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Struiken STL, Lobée D, van Tuinen EL, Touw DJ, van der Vaart H, Bourgonje AR, Rottier BL, Koppelman GH, Mian P. Evaluation of Target Attainment for Tobramycin in Children and Adults with Cystic Fibrosis. J Clin Med 2024; 13:2641. [PMID: 38731170 PMCID: PMC11084493 DOI: 10.3390/jcm13092641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 04/19/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Introduction: Patients with cystic fibrosis (CF) commonly experience pulmonary exacerbations, and it is recommended by the TOPIC study to treat this with tobramycin at a dose of 10 mg/kg once daily. The aim of this study was to evaluate the target attainment of the current dosing regimen. Methods: A single-center retrospective cohort study of child and adult patients with CF who received tobramycin between 2019 and 2022 was conducted. Descriptive statistics and linear mixed models were used to assess target attainment for tobramycin. Results: In total, 25 patients (53 courses), of which 10 were children (12 courses) and 15 were adults (41 courses), were included. Those 25 patients all received 10 mg/kg/day. The tobramycin peak concentrations were supratherapeutic in 82.9% and therapeutic in 100.0% of adults and children, respectively. The trough concentrations were outside the target range in 0% and 5.1% of children and adults, respectively. We found lower tobramycin concentrations with the same dose in children compared to adults. Conclusions: This study illustrates the need to validate dosing advice in a real-world setting, as supratherapeutic concentrations of tobramycin were prevalent in adults with CF.
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Affiliation(s)
- Sheseira T. L. Struiken
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9712 GZ Groningen, The Netherlands; (S.T.L.S.); (D.L.); (E.L.v.T.); (D.J.T.)
| | - Danique Lobée
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9712 GZ Groningen, The Netherlands; (S.T.L.S.); (D.L.); (E.L.v.T.); (D.J.T.)
| | - Eline L. van Tuinen
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9712 GZ Groningen, The Netherlands; (S.T.L.S.); (D.L.); (E.L.v.T.); (D.J.T.)
| | - Daniel J. Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9712 GZ Groningen, The Netherlands; (S.T.L.S.); (D.L.); (E.L.v.T.); (D.J.T.)
- Department of Pharmaceutical Analysis, Groningen Research Institute for Pharmacy, University of Groningen, 9712 GZ Groningen, The Netherlands
| | - Hester van der Vaart
- Department of Pulmonary Diseases and Tuberculosis, University Medical Center Groningen, University of Groningen, 9712 GZ Groningen, The Netherlands;
| | - Arno R. Bourgonje
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, 9712 GZ Groningen, The Netherlands;
- Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Bart L. Rottier
- Department of Pediatric Pulmonology and Pediatric Allergology, University Medical Center Groningen, Beatrix Children’s Hospital, University of Groningen, 9712 GZ Groningen, The Netherlands; (B.L.R.); (G.H.K.)
- Department of Pediatric Pulmonology, University Medical Center Groningen, University of Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), 9712 GZ Groningen, The Netherlands
| | - Gerard H. Koppelman
- Department of Pediatric Pulmonology and Pediatric Allergology, University Medical Center Groningen, Beatrix Children’s Hospital, University of Groningen, 9712 GZ Groningen, The Netherlands; (B.L.R.); (G.H.K.)
- Department of Pediatric Pulmonology, University Medical Center Groningen, University of Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), 9712 GZ Groningen, The Netherlands
| | - Paola Mian
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9712 GZ Groningen, The Netherlands; (S.T.L.S.); (D.L.); (E.L.v.T.); (D.J.T.)
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Schlegtendal A, Rettberg S, Maier C, Brinkmann F, Koerner-Rettberg C. Necessity of Tobramycin trough Levels in Once Daily Iv-Treatment in Patients with Cystic Fibrosis. KLINISCHE PADIATRIE 2024; 236:116-122. [PMID: 38286409 DOI: 10.1055/a-2244-6903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Once daily intravenous (iv) treatment with tobramycin for Pseudomonas aeruginosa infection in patients with cystic fibrosis (pwCF) is frequently monitored by measuring tobramycin trough levels (TLs). Although the necessity of these TLs is recently questioned in pwCF without renal impairment, no study has evaluated this so far. The aim of this observational study was to evaluate the frequency of increased tobramycin TLs in pwCF treated with a once daily tobramycin dosing protocol. METHODS Patient records of all consecutive once daily iv tobramycin courses in 35 pwCF between 07/2009 and 07/2019 were analyzed for tobramycin level, renal function, co-medication and comorbidity. RESULTS Eight elevated TLs (2.9% of 278 courses) were recorded in four patients, two with normal renal function. One of these resolved without adjustment of tobramycin dosages suggesting a test timing or laboratory error. In the other patient the elevated tobramycin level decreased after tobramycin dosage adjustment. Six of the elevated levels occurred in two patients with chronic renal failure. In 15 other patients with reduced glomerular filtration rate (GFR) (36 courses) but normal range creatinine no case of elevated tobramycin trough levels was detected. Neither cumulative tobramycin dosages nor concomitant diabetes or nutritional status were risk factors for elevated TLs. CONCLUSION Our data show that elevated tobramycin TLs are rare but cannot be excluded, so determination of tobramycin TLs is still recommended for safety.
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Affiliation(s)
- Anne Schlegtendal
- Department of pediatrics, Ruhr-Universität Bochum Medizinische Fakultät, Bochum, Germany
| | - Sophia Rettberg
- Department of pediatrics, Ruhr-Universität Bochum Medizinische Fakultät, Bochum, Germany
| | - Christoph Maier
- Department of pediatrics, Ruhr-Universität Bochum Medizinische Fakultät, Bochum, Germany
| | - Folke Brinkmann
- Department of pediatrics, Ruhr-Universität Bochum Medizinische Fakultät, Bochum, Germany
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Katz JB, Shah P, Trillo CA, Alshaer MH, Peloquin C, Lascano J. Therapeutic drug monitoring in cystic fibrosis and associations with pulmonary exacerbations and lung function. Respir Med 2023; 212:107237. [PMID: 37030586 DOI: 10.1016/j.rmed.2023.107237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/20/2023] [Accepted: 04/01/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy have resulted in longer life expectancies, yet pulmonary exacerbations remain a leading cause of morbidity. Intravenous antibiotics is the mainstay treatment, however achieving adequate concentrations remains challenging. The effect of therapeutic drug monitoring (TDM) of beta-lactams on exacerbations and lung function has not been studied. METHODS Patient demographics, antibiotic regimens, forced expiratory volume 1 second (FEV1), and exacerbation history was obtained from 32 patients with cystic fibrosis admitted for exacerbations. All patients were colonized with Pseudomonas aeruginosa, received CFTR therapy for at least one year, and had 3-month interval follow ups. Plasma concentrations, FEV1, and exacerbation history was obtained before and after therapeutic drug monitoring. This included peak and trough plasma concentrations of piperacillin-tazobactam and cefepime using liquid chromatography with mass spectrometry. T-test and Mann-Whitney U test were used to compare medians/means of FEV1 and pulmonary exacerbations pre and post-TDM as well as free trough-to-minimum inhibitory concentration ratio (fCmin/MIC) ≥1 and ≥ 4. RESULTS TDM was associated with decreased exacerbations/year from 1.91 to 1.31 (p = 0.04) and among the cohort with >/ = 2 exacerbations per year, there was a longer exacerbation free interval after TDM (196.2 vs 103.7 days, p = 0.02). The decline in FEV1% predicted after therapeutic drug monitoring to the first exacerbation was -4.9 compared to -9.7 prior (p = 0.03). CONCLUSIONS TDM for cystic fibrosis pulmonary exacerbations results in decreased pulmonary exacerbations, longer intervals to pulmonary exacerbation, and lower decline in FEV1% predicted.
