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Maranchick NF, Peloquin CA. Role of therapeutic drug monitoring in the treatment of multi-drug resistant tuberculosis. J Clin Tuberc Other Mycobact Dis 2024; 36:100444. [PMID: 38708036 PMCID: PMC11067344 DOI: 10.1016/j.jctube.2024.100444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Tuberculosis (TB) is a leading cause of mortality worldwide, and resistance to anti-tuberculosis drugs is a challenge to effective treatment. Multi-drug resistant TB (MDR-TB) can be difficult to treat, requiring long durations of therapy and the use of second line drugs, increasing a patient's risk for toxicities and treatment failure. Given the challenges treating MDR-TB, clinicians can improve the likelihood of successful outcomes by utilizing therapeutic drug monitoring (TDM). TDM is a clinical technique that utilizes measured drug concentrations from the patient to adjust therapy, increasing likelihood of therapeutic drug concentrations while minimizing the risk of toxic drug concentrations. This review paper provides an overview of the TDM process, pharmacokinetic parameters for MDR-TB drugs, and recommendations for dose adjustments following TDM.
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Affiliation(s)
- Nicole F. Maranchick
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
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Grit GF, Toren-Wielema ML, Colin PJ, Touw DJ. Gentamicin Administration in Dialysis Patients: Before or After Hemodialysis? Ther Drug Monit 2023; 45:697-701. [PMID: 36730889 DOI: 10.1097/ftd.0000000000001058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gentamicin is used to treat severe infections and has a small therapeutic window. This study aimed to optimize the dosing strategy of gentamicin in intermittently hemodialyzed patients by simulating concentration-time profiles during pre- and postdialysis dosing, based on a published pharmacokinetic model. METHODS Pharmacokinetic simulations were performed with virtual patients, including septic patients, who were treated with gentamicin and received weekly hemodialysis with an interval of 48 h-48 h-72 h. The following dosing regimens were simulated: for nonseptic patients, 5 mg/kg gentamicin was given 1 h or 2 h before dialysis or a starting dose of 2.5 mg/kg and a maintenance dose of 1.5 mg/kg immediately after dialysis were given; for septic patients, 6 mg/kg gentamicin was given 1 h or 2 h before dialysis or a starting dose of 3 mg/kg and a maintenance dose of 1.8 mg/kg immediately were given after dialysis. The mean maximum concentration (C max ), area under the curve (AUC) 24 h , and target attainment (TA) of pharmacodynamic targets were calculated and compared. The following targets were adopted from the literature: C max >8 mg/L and <20 mg/L and AUC 24 h >70 mg·h/L and <120 mg·h/L. RESULTS In nonseptic patients, postdialysis dosing resulted in a TA of 35% for C max of >8 mg/L, 100% for <20 mg/L and AUC 24 h >70 mg·h/L, and 45% for <120 mg·h/L. Dosing 2 h before dialysis resulted in a TA of 100% for C max of >8 mg/L, 40% for <20 mg/L, 65% for AUC 24 h >70 mg·h/L, and 77% for <120 mg·h/L. Simulations of septic patients resulted in comparable outcomes with higher TAs for C max <20 mg/L (96%), AUC 24 h >70 mg·h/L (90%), and AUC 24 h <120 mg·h/L (53%) for dosing 1 h before dialysis. CONCLUSIONS Postdialysis dosing resulted in a low TA of C max >8 mg/L; however, predialysis dosing ensured a high TA of C max >8 mg/L and acceptable TA of C max <20 mg/L, AUC 24 h >70 mg·h/L, and AUC 24 h <120 mg·h/L, which could increase the efficacy of gentamicin. Therefore, clinicians should consider predialysis dosing of gentamicin in patients undergoing intermittent hemodialysis.
