicillin (87% by CLSI and EUCAST breakpoints) and trimethoprim/sulfamethoxazole (67.4% and 72% by CLSI and EUCAST breakpoints, respectively). Susceptibility using EUCAST breakpoints (where these are published) was similar, except for cefuroxime (oral) with 3.8% of isolates susceptible. PK/PD breakpoints indicated low susceptibility to macrolides (5.9%-10%) and cefaclor (13%). The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified. CONCLUSIONS Antibiotic susceptibility of S. pneumoniae was generally low, which is in keeping with evidence of inappropriate and high antibiotic use in Turkey. H. influenzae susceptibility was high. These data are important for empirical therapy of CA-RTIs.
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Affiliation(s)
- D Torumkuney
- GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK
| | - A Tunger
- Ege University Medical Faculty, Department of Medical Microbiology, Bornova, Izmir, Turkey
| | - B Sancak
- Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - A Bıçakçıgil
- Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - B Altun
- Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Z Aktas
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - C Kayacan
- Istanbul Aydin University, Faculty of Medicine, Istanbul, Turkey
| | - I Morrissey
- IHMA Europe Sàrl, Route de l'Ile-au-Bois 1A, 1870 Monthey/VS, Switzerland
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Torumkuney D, Smayevsky J, Relloso MS, Sucari A, Pennini M, Brilla E, Vilches V, De la Cruz Y, Morrissey I. Results from the Survey of Antibiotic Resistance (SOAR) 2015-17 in Latin America (Argentina, Chile and Costa Rica): data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. J Antimicrob Chemother 2021; 75:i43-i59. [PMID: 32337593 DOI: 10.1093/jac/dkaa083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates from community-acquired respiratory tract infections (CA-RTIs) collected in 2015-17 from Argentina, Chile and Costa Rica. METHODS MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. RESULTS A total of 170 S. pneumoniae and 218 H. influenzae isolates were collected at five centres in Argentina, Chile and Costa Rica in 2015-17. Small S. pneumoniae isolate numbers from Costa Rica (n = 2) meant that these could only be included in the penicillin susceptibility analysis; they were excluded from further country analyses. Around one-third of pneumococcal isolates from Argentina and two-thirds from Chile were non-susceptible to penicillin by CLSI oral or EUCAST low-dose IV breakpoints, but most (≥89%) were susceptible by CLSI IV or EUCAST high-dose breakpoints. Amongst pneumococci from Argentina, about 80% or more were susceptible to most other antibiotics except cefaclor (all breakpoints), cefixime (PK/PD breakpoints), cefuroxime (EUCAST breakpoints) and trimethoprim/sulfamethoxazole (CLSI and PK/PD breakpoints). S. pneumoniae isolates from Chile showed significantly lower susceptibility (P < 0.05) using CLSI breakpoints compared with those from Argentina for many of the antibiotics tested. Among isolates of H. influenzae from Latin America, more than 90% were susceptible to amoxicillin/clavulanic acid (high dose), cefixime, cefpodoxime, ceftriaxone and fluoroquinolones, irrespective of the breakpoints used. The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified. CONCLUSIONS Antibiotic susceptibility of H. influenzae isolates was generally high in the Latin American countries studied; however, susceptibility profiles varied for S. pneumoniae by country and depending on the breakpoints used, especially for cefaclor. These factors are important in decision making for empirical therapy of bacterial infections.