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Affiliation(s)
- Jason Brandon Katz
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
| | - Purav Shah
- Department of Internal Medicine, Pulmonary and Critical Care Division, Emory, Atlanta, GA, 30322, USA.
| | - Cesar A Trillo
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, University of Florida Infectious Disease Pharmacokinetics Laboratory, UF College of Pharmacy, Gainesville, FL, 32610, USA.
| | - Charles Peloquin
- Department of Pharmacotherapy and Translational Research, University of Florida Infectious Disease Pharmacokinetics Laboratory, UF College of Pharmacy, Gainesville, FL, 32610, USA.
| | - Jorge Lascano
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
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4
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Koloskoff K, Thirion DJG, Matouk E, Marsot A. New Recommendations of a Height-Based Dosing Regimen of Tobramycin for Cystic Fibrosis in Adults: A Population Pharmacokinetic Analysis. Ther Drug Monit 2023; 45:251-258. [PMID: 36070759 DOI: 10.1097/ftd.0000000000001021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute pulmonary exacerbations (APEs) in patients with adult cystic fibrosis (CF) are treated with a beta-lactam and an aminoglycoside for activity against Pseudomonas aeruginosa (PA). Emerging drug resistance and changing pharmacokinetic profile in an aging population involve a reevaluation of tobramycin dosing recommendations. The objective of this study was to develop a population pharmacokinetic model and establish optimal dosing recommendations for tobramycin using Monte Carlo simulations. METHODS This retrospective clinical study and data collection were performed at the CF center of the McGill University Health Center (MUHC), Canada. Model development and simulations were performed using a nonlinear mixed-effect modeling approach (NONMEM, version 7.4.2). The ratios of maximal concentration (C max ) to the minimal inhibitory concentration (MIC) (C max /MIC ≥8 and ≥10) and area under the curve (AUC) to the MIC (AUC/MIC ≥70 and ≥100) were evaluated. RESULTS Adult patients with CF (n = 51) treated with tobramycin were included in the study. Plasma concentrations of tobramycin were obtained for 699 samples from the MUHC database. The two-compartmental model best described the pharmacokinetics of tobramycin. The association of patient height with the central volume of distribution significantly improved this model. Height, rather than weight, induced the best reduction in objective function. According to simulations, doses between 3.4 mg/cm and 4.4 mg/cm were necessary to achieve C max /MIC values of ≥8 and ≥10, respectively. However, higher doses were required to achieve the AUC/MIC targets. CONCLUSIONS This study demonstrated that height of the patients seems to be more suitable than their weight for dosing adjustments in adult patients with CF. According to this model, initial doses of tobramycin between 3.4 and 4.4 mg/cm should be recommended for patients with a median height of 164 cm and weight of 55 kg to achieve the target plasma concentrations.
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Affiliation(s)
- Kevin Koloskoff
- Faculty of Pharmacy, Université de Montréal
- Laboratoire STP2, Faculty of Pharmacy, Université de Montréal; and
| | - Daniel J G Thirion
- Faculty of Pharmacy, Université de Montréal
- Pharmacy Department, Royal Victoria Hospital, McGill University Health Centre
| | - Elias Matouk
- Adult Cystic Fibrosis Clinic, Montreal Chest Institute, McGill University, Montreal, Quebec, Canada
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal
- Laboratoire STP2, Faculty of Pharmacy, Université de Montréal; and
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Imburgia TA, Seagren RM, Christensen H, Lasarev MR, Bogenschutz MC. Review of Tobramycin Dosing in Pediatric Patients With Cystic Fibrosis. J Pediatr Pharmacol Ther 2023; 28:63-70. [PMID: 36777977 PMCID: PMC9901314 DOI: 10.5863/1551-6776-28.1.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/08/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE An institution's tobramycin pharmacokinetics (PK) database was reviewed to evaluate the efficacy and safety of empiric tobramycin dosing and monitoring strategies used in pediatric patients with cystic fibrosis (CF). The relationship between patient age and tobramycin dosing needed to achieve the area under the curve (AUC) goal was investigated. METHODS Retrospective chart review was performed for patients who received tobramycin during a CF exacerbation from 2009 to 2019 who received PK monitoring by pediatric pharmacists. Tobramycin dosing needed to achieve an AUC of 100 mg·hr/L was calculated for each patient. Serum creatinine and concomitant nephrotoxin use were collected as surrogate nephrotoxicity endpoints to evaluate safety. RESULTS Goal AUC (100 ± 15 mg·hr/L) was achieved based on initial or repeat PK calculations in 43.5% (95% CI, 37.7-49.3) of 85 unique patients across 326 encounters. Patients with calculated recommended doses of 9.5 to 11.9 mg/kg every 24 hours empirically achieved goal AUC in 77% (78/101) of encounters. The odds of achieving goal AUC were 56% higher for children aged 10 vs 5 years (OR = 1.56; 95% CI, 1.04-2.34; p = 0.033) and 32% higher for children aged 15 vs 10 years (OR = 1.32; 95% CI, 1.07-1.61; p = 0.008). Overall rates of acute kidney injury and concomitant nephrotoxin use were 10.8% (95% CI, 6.2-15.5) and 80.7% (95% CI, 74.3-87.1), respectively. CONCLUSIONS Desired AUC was achieved by 43.5% of pediatric patients with CF using tobramycin 10 mg/kg every 24 hours. Older patient age was associated with higher initial AUC attainment and fewer dose modifications. Younger children may require higher weight-based dosing to meet AUC goals.
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Affiliation(s)
- Taylor A. Imburgia
- Department of Pharmacy (TAI, RMS, HC, MCB), American Family Children's Hospital at University of Wisconsin Health, Madison, WI
| | - Ryan M. Seagren
- Department of Pharmacy (TAI, RMS, HC, MCB), American Family Children's Hospital at University of Wisconsin Health, Madison, WI
| | - Hanna Christensen
- Department of Pharmacy (TAI, RMS, HC, MCB), American Family Children's Hospital at University of Wisconsin Health, Madison, WI
| | - Michael R. Lasarev
- Department of Biostatistics and Medical Informatics (MRL), University of Wisconsin–Madison, Madison, WI
| | - Monica C. Bogenschutz
- Department of Pharmacy (TAI, RMS, HC, MCB), American Family Children's Hospital at University of Wisconsin Health, Madison, WI
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Larcombe R, Coulthard K, Eaton V, Tai A, Reuter S, Ward M. Is there a multinational consensus of tobramycin prescribing and monitoring for cystic fibrosis? Survey of current therapeutic drug monitoring practices in USA/Canada, UK/Ireland, and Australia/New Zealand. Eur J Hosp Pharm 2022:ejhpharm-2022-003545. [PMID: 36600520 DOI: 10.1136/ejhpharm-2022-003545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Sophisticated scientific methods have facilitated dose individualisation with substantial advancements in therapeutic drug monitoring (TDM) practice. It is unclear whether these methods have translated to the clinical setting. This study aimed to determine current TDM practice for tobramycin monitoring in cystic fibrosis (CF) centres in the USA and Canada, UK and Ireland, and Australia and New Zealand due to a high prevalence of CF. METHODS A web-based survey was developed and circulated via CF specialist groups within the targeted geographical regions. Themes included centre demographics, tobramycin usage, dosing and infusion practices, TDM practices, and blood sampling methods. RESULTS In total 77 responses were received from 75 different CF centres over the 3-month evaluation period (October 2019-January 2020). Respondents were from the USA and Canada (60%), Australia and New Zealand (25%), and the UK and Ireland (15%). Tobramycin was used in 97% of sites, with an international variation in practice across all survey aspects including dosing and infusion practice. TDM-based dose adjustment in the UK and Ireland was most commonly based only on trough sample collection for avoidance of toxicity, where use of computer programs for targeting both efficacy and toxicity endpoints were most common in Australia and New Zealand. The underlying pharmacokinetic basis of that program was not known by 33% of sites who utilised a computer program for tobramycin dose individualisation. CONCLUSION There remains substantial heterogeneity in tobramycin management worldwide. Despite two decades of research into TDM of tobramycin, there has been a slow uptake of new technologies and evolution of practice. An improved understanding of TDM processes is required for translation of evidence-based research into clinical practice. International guidelines require updating due to the advances in research to support confidence in the changes in clinical practice.
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Affiliation(s)
- Rebecca Larcombe
- University of South Australia, Adelaide, South Australia, Australia
- Flinders Medical Centre, Bedford Park, South Australia, Australia
| | | | - Vaughn Eaton
- Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Andrew Tai
- Department Paediatrics, Women's and Children's Hospital, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Stephanie Reuter
- University of South Australia, Adelaide, South Australia, Australia
| | - Michael Ward
- University of South Australia, Adelaide, South Australia, Australia
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Hemmann B, Woods E, Makhlouf T, Gillette C, Perry C, Subramanian M, Hanes H. Impact of Patient-Specific Aminoglycoside Monitoring for Treatment of Pediatric Cystic Fibrosis Pulmonary Exacerbations. J Pediatr Pharmacol Ther 2022; 27:655-662. [DOI: 10.5863/1551-6776-27.7.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/29/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Aminoglycosides are frequently used for empiric and definitive treatment of cystic fibrosis (CF) pulmonary exacerbations. Various methods have been described for aminoglycoside therapeutic drug monitoring. The objective of this study is to evaluate the effect of patient-specific pharmacokinetic calculations for aminoglycosides used to treat CF pulmonary exacerbations.
METHODS
Ambidirectional cohort study of patients admitted to a children's hospital from June 1, 2018, through February 28, 2019, and June 1, 2019, through February 8, 2021. The primary outcome was the occurrence of dosing changes after analysis of initial serum concentrations in either group. Secondary outcomes included occurrence of nephrotoxicity, duration of antibiotics, and length of stay.
RESULTS
Twenty-four patients (75%) in the intervention group versus zero in the control group required dosing adjustments after initial analysis of serum concentrations were completed (p < 0.001). There was not a statistically significant between-group difference for duration of antibiotics in days (median, 14 vs 13.5; Z, 1.07; p = 0.29) or length of stay (median, 11 vs 11; Z, −0.31; p = 0.76). There was also not a statistically significant between-group difference in forced expiratory volume in one second (FEV1) change from admission to discharge (11.4% vs 13.9%; t, 0.61; Degrees of Freedom, 39; p = 0.55). Two patients (6.25%) in the intervention group experienced nephrotoxicity compared with zero patients in the control group (risk difference, 6.25%; 95% CI, −2.14 to 14.64; number needed to harm, 16).