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Affiliation(s)
- Geeske F Grit
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and
| | - Martha L Toren-Wielema
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and
| | - Pieter J Colin
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; and
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Selig DJ, Reed T, Chung KK, Kress AT, Stewart IJ, DeLuca JP. Hemoperfusion with Seraph 100 Microbind Affinity Blood Filter Unlikely to Require Increased Antibiotic Dosing: A Simulations Study Using a Pharmacokinetic/Pharmacodynamic Approach. Blood Purif 2023; 52:25-31. [PMID: 35526522 DOI: 10.1159/000524457] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/04/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The Seraph® 100 Microbind® Affinity Blood Filter (Seraph 100) is a hemoperfusion device that can remove pathogens from central circulation. However, the effect of Seraph 100 on achieving pharmacodynamic (PD) targets is not well described. We sought to determine the impact of Seraph 100 on ability to achieve PD targets for commonly used antibiotics. METHODS Estimates of Seraph 100 antibiotic clearance were obtained via literature. For vancomycin and gentamicin, published pharmacokinetic models were used to explore the effect of Seraph 100 on ability to achieve probability of target attainment (PTA). For meropenem and imipenem, the reported effect of continuous kidney replacement therapy (CKRT) on achieving PTA was used to extrapolate decisions for Seraph 100. RESULTS Seraph 100 antibiotic clearance is likely less than 0.5 L/h for most antibiotics. Theoretical Seraph 100 clearance up to 0.5 L/h and 2 L/h had a negligible effect on vancomycin PTA in virtual patients with creatinine clearance (CrCl) = 14 mL/min and CrCl >14 mL/min, respectively. Theoretical Seraph 100 clearance up to 0.5 L/h and 2 L/h had a negligible effect on gentamicin PTA in virtual patients with CrCl = 120 mL/min and CrCl <60 mL/min, respectively. CKRT intensity resulting in antibiotic clearance up to 2 L/h generally does not require dose increases for meropenem or imipenem. As Seraph 100 is prescribed intermittently and likely contributes far less to antibiotic clearance, dose increases would also not be required. CONCLUSION Seraph 100 clearance of vancomycin, gentamicin, meropenem, and imipenem is likely clinically insignificant. There is insufficient evidence to recommend increased doses. For aminoglycosides, we recommend extended interval dosing and initiating Seraph 100 at least 30 min to 1 h after completion of infusion to avoid the possibility of interference with maximum concentrations.
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Affiliation(s)
- Daniel J Selig
- Department of Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Tyler Reed
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Adrian T Kress
- Department of Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Ian J Stewart
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jesse P DeLuca
- Department of Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
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Bellairs JA, Redila VA, Wu P, Tong L, Webster A, Simon JA, Rubel EW, Raible DW. An in vivo Biomarker to Characterize Ototoxic Compounds and Novel Protective Therapeutics. Front Mol Neurosci 2022; 15:944846. [PMID: 35923755 PMCID: PMC9342690 DOI: 10.3389/fnmol.2022.944846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/21/2022] [Indexed: 11/18/2022] Open
Abstract
There are no approved therapeutics for the prevention of hearing loss and vestibular dysfunction from drugs like aminoglycoside antibiotics. While the mechanisms underlying aminoglycoside ototoxicity remain unresolved, there is considerable evidence that aminoglycosides enter inner ear mechanosensory hair cells through the mechanoelectrical transduction (MET) channel. Inhibition of MET-dependent uptake with small molecules or modified aminoglycosides is a promising otoprotective strategy. To better characterize mammalian ototoxicity and aid in the translation of emerging therapeutics, a biomarker is needed. In the present study we propose that neonatal mice systemically injected with the aminoglycosides G418 conjugated to Texas Red (G418-TR) can be used as a histologic biomarker to characterize in vivo aminoglycoside toxicity. We demonstrate that postnatal day 5 mice, like older mice with functional hearing, show uptake and retention of G418-TR in cochlear hair cells following systemic injection. When we compare G418-TR uptake in other tissues, we find that kidney proximal tubule cells show similar retention. Using ORC-13661, an investigational hearing protection drug, we demonstrate in vivo inhibition of aminoglycoside uptake in mammalian hair cells. This work establishes how systemically administered fluorescently labeled ototoxins in the neonatal mouse can reveal important details about ototoxic drugs and protective therapeutics.