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Affiliation(s)
- D Torumkuney
- GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK
| | - J Smayevsky
- Centro de Educación Médica e Investigaciones Clínicas Dr Norberto Quirno (CEMIC), Buenos Aires, Argentina
| | - M S Relloso
- Centro de Educación Médica e Investigaciones Clínicas Dr Norberto Quirno (CEMIC), Buenos Aires, Argentina
| | - A Sucari
- Stamboulian Servicios de Salud, Unidad Microbiología, Buenos Aires, Argentina
| | - M Pennini
- Stamboulian Servicios de Salud, Unidad Microbiología, Buenos Aires, Argentina
| | - E Brilla
- Microbiólogo Químico Clínico, Laboratorio Centro de Investigaciones Médicas, San Jose, Costa Rica
| | - V Vilches
- Hospital Universitario Austral, Buenos Aires, Argentina
| | - Y De la Cruz
- Hospital Universitario Austral, Buenos Aires, Argentina
| | - I Morrissey
- IHMA Europe Sàrl, Route de l'Ile-au-Bois 1A, 1870 Monthey/VS, Switzerland
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Torumkuney D, Bratus E, Yuvko O, Pertseva T, Morrissey I. Results from the Survey of Antibiotic Resistance (SOAR) 2016-17 in Ukraine: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. J Antimicrob Chemother 2021; 75:i100-i111. [PMID: 32337596 DOI: 10.1093/jac/dkaa087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates from community-acquired respiratory tract infections (CA-RTIs) collected in 2016-17 from Ukraine. METHODS MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. RESULTS A total of 177 viable clinical isolates, including 78 S. pneumoniae and 99 H. influenzae, were collected. Overall, ∼98% of S. pneumoniae isolates were susceptible to penicillin by CLSI IV or EUCAST high-dose breakpoints and 73.1% were susceptible by CLSI oral or EUCAST low-dose IV breakpoints. Susceptibility rates of 76.9%-100% were observed for most antibiotics by all breakpoints except trimethoprim/sulfamethoxazole (41%-69.2%) and cefaclor, which showed the greatest difference between breakpoints: 0% by EUCAST, 28.2% by PK/PD and 73.1% by CLSI. All S. pneumoniae isolates were susceptible to amoxicillin/clavulanic acid by CLSI and PK/PD breakpoints. H. influenzae isolates were almost all β-lactamase negative (90.9%). One isolate was β-lactamase negative and ampicillin resistant (BLNAR) by CLSI and four isolates were BLNAR by EUCAST criteria. Susceptibility of isolates was high (≥90.9%) by CLSI breakpoints for all antibiotics tested except trimethoprim/sulfamethoxazole (61.6%). Susceptibility using EUCAST breakpoints was similar for ampicillin (90.9%) and amoxicillin/clavulanic acid (95%) but was low for cefuroxime (oral), where only 10.1% of isolates were susceptible. All S. pneumoniae and H. influenzae isolates were susceptible to the fluoroquinolones by all breakpoints. Susceptibility to ceftriaxone was also 100% for H. influenzae and ≥91% for S. pneumoniae isolates by all breakpoints. The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified. CONCLUSIONS Antibiotic susceptibility in these respiratory tract pathogens was generally high in Ukraine. These data are important for empirical therapy choices in the treatment of CA-RTIs.
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Affiliation(s)
- D Torumkuney
- GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK
| | - E Bratus
- Dnipropetrovsk State Medical Academy Diagnostic Center, Soborna Square, 4, 49027 Dnipro, Ukraine
| | - O Yuvko
- Dnipropetrovsk State Medical Academy Diagnostic Center, Soborna Square, 4, 49027 Dnipro, Ukraine
| | - T Pertseva
- Dnipropetrovsk State Medical Academy, Vernadskogo Street, 9, 49044 Dnipro, Ukraine
| | - I Morrissey
- IHMA, Europe Sàrl, Route de l'Ile-au-Bois, 1A, 1870 Monthey/VS, Switzerland
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12
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Torumkuney D, Van PH, Thinh LQ, Koo SH, Tan SH, Lim PQ, Sivhour C, Lamleav L, Somary N, Sosorphea S, Lagamayo E, Morrissey I. Results from the Survey of Antibiotic Resistance (SOAR) 2016-18 in Vietnam, Cambodia, Singapore and the Philippines: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. J Antimicrob Chemother 2021; 75:i19-i42. [PMID: 32337597 DOI: 10.1093/jac/dkaa082] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates collected from community-acquired respiratory tract infections (CA-RTIs) in 2016-18 in four Asian countries. METHODS MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. RESULTS In total, 260 S. pneumoniae and 258 H. influenzae isolates were tested. Pneumococci from Vietnam (n = 161) were the least susceptible, with rates of susceptibility >90% for fluoroquinolones by CLSI breakpoints, ∼60% for amoxicillin, amoxicillin/clavulanic acid and ceftriaxone but <14% for most other agents. Pneumococcal isolates from Cambodia (n = 48) and Singapore (n = 34) showed susceptibilities ranging from ∼30% for trimethoprim/sulfamethoxazole and oral penicillin to 100% for fluoroquinolones. Among isolates of H. influenzae from Cambodia (n = 30), the Philippines (n = 59) and Singapore (n = 80), rates of susceptibility using CLSI breakpoints were >90% for amoxicillin/clavulanic acid, cephalosporins [except cefaclor in Singapore (77.5%)], macrolides and fluoroquinolones; for isolates from Vietnam (n = 89) the rates of susceptibility were >85% only for amoxicillin/clavulanic acid (95.5%), ceftriaxone (100%) and macrolides (87.6%-89.9%). Susceptibility to other antibiotics ranged from 7.9% (trimethoprim/sulfamethoxazole) to 57.3%-59.6% (fluoroquinolones) and 70.8% (cefixime). The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified. A limitation of the study was the small sample sizes and only one or two sites participating per country; however, since susceptibility data are scarce in some of the participating countries any information concerning antibiotic susceptibility is of value. CONCLUSIONS Antibiotic susceptibility varied across countries and species, with isolates from Vietnam demonstrating the lowest susceptibility. Knowledge of resistance patterns can be helpful for clinicians when choosing empirical therapy options for CA-RTIs.