CONCLUSIONS
Patient-specific pharmacokinetic monitoring led to significantly more dosing changes and was associated with similar patient outcomes as trough-only monitoring. Further studies are needed to identify methods to optimize aminoglycoside dosing and monitoring for these patients with the goal of reducing toxicities while maximizing efficacy.
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Affiliation(s)
- Brianna Hemmann
- Department of Pharmacy (BH), Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Elizabeth Woods
- Departments of Pharmacy (EW, TM, CP, MS), Wake Forest Baptist Health Brenner Children's Hospital, Winston-Salem, NC
| | - Tanya Makhlouf
- Departments of Pharmacy (EW, TM, CP, MS), Wake Forest Baptist Health Brenner Children's Hospital, Winston-Salem, NC
| | - Chris Gillette
- Department of Physician Assistant Studies (CG, CP), Wake Forest School of Medicine, Winston-Salem, NC
| | - Courtney Perry
- Departments of Pharmacy (EW, TM, CP, MS), Wake Forest Baptist Health Brenner Children's Hospital, Winston-Salem, NC
- Department of Physician Assistant Studies (CG, CP), Wake Forest School of Medicine, Winston-Salem, NC
| | - Mary Subramanian
- Departments of Pharmacy (EW, TM, CP, MS), Wake Forest Baptist Health Brenner Children's Hospital, Winston-Salem, NC
| | - Holly Hanes
- Department of Pediatrics (HH), Wake Forest Baptist Health Brenner Children's Hospital, Winston-Salem, NC
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Thorn CR, Wignall A, Kopecki Z, Kral A, Prestidge CA, Thomas N. Liquid Crystal Nanoparticles Enhance Tobramycin Efficacy in a Murine Model of Pseudomonas aeruginosa Biofilm Wound Infection. ACS Infect Dis 2022; 8:841-854. [PMID: 35255215 DOI: 10.1021/acsinfecdis.1c00606] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Chronic Pseudomonas aeruginosa wound infections are highly prevalent and often untreatable due to biofilm formation, resulting in high antimicrobial tolerance. Standard antibiotic therapy for P. aeruginosa infections involves tobramycin, yet it is highly ineffective as monotherapy as tobramycin cannot penetrate the biofilm to elicit its antimicrobial effect. Lipid liquid crystal nanoparticles (LCNPs) have previously been shown to increase the antimicrobial efficacy and penetration of tobramycin against P. aeruginosa biofilms in vitro and ex vivo. Here, for the first time, we have developed a chronic P. aeruginosa biofilm infection in full-thickness wounds in mice to examine the potential of LCNPs to improve the effect of tobramycin, preclinically. After three doses, administered once a day, tobramycin-LCNPs significantly reduced the P. aeruginosa bacterial load in murine wounds 1000-fold more than unformulated tobramycin, which in turn showed no significant difference to the saline control treatment. Consistent with the improved P. aeruginosa eradication, the tobramycin-LCNPs promoted wound healing. In comparison to previous in vitro and ex vivo data, we show a strong in vitro-in vivo correlation between P. aeruginosa biofilm infection models. The enhanced activity of tobramycin-LCNPs in vivo in the preclinical murine model demonstrates the strong potential of LCNPs as a next-generation formulation approach to improve the efficacy of tobramycin against P. aeruginosa biofilm wound infections.
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Affiliation(s)
- Chelsea R. Thorn
- University of South Australia, Clinical and Health Science, North Tce, Adelaide, SA 5000, Australia
- The Basil Hetzel Institute for Translational Health Research, Woodville, SA 5011, Australia
- Biofilm Test Facility, Cancer Research Institute, University of South Australia, North Tce, Adelaide, SA 5000, Australia
| | - Anthony Wignall
- University of South Australia, Clinical and Health Science, North Tce, Adelaide, SA 5000, Australia
| | - Zlatko Kopecki
- University of South Australia, Clinical and Health Science, North Tce, Adelaide, SA 5000, Australia
- Future Industries Institute, UniSA, Mawson Lakes, SA 5095, Australia
| | - Anita Kral
- University of South Australia, Clinical and Health Science, North Tce, Adelaide, SA 5000, Australia
- Centre for Cancer Biology, S.A. Pathology and University of South Australia, Adelaide, SA 5000, Australia
| | - Clive A. Prestidge
- University of South Australia, Clinical and Health Science, North Tce, Adelaide, SA 5000, Australia
| | - Nicky Thomas
- University of South Australia, Clinical and Health Science, North Tce, Adelaide, SA 5000, Australia
- The Basil Hetzel Institute for Translational Health Research, Woodville, SA 5011, Australia
- Biofilm Test Facility, Cancer Research Institute, University of South Australia, North Tce, Adelaide, SA 5000, Australia
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Rohani R, Hoff B, Jain M, Philbrick A, Salama S, Cullina JF, Rhodes NJ. Defining the Importance of Age-Related Changes in Drug Clearance to Optimizing Aminoglycoside Dosing Regimens for Adult Patients with Cystic Fibrosis. Eur J Drug Metab Pharmacokinet 2021; 47:199-209. [PMID: 34882292 DOI: 10.1007/s13318-021-00734-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE The number of adults living with cystic fibrosis (CF) has increased and will continue to do so with the approval of cystic fibrosis transmembrane conductance regulator (CFTR) modulators. Because systemic aminoglycosides are commonly administered for CF pulmonary exacerbations, we sought to define optimized dosing regimens using a population pharmacokinetic modeling and simulation approach. METHODS Adult CF patients admitted for pulmonary exacerbation, receiving at least 72 h of systemic gentamicin, tobramycin, or amikacin, with measured concentrations were included. Covariates [e.g., age, weight, creatinine clearance (CRCL)] were screened. Population modeling was completed using Monolix, and simulations were conducted in R. Simulated exposures were calculated using noncompartmental analysis. Once-daily fixed (10 mg/kg) and exposure-matched dosing (i.e., 15, 10, 7.5, 6 mg/kg for ages 20, 30, 40, and 50 years, respectively) strategies were compared. First-24 h exposures were evaluated for each strategy according to the probability of target attainment (PTA) (ratio of peak plasma concentrations relative to the minimum inhibitory concentration [Cmax/MIC] or ratio of the area under the concentration-time curve to MIC [AUC/MIC]) and the probability of toxic exposure (PTE) (trough concentration, Ctrough > 2 mg/l). RESULTS Forty-eight adult patients (55% female) were included. A one-compartment model best fit the data. Estimates for volume of distribution (V) and clearance (CL) were 22 l and 5.57 l/h, respectively. Weight significantly modified CL and V. Age significantly modified CL and was more influential than CRCL. PTA was > 90% at MICs ≤ 1 mg/l for fixed doses of 10 mg/kg and for exposure-matched doses at MIC ≤ 1 mg/l. Exposure-matched dosing reduced PTE roughly 50% in patients aged 40 and 50 years vs. fixed dosing. CONCLUSIONS Exposure-matching maintained PTA at MICs ≤ 1 mg/l while reducing toxicity risk in older patients compared to fixed dosing. Confirmatory studies are needed.
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Affiliation(s)
- Roxane Rohani
- Midwestern University College of Pharmacy Downers Grove Campus, 555 31st Street, Downers Grove, IL, 60515, USA.,Midwestern University College of Pharmacy Downers Grove Campus, Pharmacometrics Center of Excellence, Downers Grove, IL, USA.,Department of Pharmacy, Northwestern Medicine, Chicago, IL, USA
| | - Brian Hoff
- Department of Pharmacy, Northwestern Medicine, Chicago, IL, USA
| | - Manu Jain
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Sara Salama
- Midwestern University College of Pharmacy Downers Grove Campus, 555 31st Street, Downers Grove, IL, 60515, USA
| | | | - Nathaniel J Rhodes
- Midwestern University College of Pharmacy Downers Grove Campus, 555 31st Street, Downers Grove, IL, 60515, USA. .,Midwestern University College of Pharmacy Downers Grove Campus, Pharmacometrics Center of Excellence, Downers Grove, IL, USA. .,Department of Pharmacy, Northwestern Medicine, Chicago, IL, USA.
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10
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Ochs MA, Dillman NO, Caverly LJ, Chaffee VD. Aminoglycoside dosing and monitoring for Pseudomonas aeruginosa during acute pulmonary exacerbations in cystic fibrosis. Pediatr Pulmonol 2021; 56:3634-3643. [PMID: 33983680 DOI: 10.1002/ppul.25441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/28/2021] [Accepted: 04/14/2021] [Indexed: 11/11/2022]
Abstract
Aminoglycosides are commonly used for the treatment of Pseudomonas aeruginosa (PsA) in the setting of acute pulmonary exacerbations (PEx) in pediatric patients with cystic fibrosis (CF). There are controversies and practice differences between institutions related to aminoglycoside dosing and monitoring strategies. The purpose of this review article is to summarize the currently available literature and identify gaps in the literature related to pharmacokinetic parameter goals, aminoglycoside dosing strategies, and methods for monitoring serum aminoglycoside concentrations for treatment of PsA in CF PEx, and throughout will discuss anticipated changes with the increasing availability of highly effective CF transmembrane conductance regulator modulators. This review focuses on tobramycin, as it is the most commonly used aminoglycoside in CF PEx, and will briefly discuss special circumstances surrounding use of amikacin and gentamicin.