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Affiliation(s)
- Joseph A. Bellairs
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, United States
| | - Van A. Redila
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, United States
- Virginia Merrill Bloedel Hearing Research Center, University of Washington, Seattle, WA, United States
| | - Patricia Wu
- Virginia Merrill Bloedel Hearing Research Center, University of Washington, Seattle, WA, United States
- Department of Biological Structure, University of Washington, Seattle, WA, United States
| | - Ling Tong
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, United States
- Virginia Merrill Bloedel Hearing Research Center, University of Washington, Seattle, WA, United States
| | - Alyssa Webster
- Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Julian A. Simon
- Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Edwin W. Rubel
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, United States
- Virginia Merrill Bloedel Hearing Research Center, University of Washington, Seattle, WA, United States
| | - David W. Raible
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, United States
- Virginia Merrill Bloedel Hearing Research Center, University of Washington, Seattle, WA, United States
- Department of Biological Structure, University of Washington, Seattle, WA, United States
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Does Circadian Rhythm Affect the Pharmacokinetics of Once-Daily Tobramycin in Adults With Cystic Fibrosis? Ther Drug Monit 2021; 42:595-599. [PMID: 32049889 DOI: 10.1097/ftd.0000000000000743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the era of multiple daily dosing of systemic aminoglycosides, a circadian rhythm in the clearance of these vital antibiotics has been demonstrated in animals and healthy volunteers. Over the past decade, once-daily dosing regimens have been proved to be less nephrotoxic and were therefore adopted worldwide for most indications requiring treatment with an aminoglycoside. In this study, the effect of the time of administration on the pharmacokinetics of once-daily tobramycin in adults with cystic fibrosis (CF) experiencing a pulmonary exacerbation was investigated. METHODS In this open randomized study, patients with CF received intravenous tobramycin at 8:00 or 22:00 hours. Pharmacokinetic and kidney function parameters were compared between the 2 groups. RESULTS Twenty-five patients were included. The mean weight-corrected clearances of tobramycin were 1.46 versus 1.43 mL/h*kg (P = 0.50) and mean volumes of distribution were 0.25 versus 0.27 L/kg (P = 0.54) for the 8:00 and 22:00 groups, respectively. In addition, no significant differences were detected in changes in estimated clearances of creatinine or tobramycin on day 1 and day 8 in the 8:00 or 22:00 group, indicating that there was no decline in clearance over time. At day 8 of therapy, the increase in serum blood urea nitrogen in the 22:00 group was significantly higher than that in the 8:00 group (1.8 versus 0.2 mmol/L, P = 0.015). CONCLUSIONS The time of administration (8:00 versus 22:00) did not affect tobramycin pharmacokinetics in the adult CF population studied. The increase in serum blood urea nitrogen in the 22:00 group requires further investigation.
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Activity of fosfomycin and amikacin against fosfomycin-heteroresistant Escherichia coli strains in a hollow-fiber infection model. Antimicrob Agents Chemother 2021; 65:AAC.02213-20. [PMID: 33685903 PMCID: PMC8092889 DOI: 10.1128/aac.02213-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objectives:To evaluate human-like intravenous doses of fosfomycin (8g/Q8h) and amikacin (15mg/kg/Q24h) efficacy in monotherapy and in combination against six fosfomycin-heteroresistant Escherichia coli isolates using a hollow-fiber infection model (HFIM).Materials and methods:Six fosfomycin-heteroresistant E. coli isolates (4 with strong mutator phenotype) and the control strain E. coli ATCC 25922 were used. Mutant frequencies for rifampin (100mg/L), fosfomycin (50 and 200mg/L) and amikacin (32mg/L) were determined. Fosfomycin and amikacin MICs were assessed by agar dilution (AD), gradient strip (GSA) and broth microdilution (BMD) assays. Fosfomycin and amikacin synergies were studied by checkerboard and time-kill assays at different concentrations. Fosfomycin (8g/Q8h) and amikacin (15mg/kg/Q24h) efficacy alone and in combination were assessed using a HFIM.Results:Five isolates were resistant to fosfomycin by AD and BMD, but all susceptible by GSA. All isolates were considered susceptible to amikacin. Antibiotic combinations were synergistic in two isolates and no antagonism was detected. In time-kill assays, all isolates survived under fosfomycin at 64mg/L, although, at 307mg/L, only the normomutators and two hypermutators survived. Four isolates survived under 16mg/L amikacin and none at 45mg/L. No growth was detected under combination conditions. In HFIM, fosfomycin and amikacin monotherapies failed to sterilise bacterial cultures, however, fosfomycin and amikacin combination showed a rapid eradication.Conclusions.There may be a risk of treatment failure of fosfomycin-heteroresistant E. coli isolates using either amikacin or fosfomycin in monotherapy. These results support that the combination amikacin-fosfomycin can rapidly decrease bacterial burden and prevent the emergence of resistant subpopulations against fosfomycin-heteroresistant strains.
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Mouton Y, Dubreuil L. In Vitro Antibiotic Testing and Its Relationship to Clinical Activity. J Chemother 2021. [DOI: 10.1080/1120009x.1997.12113194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Y. Mouton
- Service Regional Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, 135 rue du Président Coty, B.P. 619 - 59208 Tourcoing, France. Tel. ; fax.
| | - L. Dubreuil
- Service Regional Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, 135 rue du Président Coty, B.P. 619 - 59208 Tourcoing, France. Tel. ; fax.