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Affiliation(s)
- D Torumkuney
- GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK
| | - P H Van
- Nguyen Tri Phuong Hospital, Ho Chi Minh City, Vietnam
| | - L Q Thinh
- Children Hospital 1, Ho Chi Minh City, Vietnam
| | - S H Koo
- Clinical Trials & Research Unit, Changi General Hospital, 2 Simei Street 3, 529889 Singapore
| | - S H Tan
- Department of Laboratory Medicine, 2 Simei Street 3, 529889 Singapore
| | - P Q Lim
- Clinical Trials & Research Unit, Changi General Hospital, 2 Simei Street 3, 529889 Singapore
| | - C Sivhour
- Battambang Provincial Referral Hospital Prek Mohatep Village, Svaypor Commune, Battambang City and Battambang Province, Cambodia
| | - L Lamleav
- Siem Reap Provincial Referral Hospital Mondul 1 Village, Svay Dangum Commune, Siem Reap City, Siem Reap Province, Cambodia
| | - N Somary
- Kampong Cham Provincial Referral Hospital, Praketmealea Road, #7 Village, Kampong Cham Commune, Kampong Cham City, Kampong Cham Province, Cambodia
| | - S Sosorphea
- Takeo Provincial Referral Hospital, Phumi 3 Village, RokaKnong Commune, Daunkeo Town, Takeo Province, Cambodia
| | - E Lagamayo
- St. Luke's Medical Center Quezon City, Institute of Pathology, Microbiology Section, 279 E Rodriguez SR. BLVD Cathedral Heights, Quezon City, Philippines
| | - I Morrissey
- IHMA Europe Sàrl, Route de l'Ile-au-Bois 1A, 1870 Monthey/VS, Switzerland
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13
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Torumkuney D, Hammami A, Mezghani Maalej S, Ayed NB, Revathi G, Zerouali K, Elmdaghri N, Gachii AK, Morrissey I. Results from the Survey of Antibiotic Resistance (SOAR) 2015-18 in Tunisia, Kenya and Morocco: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. J Antimicrob Chemother 2021; 75:i2-i18. [PMID: 32337595 DOI: 10.1093/jac/dkaa081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine antibiotic susceptibility of community-acquired respiratory tract infection (CA-RTI) isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2015-18 from Tunisia, Kenya and Morocco. METHODS MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. RESULTS S. pneumoniae isolates from Tunisia (n = 79), Kenya (n = 44) and Morocco (n = 19) and H. influenzae isolates (n = 74) from Tunisia only were collected and analysed. Low antibiotic susceptibility was observed in S. pneumoniae from Tunisia, with >90% susceptible only to the fluoroquinolones (all breakpoints), penicillin (CLSI IV and EUCAST high-dose) and ceftriaxone (CLSI, EUCAST high-dose and PK/PD breakpoints). In addition, isolate susceptibility in Kenya was >90% to amoxicillin and amoxicillin/clavulanic acid (CLSI and PK/PD breakpoints). Antibiotic activity was highest in Morocco, where ≥89.5% of pneumococci were susceptible to most antibiotics, excluding trimethoprim/sulfamethoxazole (68.4% by CLSI or PK/PD and 79%-84.2% by EUCAST), macrolides (79%-84.2% by all breakpoints) and cefaclor (0% by EUCAST and 52.6% by PK/PD). The majority (≥86.5%) of H. influenzae isolates from Tunisia were susceptible to most antibiotics by all available breakpoints, except ampicillin and amoxicillin (almost one-third were β-lactamase positive), trimethoprim/sulfamethoxazole (51.4%-56.8%), cefaclor (1.4% by PK/PD), cefuroxime (4.1% by EUCAST), macrolides (1.4%-2.7% by PK/PD) and cefdinir (66.2% by PK/PD). The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified. CONCLUSIONS Low antibiotic susceptibility was observed in S. pneumoniae from Tunisia, but susceptibility was higher in isolates from Kenya and highest in those from Morocco. H. influenzae from Tunisia were highly susceptible to most antibiotics. These factors are important in decision making for empirical therapy of CA-RTIs.
