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Črček M, Grabnar I, Zdovc JA, Grosek Š, Kos MK. External validation of population pharmacokinetic models of gentamicin in paediatric population from preterm newborns to adolescents. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2023; 73:175-194. [PMID: 37307377 DOI: 10.2478/acph-2023-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/04/2023] [Indexed: 06/14/2023]
Abstract
The aim of this study was to externally validate the predictive performance of published population pharmacokinetic models of gentamicin in all paediatric age groups, from preterm newborns to adolescents. We first selected published population pharmacokinetic models of gentamicin developed in the paediatric population with a wide age range. The parameters of the literature models were then re-estimated using the PRIOR subroutine in NONMEM®. The predictive ability of the literature and the tweaked models was evaluated. Retrospectively collected data from a routine clinical practice (512 concentrations from 308 patients) were used for validation. The models with covariates characterising developmental changes in clearance and volume of distribution had better predictive performance, which improved further after re-estimation. The tweaked model by Wang 2019 performed best, with suitable accuracy and precision across the complete paediatric population. For patients treated in the intensive care unit, a lower proportion of patients would be expected to reach the target trough concentration at standard dosing. The selected model could be used for model-informed precision dosing in clinical settings where the entire paediatric population is treated. However, for use in clinical practice, the next step should include additional analysis of the impact of intensive care treatment on gentamicin pharmacokinetics, followed by prospective validation.
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Affiliation(s)
- Mateja Črček
- 1University of Ljubljana, Faculty of Pharmacy, Department of Biopharmacy and Pharmacokinetics, 1000 Ljubljana Slovenia
| | - Iztok Grabnar
- 1University of Ljubljana, Faculty of Pharmacy, Department of Biopharmacy and Pharmacokinetics, 1000 Ljubljana Slovenia
| | - Jurij Aguiar Zdovc
- 1University of Ljubljana, Faculty of Pharmacy, Department of Biopharmacy and Pharmacokinetics, 1000 Ljubljana Slovenia
| | - Štefan Grosek
- 2University of Ljubljana, Faculty of Medicine, Department of Pediatrics 1000 Ljubljana, Slovenia
- 3University Medical Centre Ljubljana Division of Obstetrics and Gynecology, Department of Perinatology Neonatology Section, 1000 Ljubljana Slovenia
- 4University Medical Centre Ljubljana Division of Paediatrics, Department of Paediatric Intensive Therapy, 1000 Ljubljana, Slovenia
| | - Mojca Kerec Kos
- 1University of Ljubljana, Faculty of Pharmacy, Department of Biopharmacy and Pharmacokinetics, 1000 Ljubljana Slovenia
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Coste A, Bellouard R, Deslandes G, Jalin L, Roger C, Ansart S, Dailly E, Bretonnière C, Grégoire M. Development of a Predictive Dosing Nomogram to Achieve PK/PD Targets of Amikacin Initial Dose in Critically Ill Patients: A Non-Parametric Approach. Antibiotics (Basel) 2023; 12:antibiotics12010123. [PMID: 36671324 PMCID: PMC9854650 DOI: 10.3390/antibiotics12010123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/30/2022] [Accepted: 01/04/2023] [Indexed: 01/10/2023] Open
Abstract
French guidelines recommend reaching an amikacin concentration of ≥8 × MIC 1 h after beginning infusion (C1h), with MIC = 8 mg/L for probabilistic therapy. We aimed to elaborate a nomogram guiding clinicians in choosing the right first amikacin dose for ICU patients in septic shock. A total of 138 patients with 407 observations were prospectively recruited. A population pharmacokinetic model was built using a non-parametric, non-linear mixed-effects approach. The total body weight (TBW) influenced the central compartment volume, and the glomerular filtration rate (according to the CKD-EPI formula) influenced its clearance. A dosing nomogram was produced using Monte Carlo simulations of the amikacin amount needed to achieve a C1h ≥ 8 × MIC. The dosing nomogram recommended amikacin doses from 1700 mg to 4200 mg and from 28 mg/kg to 49 mg/kg depending on the patient's TBW and renal clearance. However, a Cthrough ≤ 2.5 mg/L 24 h and 48 h after an optimal dose of amikacin was obtained with probabilities of 0.20 and 0.81, respectively. Doses ≥ 30 mg/kg are required to achieve a C1h ≥ 8 × MIC with MIC = 8 mg/L. Targeting a MIC = 8 mg/L should depend on local ecology.