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Hamilton-Miller J. Breakpoints in Antibiotic Sensitivity Testing and Their Clinical Relevance. J Chemother 2021. [DOI: 10.1080/1120009x.1997.12113189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Affiliation(s)
- A.P. Macgowan
- Bristol Centre for Antimicrobial Research and Evaluation, Southmead Health Services NHS Trust and University of Bristol, Department of Medical Microbiology, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, UK. Tel: ; Fax:
| | - K.E. Bowker
- Bristol Centre for Antimicrobial Research and Evaluation, Southmead Health Services NHS Trust and University of Bristol, Department of Medical Microbiology, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, UK. Tel: ; Fax:
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Oda K, Fujii S, Yamamoto T, Mayumi T, Takesue Y. Evaluation of once-daily dosing and target concentrations in therapeutic drug monitoring for arbekacin: A meta-analysis. J Infect Chemother 2020; 27:26-31. [PMID: 32828677 DOI: 10.1016/j.jiac.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/17/2020] [Accepted: 08/03/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Arbekacin is the first aminoglycoside antibacterial agent approved for treating methicillin-resistant Staphylococcus aureus infection in Japan. Although therapeutic drug monitoring (TDM) is recommended during arbekacin treatment, little evidence for the target exposure and once-daily dosing has been reported. This study aimed to clarify the target peak/trough concentrations and the effectiveness of once-daily dosing of arbekacin against nephrotoxicity or treatment failure via meta-analysis. METHODS A literature search was performed using MEDLINE, Cochrane Library, and Ichushi-Web. RESULTS Nine observational cohort studies met the inclusion criteria. A peak arbekacin concentration of ≥15-16 μg/mL did not exhibit a statistically significant lower risk of treatment failure (risk ratio [RR] = 0.61, 95% confidence interval [CI] = 0.30-1.24). A trough arbekacin concentration of <2 μg/mL resulted in a significantly lower risk of nephrotoxicity (RR = 0.30, 95% CI = 0.15-0.61). Once-daily dosing significantly reduced the risk of treatment failure (RR = 0.61, 95% CI = 0.39-0.97) but not nephrotoxicity (RR = 0.54, 95% CI = 0.16-1.75). CONCLUSIONS Once-daily dosing can improve the therapeutic efficacy of arbekacin, and a trough arbekacin concentration of <2 μg/mL can reduce the risk of nephrotoxicity. A peak arbekacin concentration of ≥15-16 μg/mL did not exhibit the significant lower risk of treatment failure. Additional clinical trials are required to confirm these findings.
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Affiliation(s)
- Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1, Honjo, Chuo-ku, Kumamoto, 860-8556, Japan; Department of Infection Control, Kumamoto University Hospital, 1-1-1, Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
| | - Satoshi Fujii
- Department of Pharmacy, Sapporo Medical University Hospital, S1 W16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Takehito Yamamoto
- Department of Pharmacy, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishi-ku Kitakyushu, Fukuoka, 807-8555, Japan.
| | - Yoshio Takesue
- Department of Infection Control and Prevention, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
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Ogier JM, Lockhart PJ, Burt RA. Intravenously delivered aminoglycoside antibiotics, tobramycin and amikacin, are not ototoxic in mice. Hear Res 2020; 386:107870. [PMID: 31864009 DOI: 10.1016/j.heares.2019.107870] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/24/2019] [Accepted: 12/09/2019] [Indexed: 12/20/2022]
Abstract
Many drugs on the World Health Organization's list of critical medicines are ototoxic, destroying sensory hair cells within the ear. These drugs preserve life, but patients can experience side effects including permanent hearing loss and vestibular dysfunction. Aminoglycoside ototoxicity was first recognised 80 years ago. However, no preventative treatments have been developed. In order to develop such treatments, we must identify the factors driving hair cell death. In vivo, studies of cell death are typically conducted using mouse models. However, a robust model of aminoglycoside ototoxicity does not exist. Previous studies testing aminoglycoside delivery via intraperitoneal or subcutaneous injection have produced variable ototoxic effects in the mouse. As a result, surgical drug delivery to the rodent ear is often used to achieve ototoxicity. However, this technique does not accurately model clinical practice. In the clinic, aminoglycosides are administered to humans intravenously (i.v.). However, repeated i.v. delivery has not been reported in the mouse. This study evaluated whether repeated i.v. administration of amikacin or tobramycin would induce hearing loss. Daily i.v. injections over a two-week period were well tolerated and transient low frequency hearing loss was observed in the aminoglycoside treatment groups. However, the hearing changes observed did not mimic the high frequency patterns of hearing loss observed in humans. Our results indicate that the i.v. delivery of tobramycin or amikacin is not an effective technique for inducing ototoxicity in mice. This result is consistent with previously published reports indicating that the mouse cochlea is resistant to systemically delivered aminoglycoside ototoxicity.