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Affiliation(s)
- D Torumkuney
- GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK
| | - A Hammami
- Department of Microbiology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - S Mezghani Maalej
- Department of Microbiology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - N Ben Ayed
- Department of Microbiology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - G Revathi
- Department of Pathology, Aga Khan University Hospital, Nairobi, Kenya
| | - K Zerouali
- Laboratory of Bacteriology & Virology and Hygiene, CHU Ibn Rochd, Casablanca, Morocco.,Laboratory of Microbiology, Faculté de Médecine et de Pharmacie, Hassan II University, Casablanca, Morocco
| | - N Elmdaghri
- Laboratory of Bacteriology & Virology and Hygiene, CHU Ibn Rochd, Casablanca, Morocco.,Laboratory of Microbiology, Faculté de Médecine et de Pharmacie, Hassan II University, Casablanca, Morocco
| | - A K Gachii
- Department of Pathology, Kenyatta National Hospital, Nairobi, Kenya
| | - I Morrissey
- IHMA Europe Sàrl, Route de l'Ile-au-Bois 1A, 1870 Monthey/VS, Switzerland
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Torumkuney D, Mokaddas E, Jiman-Fatani A, Ageel A, Daoud Z, Bouferraa Y, Zerdan MB, Morrissey I. Results from the Survey of Antibiotic Resistance (SOAR) 2015-17 in the Middle East (Kuwait, Lebanon and Saudi Arabia): data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. J Antimicrob Chemother 2021; 75:i60-i75. [PMID: 32337592 DOI: 10.1093/jac/dkaa084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates from community-acquired respiratory tract infections (CA-RTIs) collected in 2015-17 from Kuwait, Lebanon and Saudi Arabia. METHODS MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. RESULTS A total of 139 S. pneumoniae isolates were collected from four centres in Kuwait, Lebanon and Saudi Arabia in 2015-17 and 55 H. influenzae isolates were collected and analysed from Saudi Arabia over the same time period. Pneumococci from all three countries were commonly non-susceptible to penicillin based on CLSI oral or low-dose IV penicillin using EUCAST breakpoints (39% in Kuwait to 57.1% in Lebanon) but by CLSI IV and EUCAST high-dose breakpoints most isolates were susceptible (∼90% in Kuwait and Saudi Arabia, and 100% in Lebanon). Isolates from Lebanon were highly susceptible to most other antibiotics (>90%) except cefaclor, oral cefuroxime and cefpodoxime (EUCAST breakpoints only). Overall, susceptibility was significantly lower in Kuwait and Saudi Arabia than Lebanon. Although all H. influenzae isolates (Saudi Arabia only) were β-lactamase negative, 3.6% and 12.7% were ampicillin resistant by CLSI and EUCAST breakpoints, respectively. Otherwise susceptibility was high in H. influenzae. The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified. CONCLUSIONS Relatively low antibiotic susceptibility was observed in S. pneumoniae from Kuwait and Saudi Arabia in contrast to Lebanon, where rates of susceptibility were generally higher. Isolates of H. influenzae from Saudi Arabia were susceptible to most antibiotics. These factors are important in decision making for empirical therapy of CA-RTIs.