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Affiliation(s)
- Anne Coste
- Service de Maladies Infectieuses et Tropicales, CHU de Brest, 29200 Brest, France
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Laboratoire de Traitement de l’Information Médicale, INSERM, UMR1101, Brest Université, 29200 Brest, France
- Correspondence:
| | - Ronan Bellouard
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Service de Pharmacologie Clinique, CHU Nantes, 44000 Nantes, France
| | | | - Laurence Jalin
- Unité de Neuro-Anesthésie-Réanimation, Groupe Hospitalier Pitié-Salpétrière, AP-HP, 75013 Paris, France
| | - Claire Roger
- Département d’anesthésie et réanimation, douleur et médecine d’urgence, CHU Carémeau, 30029 Nîmes, France
- UR UM 103 IMAGINE, Faculté de Médecine, Montpellier Université, 30029 Nîmes, France
| | - Séverine Ansart
- Service de Maladies Infectieuses et Tropicales, CHU de Brest, 29200 Brest, France
- Laboratoire de Traitement de l’Information Médicale, INSERM, UMR1101, Brest Université, 29200 Brest, France
| | - Eric Dailly
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Service de Pharmacologie Clinique, CHU Nantes, 44000 Nantes, France
| | - Cédric Bretonnière
- Service des Soins Intensifs de Pneumologie, CHU Nantes, 44000 Nantes, France
| | - Matthieu Grégoire
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Service de Pharmacologie Clinique, CHU Nantes, 44000 Nantes, France
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Liu L, Zhang L, Zheng X, Liu X, Liu W, Wu J. LC -MS/MS-based multiplex antibacterial platform for therapeutic drug monitoring in intensive care unit patients. Front Pharmacol 2023; 14:1116071. [PMID: 37144212 PMCID: PMC10151781 DOI: 10.3389/fphar.2023.1116071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/05/2023] [Indexed: 05/06/2023] Open
Abstract
Empirically prescribed standard dosing regimens of antibacterial agents may result in insufficient or excess plasma concentrations with persistently poor clinical outcomes, especially for patients in intensive care units (ICUs). Therapeutic drug monitoring (TDM) of antibacterial agents can guide dose adjustments to benefit patients. In this study, we developed a robust, sensitive, and simple liquid chromatography-tandem mass spectrometry (LC-MS/MS) platform for the quantification of 14 antibacterial and antifungal agents (beta-lactams piperacillin, cefoperazone, and meropenem; beta-lactamase inhibitors tazobactam and sulbactam; antifungal agents fluconazole, caspofungin, posaconazole, and voriconazole; and daptomycin, vancomycin, teicoplanin, linezolid, and tigecycline) that can be used for patients with severe infection. This assay requires only 100 µL of serum with rapid protein precipitation. Chromatographic analysis was performed using a Waters Acquity UPLC C8 column. Three stable isotope-labeled antibacterial agents and one analogue were used as internal standards. Calibration curves ranged from 0.1-100 μg/mL, 0.1-50 μg/mL, and 0.3-100 μg/mL for different drugs, and all correlation coefficients were greater than 0.9085. Intra- and inter-day imprecision and inaccuracy values were below 15%. After validation, this new method was successfully employed for TDM in routine practice.