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Affiliation(s)
- Jacqueline M Ogier
- Bruce Lefroy Centre, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, 3010, Australia.
| | - Paul J Lockhart
- Bruce Lefroy Centre, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, 3010, Australia
| | - Rachel A Burt
- Bruce Lefroy Centre, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia; School of Biosciences, University of Melbourne, Parkville, VIC, 3010, Australia
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Heffernan AJ, Sime FB, Sun J, Lipman J, Kumar A, Andrews K, Ellwood D, Grimwood K, Roberts J. β-lactam antibiotic versus combined β-lactam antibiotics and single daily dosing regimens of aminoglycosides for treating serious infections: A meta-analysis. Int J Antimicrob Agents 2019; 55:105839. [PMID: 31704215 DOI: 10.1016/j.ijantimicag.2019.10.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 10/21/2019] [Accepted: 10/27/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Combining aminoglycosides with β-lactam antibiotics for treating serious infections has not been associated with reduced mortality in previous meta-analyses. However, the multiple daily aminoglycoside dosing regimen principally used in most of the included studies is inconsistent with current practice. OBJECTIVE To determine if a combination of an aminoglycoside administered as a single daily dose and a β-lactam antibiotic reduces all-cause mortality in patients compared with β-lactam antibiotic monotherapy. METHODS A systematic review and meta-analysis of clinical studies was performed (Prospero registration number #68506). Studies were included if they compared β-lactam antibiotic monotherapy with combined β-lactam and single daily dose aminoglycoside therapy for treating serious infections. Studies investigating multiple daily dosing aminoglycoside regimens, infective endocarditis and febrile neutropaenia were excluded. Study quality was assessed using the PEDro and Newcastle-Ottawa scoring systems. The end points for outcome analyses were 30-day all-cause mortality, clinical cure and nephrotoxicity. RESULTS Four randomised controlled trials and five retrospective cohort studies were analysed. Compared with β-lactam antibiotic monotherapy, single daily aminoglycoside dosing in combination with β-lactam antibiotics was not associated with reduced mortality compared with β-lactam antibiotic monotherapy (n = 3686, OR 0.82, 95% CI 0.63-1.08, P = 0.10, I2 42%). A subgroup analysis of cohort studies suggested reduced mortality with combination therapy (n = 3563, OR 0.79, 95% CI 0.64-0.99, P = 0.04, I2 32%). No increased risk of nephrotoxicity was identified (n = 1110, OR 1.31, 95% CI 0.83-2.09, P = 0.40, I2 0%). CONCLUSIONS The existing evidence suggests no added survival benefit from a single daily dosing regimen of an aminoglycoside when combined with β-lactam antibiotics.