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Affiliation(s)
- D Torumkuney
- GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK
| | - E Mokaddas
- Microbiology Department, Faculty of Medicine, Kuwait University, Jabrya, Kuwait
| | - A Jiman-Fatani
- Department of Medical Microbiology and Parasitology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia and Clinical and Molecular Microbiology Laboratory, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - A Ageel
- Pathology and Clinical Laboratory Medicine Administration, King Fahad Medical City, Dhabab Street, PO Box 59046 Riyadh, Saudi Arabia
| | - Z Daoud
- Faculty of Medicine and Medical Sciences, University of Balamand, Al Koura, Tripoli, Lebanon
| | - Y Bouferraa
- Faculty of Medicine and Medical Sciences, University of Balamand, Al Koura, Tripoli, Lebanon
| | - M B Zerdan
- Faculty of Medicine and Medical Sciences, University of Balamand, Al Koura, Tripoli, Lebanon
| | - I Morrissey
- IHMA Europe Sàrl, Route de l'Ile-au-Bois 1A, 1870 Monthey/VS, Switzerland
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Torumkuney D, Anwar S, Nizamuddin S, Malik N, Morrissey I. Results from the Survey of Antibiotic Resistance (SOAR) 2015-17 in Pakistan: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. J Antimicrob Chemother 2021; 75:i76-i87. [PMID: 32337594 DOI: 10.1093/jac/dkaa085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To determine antibiotic susceptibility of community-acquired respiratory tract infection (CA-RTI) isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2015-17 from Pakistan. METHODS MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. RESULTS A total of 94 S. pneumoniae and 122 H. influenzae isolates were collected. Susceptibility to penicillin was noted in 23.4% of the S. pneumoniae isolates by CLSI oral/EUCAST low-dose IV breakpoints, although by CLSI IV and EUCAST high-dose breakpoints all isolates were characterized as susceptible. Susceptibility to trimethoprim/sulfamethoxazole (10.6%), macrolides (33%) and cefaclor (28.7%) was low but higher susceptibility was observed to ceftriaxone (100%), amoxicillin and amoxicillin/clavulanic acid (98.9%), cefuroxime (oral, 97.9%), cefpodoxime (96.8%), fluoroquinolones (93.6%-96.8%) and cefdinir (76.6%) by CLSI breakpoints. However, using EUCAST breakpoints, susceptibility to cefpodoxime (70.2%) and cefuroxime (oral, 61.7%) was reduced. H. influenzae isolates were almost all β-lactamase negative (96.7%). Using CLSI breakpoints, ≥93.4% of isolates were susceptible to all antibiotics tested except fluoroquinolones (75.4%-77.1%) and trimethoprim/sulfamethoxazole (41%). The proportion of isolates susceptible using EUCAST breakpoints was similar or identical for penicillins, trimethoprim/sulfamethoxazole and the cephalosporins that have EUCAST breakpoints; the proportion of isolates susceptible using EUCAST breakpoints was similar or identical to that using CSLI breakpoints except for cefuroxime (oral), where only 1.6% of isolates were considered susceptible. Susceptibility of H. influenzae to fluoroquinolones was also lower by EUCAST breakpoints (33.6%-34.4%). The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified. CONCLUSIONS Antibiotic susceptibility in these important respiratory tract pathogens varied in Pakistan based on different breakpoints. These data are important for empirical therapy choices in the treatment of CA-RTIs.
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Affiliation(s)
- D Torumkuney
- GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK
| | - S Anwar
- Liaquat National Hospital and Medical College, Microbiology Department, Stadium Road, Karachi, Pakistan
| | - S Nizamuddin
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Section of Microbiology, Department of Pathology, 7A Block R3, Johar Town, Lahore, Pakistan
| | - N Malik
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Section of Microbiology, Department of Pathology, 7A Block R3, Johar Town, Lahore, Pakistan
| | - I Morrissey
- IHMA Europe Sàrl, Route de l'Ile-au-Bois 1A, 1870 Monthey/VS, Switzerland
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Wicha SG, Märtson AG, Nielsen EI, Koch BCP, Friberg LE, Alffenaar JW, Minichmayr IK. From Therapeutic Drug Monitoring to Model-Informed Precision Dosing for Antibiotics. Clin Pharmacol Ther 2021; 109:928-941. [PMID: 33565627 DOI: 10.1002/cpt.2202] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/01/2021] [Indexed: 12/14/2022]
Abstract
Therapeutic drug monitoring (TDM) and model-informed precision dosing (MIPD) have evolved as important tools to inform rational dosing of antibiotics in individual patients with infections. In particular, critically ill patients display altered, highly variable pharmacokinetics and often suffer from infections caused by less susceptible bacteria. Consequently, TDM has been used to individualize dosing in this patient group for many years. More recently, there has been increasing research on the use of MIPD software to streamline the TDM process, which can increase the flexibility and precision of dose individualization but also requires adequate model validation and re-evaluation of existing workflows. In parallel, new minimally invasive and noninvasive technologies such as microneedle-based sensors are being developed, which-together with MIPD software-have the potential to revolutionize how patients are dosed with antibiotics. Nonetheless, carefully designed clinical trials to evaluate the benefit of TDM and MIPD approaches are still sparse, but are critically needed to justify the implementation of TDM and MIPD in clinical practice. The present review summarizes the clinical pharmacology of antibiotics, conventional TDM and MIPD approaches, and evidence of the value of TDM/MIPD for aminoglycosides, beta-lactams, glycopeptides, and linezolid, for which precision dosing approaches have been recommended.