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Affiliation(s)
- Madeleine A Ochs
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Nicholas O Dillman
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Lindsay J Caverly
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Valerie D Chaffee
- Department of Pharmacy, Cancer and Hematology Centers of West Michigan, Grand Rapids, Michigan, USA
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11
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PBPK Modeling and Simulation and Therapeutic Drug Monitoring: Possible Ways for Antibiotic Dose Adjustment. Processes (Basel) 2021. [DOI: 10.3390/pr9112087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Pharmacokinetics (PK) is a branch of pharmacology present and of vital importance for the research and development (R&D) of new drugs, post-market monitoring, and continued optimizations in clinical contexts. Ultimately, pharmacokinetics can contribute to improving patients’ clinical outcomes, helping enhance the efficacy of treatments, and reducing possible adverse side effects while also contributing to precision medicine. This article discusses the methods used to predict and study human pharmacokinetics and their evolution to the current physiologically based pharmacokinetic (PBPK) modeling and simulation methods. The importance of therapeutic drug monitoring (TDM) and PBPK as valuable tools for Model-Informed Precision Dosing (MIPD) are highlighted, with particular emphasis on antibiotic therapy since dosage adjustment of antibiotics can be vital to ensure successful clinical outcomes and to prevent the spread of resistant bacterial strains.
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12
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Ferreira A, Martins H, Oliveira JC, Lapa R, Vale N. PBPK Modeling and Simulation of Antibiotics Amikacin, Gentamicin, Tobramycin, and Vancomycin Used in Hospital Practice. Life (Basel) 2021; 11:life11111130. [PMID: 34833005 PMCID: PMC8620954 DOI: 10.3390/life11111130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/20/2021] [Accepted: 10/22/2021] [Indexed: 12/22/2022] Open
Abstract
The importance of closely observing patients receiving antibiotic therapy, performing therapeutic drug monitoring (TDM), and regularly adjusting dosing regimens has been extensively demonstrated. Additionally, antibiotic resistance is a contemporary concerningly dangerous issue. Optimizing the use of antibiotics is crucial to ensure treatment efficacy and prevent toxicity caused by overdosing, as well as to combat the prevalence and wide spread of resistant strains. Some antibiotics have been selected and reserved for the treatment of severe infections, including amikacin, gentamicin, tobramycin, and vancomycin. Critically ill patients often require long treatments, hospitalization, and require particular attention regarding TDM and dosing adjustments. As these antibiotics are eliminated by the kidneys, critical deterioration of renal function and toxic effects must be prevented. In this work, clinical data from a Portuguese cohort of 82 inpatients was analyzed and physiologically based pharmacokinetic (PBPK) modeling and simulation was used to study the influence of different therapeutic regimens and parameters as biological sex, body weight, and renal function on the biodistribution and pharmacokinetic (PK) profile of these four antibiotics. Renal function demonstrated the greatest impact on plasma concentration of these antibiotics, and vancomycin had the most considerable accumulation in plasma over time, particularly in patients with impaired renal function. Thus, through a PBPK study, it is possible to understand which pharmacokinetic parameters will have the greatest variation in a given population receiving antibiotic administrations in hospital context.
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Affiliation(s)
- Abigail Ferreira
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal;
- LAQV/REQUIMTE, Laboratory of Applied Chemistry, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal;
| | - Helena Martins
- Departament of Pathology, Clinical Chemistry Service, Centro Hospitalar Universitário do Porto (CHUP), 4099-001 Porto, Portugal; (H.M.); (J.C.O.)
| | - José Carlos Oliveira
- Departament of Pathology, Clinical Chemistry Service, Centro Hospitalar Universitário do Porto (CHUP), 4099-001 Porto, Portugal; (H.M.); (J.C.O.)
| | - Rui Lapa
- LAQV/REQUIMTE, Laboratory of Applied Chemistry, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal;
| | - Nuno Vale
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal;
- Department of Community Medicine, Health Information and Decision (MEDCIDS), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- Correspondence: ; Tel.: +351-220426537
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13
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Landmesser KB, Autry EB, Gardner BM, Bosko KA, Schadler A, Kuhn RJ. Comparison of the predictive value of area under the curve versus maximum serum concentration of intravenous tobramycin in cystic fibrosis patients treated for an acute pulmonary exacerbation. Pediatr Pulmonol 2021; 56:3209-3216. [PMID: 34241975 DOI: 10.1002/ppul.25569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/19/2021] [Accepted: 06/21/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The primary objective of this study was to compare the therapeutic predictive value of area under the curve (AUC24 ) versus maximum concentration (Cmax ) in cystic fibrosis (CF) patients receiving intravenous (IV) tobramycin for a Pseudomonas aeruginosa (PsA) acute pulmonary exacerbation (APE). Acute kidney injury (AKI) incidence and the relationship between time undetectable and efficacy were also assessed. METHODS A retrospective review was conducted in patients aged at least 1 month with a diagnosis of CF receiving IV tobramycin for treatment of a PsA APE and admitted to the University of Kentucky between August 2015 and August 2019. Patients were excluded if they had no growth of PsA on sputum culture or if two postdose tobramycin levels were not obtained following a dose adjustment of ≥20%. RESULTS A total of 44 pediatric and 107 adult patient encounters met inclusion criteria. In patients with therapeutic success (n = 91), 75.8% had an AUC24 ≥80% and 80.3% had a Cmax ≥8 times the highest PsA minimal inhibitory concentration. There was a significant correlation between AUC24 and Cmax (r[149] = 0.727; p < 0.001). AKI incidence was significantly higher in patients receiving IV tobramycin dosed multiple times daily versus at least every 24 h (χ2 [1, 151] = 3.9; p = 0.047). CONCLUSIONS The results of this study indicate that both AUC24 and Cmax serve as relatively accurate predictors of tobramycin efficacy. Additionally, given the significant increase in incidence of AKI, multidaily dosing of IV tobramycin should be avoided in pediatric and adult patients with CF.
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Affiliation(s)
| | - Elizabeth B Autry
- Department of Pharmacy, Kentucky Children's Hospital, Lexington, Kentucky, USA.,Department of Pharmacy, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Brian M Gardner
- Department of Pharmacy, Kentucky Children's Hospital, Lexington, Kentucky, USA.,Department of Pharmacy, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Katherine A Bosko
- Department of Pharmacy, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Aric Schadler
- Department of Pharmacy, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA.,Department of Pediatrics, Kentucky Children's Hospital, Lexington, Kentucky, USA
| | - Robert J Kuhn
- Department of Pharmacy, Kentucky Children's Hospital, Lexington, Kentucky, USA.,Department of Pharmacy, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
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14
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Population pharmacokinetic modeling and dosing simulations of tobramycin in pediatric patients with cystic fibrosis. Antimicrob Agents Chemother 2021; 65:e0073721. [PMID: 34280011 DOI: 10.1128/aac.00737-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Initial dosing and dose adjustment of intravenous tobramycin in cystic fibrosis children is challenging. The objectives of this study were to develop nonparametric population pharmacokinetic (PK) models of tobramycin in children with CF to be used for dosage design and model-guided therapeutic drug monitoring. We performed a retrospective analysis of tobramycin PK data in our CF children center. The Pmetrics package was used for nonparametric population PK analysis and dosing simulations. Both the maximal concentration over the MIC (Cmax/MIC) and daily area under the concentration-time curve to the MIC (AUC24/MIC) ratios were considered as efficacy target. Trough concentration (Cmin) was considered as the safety target. A total of 2884 tobramycin concentrations collected in 195 patients over 9 years were analyzed. A two-compartment model including total body weight, body surface area and creatinine clearance as covariates best described the data. A simpler model was also derived for implementation into the BestDose software to perform Bayesian dose adjustment. Both models were externally validated. PK/PD simulations with the final model suggest that an initial dose of tobramycin of 15 to 17.5 mg/kg/day was necessary to achieve Cmax/MIC ≥ 10 values for MIC values up to 2 mg/L in most patients. The AUC24/MIC target was associated with larger dosage requirements and higher Cmin. A daily dose of 12.5 mg/kg would optimize both efficacy and safety target attainment. We recommend to perform tobramycin TDM, model-based dose adjustment, and MIC determination to individualize intravenous tobramycin therapy in children with CF.