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Affiliation(s)
- Liang Liu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Liu Zhang
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiangyi Zheng
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xing Liu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wei Liu
- School of Physics and Technology, Wuhan University, Wuhan, China
| | - Jianhua Wu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, China
- *Correspondence: Jianhua Wu,
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Frost KJ, Hamilton RA, Hughes S, Jamieson C, Rafferty P, Troise O, Jenkins A. Systematic review of high-dose amikacin regimens for the treatment of Gram-negative infections based on EUCAST dosing recommendations. Eur J Hosp Pharm 2022:ejhpharm-2022-003421. [PMID: 36344247 DOI: 10.1136/ejhpharm-2022-003421] [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: 06/10/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Updated European Committee on Antimicrobial Susceptibility Testing (EUCAST) amikacin breakpoints for Enterobacterales and Pseudomonas aeruginosa included revised dosing recommendations of 25-30 mg/kg to achieve key pharmacokinetic/pharmacodynamic parameters, higher than recommended in the British National Formulary. The objectives of this review were to identify clinical evidence for high-dose amikacin regimens and to determine drug exposures that are related to adverse events and toxicity. METHODS The literature search was conducted in October 2021 and updated in May 2022 using electronic databases for any study reporting adult participants treated with amikacin at doses ≥20 mg/kg/day. Reference lists of included papers were also screened for potential papers. Data were extracted for pharmacokinetic parameters and clinical outcomes, presented in a summary table and consolidated narratively. Meta-analysis was not possible. Each study was assessed for bias before, during and after the intervention using the ROBINS-I tool. RESULTS Nine studies (total 501 participants in 10 reports) were identified and included, eight of which were observational studies. Assessment of bias showed substantial flaws. Dosing regimens ranged from 25 to 30 mg/kg/day. Six studies adjusted the dose in obesity when participants had a body mass index of ≥30 kg/m2. Target peak serum concentrations ranged from 60 mg/L to 80 mg/L and 59.6-81.8% of patients achieved these targets, but there was no information on clinical outcomes. Two studies reported the impact of high-dose amikacin on renal function. No studies reporting auditory or vestibular toxicity were identified. CONCLUSION All included papers were limited by a significant risk of bias, while methodological and reporting heterogeneity made drawing conclusions challenging. Lack of information on the impact on renal function or ototoxicity means high-dose regimens should be used cautiously in older people. There is a need for a consensus guideline for high-dose amikacin to be written. TRIAL REGISTRATION NUMBER PROSPERO (CRD42021250022).
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Affiliation(s)
| | - Ryan A Hamilton
- Pharmacy, De Montfort University, Leicester, UK
- Pharmacy, Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Stephen Hughes
- Pharmacy, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Conor Jamieson
- NHS England and NHS Improvement Midlands, Birmingham, UK
| | - Paul Rafferty
- Pharmacy, Southern Health and Social Care Trust, Portadown, UK
| | - Oliver Troise
- Pharmacy, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Abi Jenkins
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Botros SR, Matouk AI, Anter A, Khalifa MMA, Heeba GH. Protective effect of empagliflozin on gentamicin-induced acute renal injury via regulation of SIRT1/NF-κB signaling pathway. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2022; 94:103907. [PMID: 35697188 DOI: 10.1016/j.etap.2022.103907] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/27/2022] [Accepted: 06/08/2022] [Indexed: 06/15/2023]
Abstract
Gentamicin is a highly effective antibiotic. However, its major complication is nephrotoxicity. This study investigated the beneficial effects of empagliflozin against gentamicin-induced nephropathy. Kidney damage was induced in male Wistar rats by administration of gentamicin (100 mg/kg/day, i.p.) for 8 days. Two doses of empagliflozin (10 and 20 mg/kg, p.o.) were concomitantly given with gentamicin for 8 days. Gentamicin administration increased serum creatinine, urea, and cystatin C concentrations. Empagliflozin in both doses ameliorated these changes via mitigation of gentamicin-induced increase in renal oxidative stress, inflammation, and apoptosis. Empagliflozin added to GM treatment led to lower measured levels of TGF-B, NF-κB and caspase 3, and only the higher dose increased PAX2 levels indicating an improvement in tubular regeneration. Additionally, empagliflozin (20 mg/kg/day) markedly prevented gentamicin-induced histopathological changes. The protective effects of empagliflozin may be mediated by decreasing gentamicin concentration in renal tissue and possibly other effects like antioxidant and antiapoptotic effects.
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Affiliation(s)
- Sandy R Botros
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, El-Minia, Egypt
| | - Asmaa I Matouk
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, El-Minia, Egypt.
| | - Aliaa Anter
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, El-Minia, Egypt
| | - Mohamed M A Khalifa
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, El-Minia, Egypt
| | - Gehan H Heeba
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, El-Minia, Egypt.