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Affiliation(s)
- Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Jan-Willem Alffenaar
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Camperdown, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia.,Westmead Hospital, Wentworthville, Australia
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17
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The role of pharmacokinetics and pharmacodynamics in clinical anaesthesia practice. Curr Opin Anaesthesiol 2020; 33:483-489. [DOI: 10.1097/aco.0000000000000881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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18
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Development of Vancomycin Dose Individualization Strategy by Bayesian Prediction in Patients Receiving Continuous Renal Replacement Therapy. Pharm Res 2020; 37:108. [PMID: 32468340 DOI: 10.1007/s11095-020-02820-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/07/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE Vancomycin (VCM) concentration is often out of therapeutic range (10-20 μg/ml) in patients receiving continuous renal replacement therapy (CRRT). The purposes of this study were to develop a practical VCM population pharmacokinetic (PPK) model and to evaluate the potential of Bayesian prediction-based therapeutic drug monitoring (Bayes-TDM) in VCM dose individualization for patients receiving CRRT. METHODS We developed a VCM PPK model using 80 therapeutic concentrations in 17 patients receiving CRRT. Bayes-TDM with the VCM PPK model was evaluated in 23 patients after PPK modeling. RESULTS We identified the covariates reduced urine output (RUO, <0.5 ml/kg/h) and effluent flow rate of CRRT for the VCM PPK model. The mean VCM non CRRT clearance (CLnonCRRT) was 2.12 l/h. RUO lowered CLnonCRRT to 0.34 l/h. The volume of distribution was 91.3 l/70 kg. The target concentration attainment rate by Bayes-TDM was higher (87.0%) than that by the PPK modeling period (53.8%, P = 0.046). The variance of the second measured concentrations by the Bayes-TDM was lower (11.5, standard deviation: 3.4 μg/ml) than that by the PPK modeling period (50.5, standard deviation: 7.1 μg/ml, P = 0.003). CONCLUSIONS Bayes-TDM could be a useful tool for VCM dose individualization in patients receiving CRRT.
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Target-Controlled Infusion of Cefepime in Critically Ill Patients. Antimicrob Agents Chemother 2019; 64:AAC.01552-19. [PMID: 31685467 DOI: 10.1128/aac.01552-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 10/28/2019] [Indexed: 11/20/2022] Open
Abstract
Attainment of appropriate pharmacokinetic-pharmacodynamic (PK-PD) targets for antimicrobial treatment is challenging in critically ill patients, particularly for cefepime, which exhibits a relative narrow therapeutic-toxic window compared to other beta-lactam antibiotics. Target-controlled infusion (TCI) systems, which deliver drugs to achieve specific target drug concentrations, have successfully been implemented for improved dosing of sedatives and analgesics in anesthesia. We conducted a clinical trial in an intensive care unit (ICU) to investigate the performance of TCI for adequate target attainment of cefepime. Twenty-one patients treated with cefepime according to the standard of care were included. Cefepime was administered through continuous infusion using TCI for a median duration of 4.5 days. TCI was based on a previously developed population PK model incorporating the estimated creatinine clearance based on the Cockcroft-Gault formula as the input variable to calculate cefepime clearance. A cefepime blood concentration of 16 mg/liter was targeted. To evaluate the measured versus predicted plasma concentrations, blood samples were taken (median of 10 samples per patient), and total cefepime concentrations were measured using ultraperformance liquid chromatography-tandem mass spectrometry. The performance of the TCI system was evaluated using Varvel criteria. Half (50.3%) of the measured cefepime concentrations were within ±30% around the target value of 16 mg liter-1 The wobble was 11.4%, the median performance error (MdPE) was 21.1%, the median absolute performance error (MdAPE) was 32.0%, and the divergence was -3.72% h-1 Based on these results, we conclude that TCI is useful for dose optimization of cefepime in ICU patients. (This study has been registered at ClinicalTrials.gov under identifier NCT02688582.).