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15
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Thorn CR, Carvalho-Wodarz CDS, Horstmann JC, Lehr CM, Prestidge CA, Thomas N. Tobramycin Liquid Crystal Nanoparticles Eradicate Cystic Fibrosis-Related Pseudomonas aeruginosa Biofilms. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2021; 17:e2100531. [PMID: 33978317 DOI: 10.1002/smll.202100531] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/15/2021] [Indexed: 06/12/2023]
Abstract
Pseudomonas aeruginosa biofilms cause persistent and chronic infections, most known clinically in cystic fibrosis (CF). Tobramycin (TOB) is a standard anti-pseudomonal antibiotic; however, in biofilm infections, its efficacy severely decreases due to limited permeability across the biofilm matrix. Herewith, a biomimetic, nanostructured, lipid liquid crystal nanoparticle-(LCNP)-formulation is discovered to significantly enhance the efficacy of TOB and eradicate P. aeruginosa biofilm infections. Using an advanced, biologically-relevant co-culture model of human CF bronchial epithelial cells infected with P. aeruginosa biofilms at an air-liquid interface, nebulized TOB-LCNPs completely eradicated 1 × 109 CFU mL-1 of P. aeruginosa after two doses, a 100-fold improvement over the unformulated antibiotic. The enhanced activity of TOB is not observed with a liposomal formulation of TOB or with ciprofloxacin, an antibiotic that readily penetrates biofilms. It is demonstrated that the unique nanostructure of the LCNPs drives the enhanced penetration of TOB across the biofilm barrier, but not through the healthy lung epithelium barrier, significantly increasing the available antibiotic concentration at the site of infection. The LCNPs are an innovative strategy to improve the performance of TOB as a directed pulmonary therapy, enabling the administration of lower doses, reducing the toxicity, and amplifying the anti-biofilm activity of the anti-pseudomonal antibiotic.
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Affiliation(s)
- Chelsea R Thorn
- Clinical and Health Science, University of South Australia, North Tce, Adelaide, SA, 5000, Australia
- The Basil Hetzel Institute for Translational Health Research, Woodville, SA, 5011, Australia
- ARC Centre for Excellence in Bio-Nano Science and Technology, Australia
- Adelaide Biofilm Test Facility, Cancer Research Institute, University of South Australia, North Tce, Adelaide, SA, 5000, Australia
| | | | - Justus C Horstmann
- Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), 66123, Saarbrücken, Germany
- Department of Pharmacy, Saarland University, 66123, Saarbrücken, Germany
| | - Claus-Michael Lehr
- Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), 66123, Saarbrücken, Germany
- Department of Pharmacy, Saarland University, 66123, Saarbrücken, Germany
| | - Clive A Prestidge
- Clinical and Health Science, University of South Australia, North Tce, Adelaide, SA, 5000, Australia
- ARC Centre for Excellence in Bio-Nano Science and Technology, Australia
| | - Nicky Thomas
- Clinical and Health Science, University of South Australia, North Tce, Adelaide, SA, 5000, Australia
- The Basil Hetzel Institute for Translational Health Research, Woodville, SA, 5011, Australia
- ARC Centre for Excellence in Bio-Nano Science and Technology, Australia
- Adelaide Biofilm Test Facility, Cancer Research Institute, University of South Australia, North Tce, Adelaide, SA, 5000, Australia
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16
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Le T, Lord L, Pignataro S, Simioni D, Cheah R. Evaluating the Impact of Education on Pharmacist Tobramycin Dose Recommendations for Cystic Fibrosis and a Review of Perceptions on Pharmacist-Led Charting. J Pharm Pract 2021; 35:903-910. [PMID: 34013814 DOI: 10.1177/08971900211018419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pharmacists routinely interpret and optimize tobramycin dosing for people with cystic fibrosis (PwCF). OBJECTIVES To determine the impact of tobramycin therapeutic drug monitoring (TDM) education on pharmacist dose recommendations, and to explore nurses' and medical doctors' perceptions toward pharmacist-led TDM charting. METHODS This study involved 3 phases: a 12-month retrospective audit of PwCF prescribed tobramycin to identify the appropriateness of pharmacists' dose recommendations, a pharmacist tobramycin educational intervention utilizing a voiceover presentation with pre- and post-online tobramycin TDM assessment (involving multiple choice pharmacokinetics and case-based scenario questions), and a cross-sectional survey of respiratory nurses' and doctors' perceptions toward pharmacist-led TDM charting. The pharmacists' dose recommendations, in the audit and case-based questions, were considered appropriate if subsequent levels achieved the targeted area under the curve (AUC). RESULTS Audit results revealed that 44.4% of the 277 pharmacist dose recommendations identified were appropriate. The pre- and post-interventional assessments were completed by 51 and 52 pharmacists, respectively. Post intervention, correct scores were significantly higher than pre-intervention, evident in both the pharmacokinetics (median score 75% vs 100%; P = 0.048) and case-based scenario (median score 60% vs 90%; P < 0.0001) questions. Of the 54 nurses and medical doctors surveyed, 92.6% supported the implementation of pharmacist-led tobramycin charting. CONCLUSION The study demonstrated an increased accuracy and appropriateness of pharmacists' tobramycin pharmacokinetics knowledge and TDM dose recommendations post-educational intervention and highlighted nurses' and medical doctors' support of pharmacist-led tobramycin TDM charting.
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Affiliation(s)
- Tran Le
- Pharmacy Department, Monash Health, Melbourne, Victoria, Australia
| | - Louise Lord
- Pharmacy Department, Monash Health, Melbourne, Victoria, Australia
| | | | - Diana Simioni
- Pharmacy Department, Monash Health, Melbourne, Victoria, Australia
| | - Ron Cheah
- Pharmacy Department, Monash Health, Melbourne, Victoria, Australia.,National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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17
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Pharmacokinetic and Pharmacodynamic Optimization of Antibiotic Therapy in Cystic Fibrosis Patients: Current Evidences, Gaps in Knowledge and Future Directions. Clin Pharmacokinet 2021; 60:409-445. [PMID: 33486720 DOI: 10.1007/s40262-020-00981-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Antibiotic therapy is one of the main treatments for cystic fibrosis (CF). It aims to eradicate bacteria during early infection, calms down the inflammatory process, and leads to symptom resolution of pulmonary exacerbations. CF can modify both the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of antibiotics, therefore specific PK/PD endpoints should be determined in the context of CF. Currently available data suggest that optimal PK/PD targets cannot be attained in sputum with intravenous aminoglycosides. Continuous infusion appears preferable for β-lactam antibiotics, but optimal concentrations in sputum are unlikely to be reached, with some possible exceptions such as meropenem and ceftolozane. Usual doses are likely suboptimal for fluoroquinolones and linezolid, whereas daily doses of 45-60 mg/kg and 200 mg could be convenient for vancomycin and doxycycline, respectively. Weekly azithromycin doses of 22-30 mg/kg could also be appropriate for its anti-inflammatory effect. The difficulty with achieving optimal concentrations supports the use of combined treatments and the inhaled administration route, as very high local concentrations, concomitantly with low systemic exposure, can be obtained with the inhaled route for aminoglycosides, colistin, and fluoroquinolones, thus minimizing the risk of toxicity.
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18
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Alghanem SS, Touw DJ, Thomson AH. Pharmacokinetic/pharmacodynamic analysis of weight- and height-scaled tobramycin dosage regimens for patients with cystic fibrosis. J Antimicrob Chemother 2020; 74:2311-2317. [PMID: 31322695 DOI: 10.1093/jac/dkz192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/01/2019] [Accepted: 04/07/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine the outcomes of weight- and height-based tobramycin dosing regimens for patients with cystic fibrosis (CF). METHODS A simulated dataset of 5000 patients based on 331 patients with CF was created using NONMEM. Pharmacokinetic (PK) parameters were derived for each patient from a published model using Monte Carlo simulation. The abilities of 10 and 12 mg/kg/day and 3 and 4 mg/cm/day to achieve standard and extended Cmax (20-30 and 20-40 mg/L) and AUC0-24 (80-120 and 80-150 mg·h/L) targets were evaluated. PK/pharmacodynamic (PK/PD) indices were a Cmax/MIC ratio ≥10 and an AUC0-24/MIC ratio ≥110. For these indices and a range of MICs, cumulative fractions of response (CFRs) for Pseudomonas aeruginosa were also determined. RESULTS More patients achieved standard Cmax and AUC0-24 targets with 3 mg/cm/day (64% and 62%, respectively) than with 10 mg/kg/day (43% and 48%, respectively). AUC0-24 estimates >120 mg·h/L were more common with weight-based dosing. With higher doses, 72% achieved high target peaks with 4 mg/cm/day and 65% with 12 mg/kg/day. For the Cmax/MIC index, the maximal MIC for the target microorganism was 2 mg/L with lower doses, 2.5 mg/L with higher doses and 0.5 mg/L for AUC0-24/MIC-based regimens. The CFR for all regimens was >90% for Cmax targets and 66% to 79% for AUC0-24 targets. CONCLUSIONS A tobramycin dose of 3 mg/cm/day rather than 10 mg/kg/day achieved similar PK/PD outcomes but dose and AUC0-24 ranges were narrower and the incidence of high AUC0-24 values was lower. Height-based doses should therefore be considered for patients with CF.