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Hodiamont CJ, van den Broek AK, de Vroom SL, Prins JM, Mathôt RAA, van Hest RM. Clinical Pharmacokinetics of Gentamicin in Various Patient Populations and Consequences for Optimal Dosing for Gram-Negative Infections: An Updated Review. Clin Pharmacokinet 2022; 61:1075-1094. [PMID: 35754071 PMCID: PMC9349143 DOI: 10.1007/s40262-022-01143-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/04/2022]
Abstract
Gentamicin is an aminoglycoside antibiotic with a small therapeutic window that is currently used primarily as part of short-term empirical combination therapy. Gentamicin dosing schemes still need refinement, especially for subpopulations where pharmacokinetics can differ from pharmacokinetics in the general adult population: obese patients, critically ill patients, paediatric patients, neonates, elderly patients and patients on dialysis. This review summarizes the clinical pharmacokinetics of gentamicin in these patient populations and the consequences for optimal dosing of gentamicin for infections caused by Gram-negative bacteria, highlighting new insights from the last 10 years. In this period, several new population pharmacokinetic studies have focused on these subpopulations, providing insights into the typical values of the most relevant pharmacokinetic parameters, the variability of these parameters and possible explanations for this variability, although unexplained variability often remains high. Both dosing schemes and pharmacokinetic/pharmacodynamic (PK/PD) targets varied widely between these studies. A gentamicin starting dose of 7 mg/kg based on total body weight (or on adjusted body weight in obese patients) appears to be the optimal strategy for increasing the probability of target attainment (PTA) after the first administration for the most commonly used PK/PD targets in adults and children older than 1 month, including critically ill patients. However, evidence that increasing the PTA results in higher efficacy is lacking; no studies were identified that show a correlation between estimated or predicted PK/PD target attainment and clinical success. Although it is unclear if performing therapeutic drug monitoring (TDM) for optimization of the PTA is of clinical value, it is recommended in patients with highly variable pharmacokinetics, including patients from all subpopulations that are critically ill (such as elderly, children and neonates) and patients on intermittent haemodialysis. In addition, TDM for optimization of the dosing interval, targeting a trough concentration of at least < 2 mg/L but preferably < 0.5–1 mg/L, has proven to reduce nephrotoxicity and is therefore recommended in all patients receiving more than one dose of gentamicin. The usefulness of the daily area under the plasma concentration–time curve for predicting nephrotoxicity should be further investigated. Additionally, more research is needed on the optimal PK/PD targets for efficacy in the clinical situations in which gentamicin is currently used, that is, as monotherapy for urinary tract infections or as part of short-term combination therapy.
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Affiliation(s)
- Caspar J Hodiamont
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Annemieke K van den Broek
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Suzanne L de Vroom
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan M Prins
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Ghaffari S, Hadi AM, Najmeddin F, Shahrami B, Rouini MR, Najafi A, Mojtahedzadeh M. Evaluation of amikacin dosing schedule in critically ill elderly patients with different stages of renal dysfunction. Eur J Hosp Pharm 2022; 29:e67-e71. [PMID: 34588225 PMCID: PMC8899630 DOI: 10.1136/ejhpharm-2021-002986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/07/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Amikacin is still a widely used aminoglycoside for the treatment of life-threatening infections. The pharmacokinetic parameters of this antibiotic may be altered in critically ill conditions. Moreover, in the elderly population, pathophysiological changes affect these pharmacokinetic variables, making it difficult to predict the appropriate dose and dosing schedule for amikacin. This study aimed to characterise the pharmacokinetics of amikacin in critically ill elderly patients with renal dysfunction, and to evaluate if the available dose adjustment schedules dependent on renal function would be appropriate for empirical dosing. METHODS Critically ill patients aged >60 years with a creatinine clearance of >20 mL/min in need of treatment with amikacin were randomly enrolled. All the patients received approximately 25 mg/kg amikacin. The patients were then divided into three groups according to the stages of their renal dysfunction based on creatinine clearance, and the optimum time to re-dosing was calculated for each group. The pharmacokinetic parameters of the patients were calculated and estimated as population pharmacokinetic data. RESULTS Of 30 patients, only 20% attained the target peak levels of amikacin of >64 mg/L. In addition, the mean volume of distribution was 0.47 L/kg. There was a poor correlation between amikacin clearance and creatinine clearance. The difference in amikacin half-life was not statistically significant among any of the stages of renal impairment. CONCLUSIONS The initial dosing of amikacin in critically ill elderly patients should not be reduced, even in the context of renal impairment. Regarding the dose adjustment in renal impairment, dosing intervals estimation, no decision can be made based on the creatinine clearance and the first dose individualisation method in terms of the two-sample measurements may be considered as an appropriate strategy.
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Affiliation(s)
| | | | - Farhad Najmeddin
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Bita Shahrami
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Atabak Najafi
- Department of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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