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20
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Comment on “Target-Controlled Continuous Infusion for Antibiotic Dosing: Proof-of-Principle in an In-silico Vancomycin Trial in Intensive Care Unit Patients”. Clin Pharmacokinet 2019; 58:981-982. [DOI: 10.1007/s40262-019-00768-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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21
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Claisse G, Zufferey PJ, Trone JC, Maillard N, Delavenne X, Laporte S, Ollier E. Predicting the dose of vancomycin in ICU patients receiving different types of RRT therapy: a model-based meta-analytic approach. Br J Clin Pharmacol 2019; 85:1215-1226. [PMID: 30768726 DOI: 10.1111/bcp.13904] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/28/2019] [Accepted: 02/10/2019] [Indexed: 11/28/2022] Open
Abstract
AIM Previous pharmacokinetic (PK) studies have proposed various dosing regimens for vancomycin in intensive care unit (ICU) patients undergoing renal replacement therapy (RRT), but all are restricted to specific RRT modalities. To be useful in practice, a population PK model would need to predict vancomycin clearance during any RRT modality. Development of such a model is feasible using meta-analysis of published summarized estimates of vancomycin PK parameters. Our aims were: (i) to develop and validate a population PK model for vancomycin that takes into account any RRT modalities, and (ii) to predict vancomycin dosing for RRT patients in ICU. METHODS Vancomycin pharmacokinetics were assumed to be two-compartmental, total body clearance being the sum of non-RRT clearance and RRT-induced clearance. Drug disposition and non-RRT clearance parameters were estimated by systematic review and meta-analysis of previously published parameter estimates. The relationship between RRT-induced clearance and RRT flowrate settings was assessed using a model-based meta-analysis. Prediction performances of the PK model were assessed using external data. RESULTS The meta-analyses of disposition parameters, non-RRT clearance and RRT-induced clearance included 11, 6 and 38 studies (84 RRT clearance measurements) respectively. The model performed well in predicting external individual PK data. Individual vancomycin concentrations during RRT were accurately predicted using Bayesian estimation based solely on pre-RRT measurements. CONCLUSIONS The PK model allowed accurate prediction of the vancomycin pharmacokinetics during RRT in ICU patients. Based on the model of RRT-induced clearance, an appropriate adjustment of the vancomycin dosing regimen could be proposed for any kind of flowrate settings.
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Affiliation(s)
- Guillaume Claisse
- Service de Néphrologie, Dialyse, Transplantation Rénale, Hôpital Nord, Saint-Etienne, France
| | - Paul J Zufferey
- Unité de Recherche Clinique, Innovation, Pharmacologie, Hôpital Nord, Saint-Etienne, France.,Département d'Anesthésie-Réanimation, Hôpital Nord, Saint-Etienne, France
| | - Jane C Trone
- Département de radiothérapie, Institut de Cancérologie Lucien Neuwirth, Saint Etienne, France.,INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Etienne, France
| | - Nicolas Maillard
- Service de Néphrologie, Dialyse, Transplantation Rénale, Hôpital Nord, Saint-Etienne, France.,Groupe Immunité des Muqueuses et Agents Pathogènes (GIMAP), Saint-Etienne, France
| | - Xavier Delavenne
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Etienne, France
| | - Silvy Laporte
- Unité de Recherche Clinique, Innovation, Pharmacologie, Hôpital Nord, Saint-Etienne, France.,INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Etienne, France
| | - Edouard Ollier
- Unité de Recherche Clinique, Innovation, Pharmacologie, Hôpital Nord, Saint-Etienne, France.,INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Etienne, France
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Target Controlled Infusion in the ICU: An Opportunity to Optimize Antibiotic Therapy. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2019 2019. [DOI: 10.1007/978-3-030-06067-1_38] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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