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Affiliation(s)
- S S Alghanem
- Department of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, PO Box 24923, Safat 13110, Kuwait
| | - D J Touw
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - A H Thomson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK
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19
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Gao Y, Hennig S, Barras M. Monitoring of Tobramycin Exposure: What is the Best Estimation Method and Sampling Time for Clinical Practice? Clin Pharmacokinet 2020; 58:389-399. [PMID: 30140975 DOI: 10.1007/s40262-018-0707-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this article is to investigate the influence of blood sampling times on tobramycin exposure estimation and clinical decisions and to determine the best sampling times for two estimation methods used for therapeutic drug monitoring. METHODS Adult patients with cystic fibrosis, treated with once-daily intravenous tobramycin, were intensively sampled over one 24-h dosing interval to determine true exposure (AUC0-24). The AUC0-24s were then estimated using both log-linear regression and Bayesian forecasting methods for 21 different sampling time combinations. These were compared to true exposure using relative prediction errors. The differences in subsequent dose recommendations were calculated. RESULTS Twelve patients, with a median (range) age of 25 years (18-36) and weight of 66.5 kg (50.6-76.4) contributed 96 tobramycin concentrations. Five hundred and eighty-eight estimated AUC0-24s were compared to 12 measured true AUC0-24 values. Median relative prediction errors ranged from - 34.7 to 45.5% for the log-linear regression method and from - 14.46 to 11.23% for the Bayesian forecasting method across the 21 sampling combinations. The most unbiased exposure estimation was provided from concentrations sampled at 100/640 min after the start of the infusion using log-linear regression and at 70/160 min using Bayesian forecasting. Subsequent dosing recommendations varied greatly depending on the estimation method and the sampling times used. CONCLUSION Sampling times markedly influence bias in AUC0-24 estimation, leading to greatly varied dose adjustments. The impact of blood sampling times on dosing decisions is reduced when using Bayesian forecasting.
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Affiliation(s)
- Yanhua Gao
- School of Pharmacy, Pharmacy Australia Centre of Excellence, University of Queensland, 20 Cornwall Street, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Stefanie Hennig
- School of Pharmacy, Pharmacy Australia Centre of Excellence, University of Queensland, 20 Cornwall Street, Woolloongabba, Brisbane, QLD, 4102, Australia.
| | - Michael Barras
- School of Pharmacy, Pharmacy Australia Centre of Excellence, University of Queensland, 20 Cornwall Street, Woolloongabba, Brisbane, QLD, 4102, Australia
- Princess Alexandra Hospital, Brisbane, QLD, Australia
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20
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Downes KJ, Hayes M, Fitzgerald JC, Pais GM, Liu J, Zane NR, Goldstein SL, Scheetz MH, Zuppa AF. Mechanisms of antimicrobial-induced nephrotoxicity in children. J Antimicrob Chemother 2020; 75:1-13. [PMID: 31369087 PMCID: PMC6910165 DOI: 10.1093/jac/dkz325] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Drug-induced nephrotoxicity is responsible for 20% to 60% of cases of acute kidney injury in hospitalized patients and is associated with increased morbidity and mortality in both children and adults. Antimicrobials are one of the most common classes of medications prescribed globally and also among the most common causes of nephrotoxicity. A broad range of antimicrobial agents have been associated with nephrotoxicity, but the features of kidney injury vary based on the agent, its mechanism of injury and the site of toxicity within the kidney. Distinguishing nephrotoxicity caused by an antimicrobial agent from other potential inciting factors is important to facilitate both early recognition of drug toxicity and prompt cessation of an offending drug, as well as to avoid unnecessary discontinuation of an innocuous therapy. This review will detail the different types of antimicrobial-induced nephrotoxicity: acute tubular necrosis, acute interstitial nephritis and obstructive nephropathy. It will also describe the mechanism of injury caused by specific antimicrobial agents and classes (vancomycin, aminoglycosides, polymyxins, antivirals, amphotericin B), highlight the toxicodynamics of these drugs and provide guidance on administration or monitoring practices that can mitigate toxicity, when known. Particular attention will be paid to paediatric patients, when applicable, in whom nephrotoxin exposure is an often-underappreciated cause of kidney injury.
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Affiliation(s)
- Kevin J Downes
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Molly Hayes
- Antimicrobial Stewardship Program, Center for Healthcare Quality & Analytics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie C Fitzgerald
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Jiajun Liu
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Nicole R Zane
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
- Department of Pharmacology, College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Athena F Zuppa
- Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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21
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Development of a nebramine-cyclam conjugate as an antibacterial adjuvant to potentiate β-lactam antibiotics against multidrug-resistant P. aeruginosa. J Antibiot (Tokyo) 2019; 72:816-826. [PMID: 31420586 DOI: 10.1038/s41429-019-0221-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/07/2019] [Accepted: 07/08/2019] [Indexed: 12/21/2022]
Abstract
The β-lactams are the most widely used class of antibiotics due to their safety, effectiveness, and spectrum of activity. As a result of their ubiquitous usage, there has been a steady rise in β-lactam resistant Gram-negative bacteria, especially Pseudomonas aeruginosa, resulting in limited treatment options. P. aeruginosa can develop multidrug-resistant phenotypes using a multifaceted approach of β-lactamase expression, decreased porin production and increased efflux. Current β-lactamase inhibitors address drug hydrolyzing enzymes but may not be as effective in phenotypes with reduced permeability and/or overexpressed efflux pumps. Herein, we present the synthesis and biological evaluation of a nebramine-cyclam conjugate molecule that is able to potentiate β-lactam antibiotics, as well as other legacy antibiotics, against P. aeruginosa in vitro. Combination studies show that this adjuvant is able to synergize with β-lactams such as aztreonam and ceftazidime against multidrug-resistant and extremely drug-resistant clinical isolates through a hypothesized mechanism of outer membrane permeabilization. Importantly, the addition of low concentrations (8 µM) of the nontoxic nebramine-cyclam conjugate is able to further potentiate existing β-lactam/β-lactamase inhibitor combinations in β-lactamase-harboring P. aeruginosa strains. These data support a potential application of the nebramine-cyclam conjugate as an adjuvant for treating infections caused by P. aeruginosa strains that utilize multiple mechanisms of resistance.
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Arroyo-Currás N, Ortega G, Copp DA, Ploense KL, Plaxco ZA, Kippin TE, Hespanha JP, Plaxco KW. High-Precision Control of Plasma Drug Levels Using Feedback-Controlled Dosing. ACS Pharmacol Transl Sci 2018; 1:110-118. [PMID: 32219207 PMCID: PMC7088981 DOI: 10.1021/acsptsci.8b00033] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Indexed: 12/30/2022]
Abstract
By, in effect, rendering pharmacokinetics an experimentally adjustable parameter, the ability to perform feedback-controlled dosing informed by high-frequency in vivo drug measurements would prove a powerful tool for both pharmacological research and clinical practice. Efforts to this end, however, have historically been thwarted by an inability to measure in vivo drug levels in real time and with sufficient convenience and temporal resolution. In response, we describe a closed-loop, feedback-controlled delivery system that uses drug level measurements provided by an in vivo electrochemical aptamer-based (E-AB) sensor to adjust dosing rates every 7 s. The resulting system supports the maintenance of either constant or predefined time-varying plasma drug concentration profiles in live rats over many hours. For researchers, the resultant high-precision control over drug plasma concentrations provides an unprecedented opportunity to (1) map the relationships between pharmacokinetics and clinical outcomes, (2) eliminate inter- and intrasubject metabolic variation as a confounding experimental variable, (3) accurately simulate human pharmacokinetics in animal models, and (4) measure minute-to-minute changes in a drug's pharmacokinetic behavior in response to changing health status, diet, drug-drug interactions, or other intrinsic and external factors. In the clinic, feedback-controlled drug delivery would improve our ability to accurately maintain therapeutic drug levels in the face of large, often unpredictable intra- and interpatient metabolic variation. This, in turn, would improve the efficacy and safety of therapeutic intervention, particularly for the most gravely ill patients, for whom metabolic variability is highest and the margin for therapeutic error is smallest.
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Affiliation(s)
- Netzahualcóyotl Arroyo-Currás
- Department
of Pharmacology and Molecular Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland 21205, United States,E-mail: . Tel.: (410) 955-3569
| | - Gabriel Ortega
- ‡Department of Chemistry and Biochemistry, §Center for Bioengineering, ⊥Center for Control,
Dynamical Systems, and Computation, #Department of Psychological and Brain Sciences, and ∇The Neuroscience
Research Institute and Department of Molecular, Cellular, and Developmental
Biology, University of California Santa
Barbara, Santa
Barbara, California 93106, United States,CIC
bioGUNE, Bizkaia Technology Park, Ed. 801A, 48160, Derio, Spain
| | - David A. Copp
- ‡Department of Chemistry and Biochemistry, §Center for Bioengineering, ⊥Center for Control,
Dynamical Systems, and Computation, #Department of Psychological and Brain Sciences, and ∇The Neuroscience
Research Institute and Department of Molecular, Cellular, and Developmental
Biology, University of California Santa
Barbara, Santa
Barbara, California 93106, United States
| | - Kyle L. Ploense
- ‡Department of Chemistry and Biochemistry, §Center for Bioengineering, ⊥Center for Control,
Dynamical Systems, and Computation, #Department of Psychological and Brain Sciences, and ∇The Neuroscience
Research Institute and Department of Molecular, Cellular, and Developmental
Biology, University of California Santa
Barbara, Santa
Barbara, California 93106, United States
| | - Zoe A. Plaxco
- ‡Department of Chemistry and Biochemistry, §Center for Bioengineering, ⊥Center for Control,
Dynamical Systems, and Computation, #Department of Psychological and Brain Sciences, and ∇The Neuroscience
Research Institute and Department of Molecular, Cellular, and Developmental
Biology, University of California Santa
Barbara, Santa
Barbara, California 93106, United States
| | - Tod E. Kippin
- ‡Department of Chemistry and Biochemistry, §Center for Bioengineering, ⊥Center for Control,
Dynamical Systems, and Computation, #Department of Psychological and Brain Sciences, and ∇The Neuroscience
Research Institute and Department of Molecular, Cellular, and Developmental
Biology, University of California Santa
Barbara, Santa
Barbara, California 93106, United States
| | - João P. Hespanha
- ‡Department of Chemistry and Biochemistry, §Center for Bioengineering, ⊥Center for Control,
Dynamical Systems, and Computation, #Department of Psychological and Brain Sciences, and ∇The Neuroscience
Research Institute and Department of Molecular, Cellular, and Developmental
Biology, University of California Santa
Barbara, Santa
Barbara, California 93106, United States
| | - Kevin W. Plaxco
- ‡Department of Chemistry and Biochemistry, §Center for Bioengineering, ⊥Center for Control,
Dynamical Systems, and Computation, #Department of Psychological and Brain Sciences, and ∇The Neuroscience
Research Institute and Department of Molecular, Cellular, and Developmental
Biology, University of California Santa
Barbara, Santa
Barbara, California 93106, United States,E-mail: . Tel.: (805) 893-5558
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23
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Monitoring therapeutic colistin concentrations in critically ill patients admitted to a tertiary care hospital. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0548-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Antimicrobial Stewardship in the Treatment of Infections Among Patients With Cystic Fibrosis. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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25
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McWilliam SJ, Antoine DJ, Smyth RL, Pirmohamed M. Aminoglycoside-induced nephrotoxicity in children. Pediatr Nephrol 2017; 32:2015-2025. [PMID: 27848094 PMCID: PMC5624973 DOI: 10.1007/s00467-016-3533-z] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/28/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023]
Abstract
Aminoglycoside antibiotics, in particular gentamicin and tobramycin, are still commonly used in paediatric clinical practice. These drugs cause nephrotoxicity, which particularly affects the proximal tubule epithelial cells due to selective endocytosis and accumulation of aminoglycosides via the multi-ligand receptor megalin. Recent epidemiological studies, using more widely accepted definitions of acute kidney injury (AKI), have suggested that AKI may occur in between 20 and 33 % of children exposed to aminoglycosides. A consensus set of phenotypic criteria for aminoglycoside-induced nephrotoxicity have recently been published. These are specifically designed to provide robust phenotyping for pharmacogenomic studies, but they can pave the way for standardisation for all clinical studies. Novel renal biomarkers, in particular kidney injury molecule-1, identify aminoglycoside-induced proximal tubular injury earlier than traditional markers and have shown promise in observational studies. Further studies need to demonstrate a clear association with clinically relevant outcomes to inform translation into clinical practice. Extended interval dosing of aminoglycosides results in a reduction in nephrotoxicity, but its use needs to become more widespread. Inhibition of megalin-mediated endocytosis by statins represents a novel approach to the prevention of aminoglycoside-induced nephrotoxicity which is currently being evaluated in a clinical trial. Recommendations for future directions are provided.
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Affiliation(s)
- Stephen J McWilliam
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK.
| | - Daniel J Antoine
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Rosalind L Smyth
- Institute of Child Health, University College London, London, UK
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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26
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Stacey SR, Turner SC, Coulthard KP, Miller H. Paediatric Pharmacy in Australia: Where Have We Come From and Where Do We Need To Go? JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2013.tb00215.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Sonya R Stacey
- Royal Children's Hospital, The Queensland Children's Medical Research Institute, School of Pharmacy; The University of Queensland
| | | | | | - Hugh Miller
- Royal Children's Hospital, Children's Health Queensland Hospital and Health Service; Brisbane Queensland
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27
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Nezic L, Derungs A, Bruggisser M, Tschudin-Sutter S, Krähenbühl S, Haschke M. Therapeutic drug monitoring of once daily aminoglycoside dosing: comparison of two methods and investigation of the optimal blood sampling strategy. Eur J Clin Pharmacol 2014; 70:829-37. [PMID: 24756148 DOI: 10.1007/s00228-014-1680-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 04/03/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE Therapeutic drug monitoring of patients receiving once daily aminoglycoside therapy can be performed using pharmacokinetic (PK) formulas or Bayesian calculations. While these methods produced comparable results, their performance has never been checked against full PK profiles. We performed a PK study in order to compare both methods and to determine the best time-points to estimate AUC0-24 and peak concentrations (C max). METHODS We obtained full PK profiles in 14 patients receiving a once daily aminoglycoside therapy. PK parameters were calculated with PKSolver using non-compartmental methods. The calculated PK parameters were then compared with parameters estimated using an algorithm based on two serum concentrations (two-point method) or the software TCIWorks (Bayesian method). RESULTS For tobramycin and gentamicin, AUC0-24 and C max could be reliably estimated using a first serum concentration obtained at 1 h and a second one between 8 and 10 h after start of the infusion. The two-point and the Bayesian method produced similar results. For amikacin, AUC0-24 could reliably be estimated by both methods. C max was underestimated by 10-20% by the two-point method and by up to 30% with a large variation by the Bayesian method. CONCLUSIONS The ideal time-points for therapeutic drug monitoring of once daily administered aminoglycosides are 1 h after start of a 30-min infusion for the first time-point and 8-10 h after start of the infusion for the second time-point. Duration of the infusion and accurate registration of the time-points of blood drawing are essential for obtaining precise predictions.
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Affiliation(s)
- Lana Nezic
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel, 4031, Basel, Switzerland
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28
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Sherwin CMT, Zobell JT, Stockmann C, McCrory BE, Wisdom M, Young DC, Olson J, Ampofo K, Spigarelli MG. Pharmacokinetic and pharmacodynamic optimisation of intravenous tobramycin dosing among children with cystic fibrosis. J Pharmacokinet Pharmacodyn 2014; 41:71-9. [DOI: 10.1007/s10928-013-9348-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 12/26/2013] [Indexed: 10/25/2022]
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29
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Peckham D, Whitaker P. Drug induced complications; can we do more? J Cyst Fibros 2013; 12:547-58. [DOI: 10.1016/j.jcf.2013.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/12/2013] [Accepted: 04/25/2013] [Indexed: 01/01/2023]
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30
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Braccini G, Lori I, Neri A, Festini F, Pela I, Ciuti R, Boni V, Zavataro L, Braggion C, De Martino M, Taccetti G. Parenteral Administration of Tobramycin for Pulmonary Exacerbations in Cystic Fibrosis Patients: Toxicity, Serum Levels and Efficacy. J Chemother 2013; 21:101-4. [DOI: 10.1179/joc.2009.21.1.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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31
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Zobell JT, Young DC, Waters CD, Ampofo K, Stockmann C, Sherwin CMT, Spigarelli MG. Optimization of anti-pseudomonal antibiotics for cystic fibrosis pulmonary exacerbations: VI. Executive summary. Pediatr Pulmonol 2013; 48:525-37. [PMID: 23359557 DOI: 10.1002/ppul.22757] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 12/28/2012] [Indexed: 11/07/2022]
Abstract
Acute pulmonary exacerbations (APE) are well-described complications of cystic fibrosis (CF) and are associated with progressive morbidity and mortality. Despite aggressive management with two or more intravenous anti-pseudomonal agents, approximately 25% of exacerbations will result in a loss of lung function. The aim of this review is to provide an overview of the classes of intravenous anti-pseudomonal antibiotics, the findings of anti-pseudomonal antibiotic utilization surveys, the current antibiotic dosing recommendations from the U.S. and Europe, and the pharmacokinetic (PK) and pharmacodynamic (PD) differences between CF and non-CF individuals. Anti-pseudomonal antibiotic classes include beta-lactams, aminoglycosides, fluoroquinolones, and colistimethate sodium. Recent surveys of antibiotic utilization in CF Foundation-accredited care centers have shown that a large number of centers are not following recommended dosing strategies despite published recommendations in the U.S. and Europe. The recommended doses for anti-pseudomonal antibiotics may be higher than FDA-approved doses due to PK and PD differences. As a large portion of CF patients will not regain their lung function following an APE, it seems possible that currently available anti-pseudomonal agents are being used sub-optimally. As new anti-pseudomonal agents are not currently available, we suggest the need to optimize antibiotic dosing and dosing regimens used to treat pulmonary exacerbations in an effort to improve outcomes for CF patients infected with Pseudomonas aeruginosa.
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Affiliation(s)
- Jeffery T Zobell
- Department of Pharmacy, Intermountain Primary Children's Medical Center, Salt Lake City, Utah, USA.
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32
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Vandenbussche HL, Homnick DN. Evaluation of serum concentrations achieved with an empiric once-daily tobramycin dosage regimen in children and adults with cystic fibrosis. J Pediatr Pharmacol Ther 2012; 17:67-77. [PMID: 23118659 DOI: 10.5863/1551-6776-17.1.67] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To assess the ability of an empiric once-daily dosing (ODD) tobramycin regimen to achieve desired serum concentrations in patients with cystic fibrosis (CF); to determine an optimal dosage regimen, using pharmacodynamic parameters; and to evaluate clinical response, adverse effects, and patient/parent satisfaction with ODD. METHODS This was a prospective single-center trial in patients with CF who are 5 years of age and older requiring intravenous antibiotics. Tobramycin, 10 mg/kg every 24 hours, was infused over 60 minutes, and two serum concentrations were analyzed using 1-compartment pharmacokinetic modeling. Simulations were performed to identify dosage regimens that maximized desired pharmacodynamic parameters. Other data included demographics, symptoms, spirometry, adverse events, and satisfaction with ODD. RESULTS A total of 14 children and 11 adults completed the study. Empiric doses resulted in mean peak tobramycin concentrations of 28.7 ± 5.5 mg/L and undetectable trough concentrations. Only 42% of patients achieved desired peak serum concentrations (20-30 mg/L) with the empiric regimen. A regimen of 12 mg/kg every 24 hours would achieve modified pharmacodynamic goals with an acceptable peak range of 20 to 35 mg/L. Forced expiratory volume in 1 second improved in 15 of 20 (75%) patients with ODD. Two patients experienced reversible vestibular adverse effects attributed to tobramycin. All patients were satisfied or very satisfied with ODD because of convenience and ease of use. CONCLUSIONS An empiric tobramycin regimen of 10 mg/kg every 24 hours did not achieve desired serum concentrations for most patients, although all patients demonstrated clinical improvement. Desired tobramycin concentrations with modified pharmacodynamic goals could be achieved by using an empiric dosage of 12 mg/kg every 24 hours. Prospective evaluation of this regimen with individualized patient monitoring is needed to ensure safety and efficacy and to monitor the effects on microbial resistance patterns.
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Affiliation(s)
- Heather L Vandenbussche
- Department of Pharmacy Practice, Ferris State University, College of Pharmacy, Kalamazoo, Michigan
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34
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Prescott WA, Nagel JL. Extended-Interval Once-Daily Dosing of Aminoglycosides in Adult and Pediatric Patients with Cystic Fibrosis. Pharmacotherapy 2010; 30:95-108. [DOI: 10.1592/phco.30.1.95] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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35
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Aminoglycoside therapy against Pseudomonas aeruginosa in cystic fibrosis: A review. J Cyst Fibros 2009; 8:361-9. [DOI: 10.1016/j.jcf.2009.08.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Revised: 07/30/2009] [Accepted: 08/10/2009] [Indexed: 11/23/2022]
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Van Meter DJ, Corriveau M, Ahern JW, Lahiri T. A survey of once-daily dosage tobramycin therapy in patients with cystic fibrosis. Pediatr Pulmonol 2009; 44:325-9. [PMID: 19330772 DOI: 10.1002/ppul.20985] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The purpose of this study was to quantify the prevalence of once-daily dosage of tobramycin (ODDT) among Cystic Fibrosis Foundation-accredited care centers and affiliated programs (CFFACCs) and characterize the ODDT approaches used by these institutions. An anonymous cross-sectional survey of CFFACCs was performed using an electronic survey tool. This tool was electronically mailed to the program directors. Eighty-four out of 195 institutions completed the survey (response rate = 43%). Fifty-one (61%) of 84 centers reported using ODDT. Of those 51 institutions, 34 (67%) use a dosage of 10 mg/kg/dose. Serum creatinine was measured routinely in 51 centers (100%) with weekly monitoring being used in 40 centers (78%). Audiometric evaluation was performed routinely in 22 (43%) centers with annual assessment performed in 14 (64%) of these 22 centers. In conclusion, a majority of responding institutions use ODDT. The most common reported dosage is 10 mg/kg. Serum creatinine was routinely measured in all institutions with weekly assessment being the most common frequency. Audiometic assessment is routinely performed in <50% of centers. Of the institutions performing audiograms routinely, annual assessment is the most common frequency.
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Affiliation(s)
- Daniel J Van Meter
- Pharmacy Department, Fletcher Allen Health Care, Burlington, Vermont 05401, USA
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Hennig S, Norris R, Kirkpatrick CMJ. Target concentration intervention is needed for tobramycin dosing in paediatric patients with cystic fibrosis--a population pharmacokinetic study. Br J Clin Pharmacol 2007; 65:502-10. [PMID: 17995972 DOI: 10.1111/j.1365-2125.2007.03045.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT * Two recent papers have been published which have attempted to build a full population pharmacokinetic model for tobramycin in children with cystic fibrosis. * However, neither study was able to provide any information about between-subject variability (BSV) and between-occasion variability (BOV), which is necessary to justify and draw conclusions about the use of target concentration intervention (TCI). * In the publications no simulations were provided to show any new directions or evaluate current therapy. WHAT THIS STUDY ADDS * This study provides sound evidence that TCI must be undertaken in this patient group, as the BOV is significantly less than the BSV. * The simulations from this model clearly show that current dosing and monitoring methods will not achieve the necessary targets to maximize the pharmacokinetic-pharmacodynamic relationships of aminoglycosides in this patient group. * The model presented is able to be easily incorporated into Bayesian dose individualization software, e.g. Abbottbase or TCIworks, to achieve dosing targets more accurately. AIM The primary aim was to estimate the population pharmacokinetic parameters of once-daily intravenous (i.v.) tobramycin in paediatric cystic fibrosis (CF) patients and to investigate the influence of covariates. The second aim was to assess the need for target concentration intervention (TCI) for tobramycin in this patient group. METHODS Retrospective demographic, dosing and concentration data were collected from 35 CF patients (21 female, 14 male) aged 0.5-17.8 years, from whom 318 tobramycin plasma concentrations were available. NONMEM was used to estimate the population pharmacokinetics of tobramycin. Simulations were performed using weight-based dosing with a weight from a covariate distribution model to evaluated current dosing schedules and monitoring practices. RESULTS A two-compartment model best described the data with population parameter estimates for clearance of central compartment (CL) of 6.37 l h(-1) per 70 kg; volume of central compartment (V(c)) of 18.7 l per 70 kg; intercompartmental clearance (Q) of 0.393 l h(-1); and volume of peripheral compartment (V(per)) of 1.32 l. The inclusion of total body weight as covariate reduced the random component of between-subject variability in CL from 50.1% to 11.7% and in V(c) from 62.2% to 11.6%. The between-occasion variability on CL was estimated in the final model as 6.5%. Simulations show that one dose does not fit all and TCI and dose adjustment are required. CONCLUSIONS This study provides the first pharmacokinetic model of once-daily i.v. tobramycin for the use of target concentration intervention in paediatric CF patients.
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Affiliation(s)
- Stefanie Hennig
- School of Pharmacy, The University of Queensland, Brisbane, Australia
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Lam W, Tjon J, Seto W, Dekker A, Wong C, Atenafu E, Bitnun A, Waters V, Yau Y, Solomon M, Ratjen F. Pharmacokinetic modelling of a once-daily dosing regimen for intravenous tobramycin in paediatric cystic fibrosis patients. J Antimicrob Chemother 2007; 59:1135-40. [PMID: 17446242 DOI: 10.1093/jac/dkm097] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study was designed to determine an optimal dose range for the once-daily dosing (ODD) of tobramycin in the treatment of an acute pulmonary exacerbation in paediatric cystic fibrosis (CF) patients. In addition, we aimed to assess whether certain patient characteristics affect tobramycin pharmacokinetics and, therefore, dosing. METHODS Patient characteristics and pharmacokinetic parameters of patients receiving tobramycin three times daily from 1 January 1992 to 31 October 2005 were analysed using univariate analysis and multiple linear regression to determine statistically significant relationships and to derive dosing models. The binary partitioning method was used to derive critical values to determine stratification within the chosen dosing model. RESULTS Using multiple linear regression, age and sex were significantly associated with the volume of distribution divided by the body weight (V/kg). By the binary partitioning method, the critical value for age was 13.75 years. CONCLUSIONS Age and sex were used to derive an ODD regimen for tobramycin in paediatric CF. Using a target peak concentration range of 25-35 mg/L, the initial dose for female CF patients at least 14 years of age was calculated to be 7 mg/kg/day given intravenously as a single daily dose. All other CF patients would receive an initial dose of 9 mg/kg/day given intravenously as a single daily dose. These dosing guidelines will require prospective evaluation for safety and efficacy.
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Affiliation(s)
- Wallace Lam
- Department of Pharmacy Services, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
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