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Affiliation(s)
| | - Fekade Bruck Sime
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Woolloongabba, Queensland, Australia; Faculty of Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jing Sun
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Jeffrey Lipman
- Faculty of Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Anand Kumar
- Sections of Critical Care Medicine and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Katherine Andrews
- Griffith Institute for Drug Discovery, Griffith University, Nathan, Queensland, Australia
| | - David Ellwood
- School of Medicine and Menzies Health Institute Queensland, Gold Coast campus, Griffith University, Gold Coast, Queensland, Australia; Department of Maternal-Foetal Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Keith Grimwood
- School of Medicine and Menzies Health Institute Queensland, Gold Coast campus, Griffith University, Gold Coast, Queensland, Australia; Departments of Paediatrics and Infectious Diseases, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Jason Roberts
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Woolloongabba, Queensland, Australia; Faculty of Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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Cruz R, Sandoval R, González G, Pérez P, Sánchez L. Impacto en el consumo de amikacina y ceftriaxona en una unidad de emergencias de adultos, luego de la implementación de una guía para el tratamiento de la infección urinaria alta. INFECTIO 2019. [DOI: 10.22354/in.v23i4.804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introducción: los programas de optimización del uso de antimicrobianos son fundamentales para mejorar los resultados clínicos de los pacientes.Objetivos: determinar el impacto en el consumo de amikacina y ceftriaxona, además de cambios de sensibilidad de las principales bacterias en la unidad de emergencias del hospital Carlos van Buren de Valparaíso, Chile, luego de la implementación de una guía para el tratamiento de la ITU alta.Materiales y método: estudio cuasi-experimental antes/después. Se implementó una guía de tratamiento para la ITU alta, la cual fue enviada vía WhatsApp a los médicos de la unidad. Luego se midieron las dosis diarias definidas (DDD) de amikacina y ceftriaxona y se compararon con las DDD de los mismos meses del año anterior. Además se extrajo la sensibilidad de E.coli, K. pneumonia y P.mirabilis aisladas de urocultivos.Resultados: posterior a la intervención hubo un aumento de las DDD de amikacina y una disminución de las de ceftriaxona. K.pneumoniae mantuvo su sensibilidad a amikacina y la aumentó para cefotaxima, ertapenem y meropenem.Conclusiones: la implementación de una guía de tratamiento de la ITU alta aumentó el consumo de amikacina y disminuyó el de ceftriaxona. K.pneumoniae aumentó su sensibilidad a cefotaxima, ertapenem y meropenem.
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Bergenwall M, Walker SAN, Elligsen M, Iaboni DC, Findlater C, Seto W, Ng E. Optimizing gentamicin conventional and extended interval dosing in neonates using Monte Carlo simulation - a retrospective study. BMC Pediatr 2019; 19:318. [PMID: 31492162 PMCID: PMC6729057 DOI: 10.1186/s12887-019-1676-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although aminoglycosides are routinely used in neonates, controversy exists regarding empiric dosing regimens. The objectives were to determine gentamicin pharmacokinetics in neonates, and develop initial mg/kg dosing recommendations that optimized target peak and trough concentration attainment for conventional and extended-interval dosing (EID) regimens. METHODS Patient demographics and steady-state gentamicin concentration data were retrospectively collected for 60 neonates with no renal impairment admitted to a level III neonatal intensive care unit. Mean pharmacokinetics were calculated and multiple linear regression was performed to determine significant covariates of clearance (L/h) and volume of distribution (L). Classification and regression tree (CART) analysis identified breakpoints for significant covariates. Monte Carlo Simulation (MCS) was used to determine optimal dosing recommendations for each CART-identified sub-group. RESULTS Gentamicin clearance and volume of distribution were significantly associated with weight at gentamicin initiation. CART-identified breakpoints for weight at gentamicin initiation were: ≤ 850 g, 851-1200 g, and > 1200 g. MCS identified that a conventional dose of gentamicin 3.5 mg/kg given every 48 h or an EID of 8-9 mg/kg administered every 72 h in neonates weighing ≤ 850 g, and every 24 and 48 h, respectively, in neonates weighing 851-1200 g, provided the best probability of attaining conventional (peak: 5-10 mg/L and trough: ≤ 2 mg/L) and EID targets (peak:12-20 mg/L, trough:≤ 0.5 mg/L). Insufficient sample size in the > 1200 g neonatal group precluded further investigation of this weight category. CONCLUSIONS This study provides initial gentamicin dosing recommendations that optimize target attainment for conventional and EID regimens in neonates weighing ≤ 1200 g. Prospective validation and empiric dose optimization for neonates > 1200 g is needed.
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Affiliation(s)
- Monique Bergenwall
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
- Present Address: Grandview Medical Centre Family Health Team, 167 Hespeler Rd, Cambridge, ON N1R 3H7 Canada
| | - Sandra A. N. Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
- Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON Canada
- Sunnybrook Health Sciences Centre Research Institute, Toronto, ON Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
| | - Dolores C. Iaboni
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Carla Findlater
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Winnie Seto
- Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
- Department of Pharmacy, Hospital for Sick Children, Toronto, ON Canada
| | - Eugene Ng
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
- Department of Paediatrics, University of Toronto, Toronto, ON Canada
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15
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Hoo GSR, Liew YX, Kwa ALH. Optimisation of antimicrobial dosing based on pharmacokinetic and pharmacodynamic principles. Indian J Med Microbiol 2018; 35:340-346. [PMID: 29063877 DOI: 10.4103/ijmm.ijmm_17_278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
While suboptimal dosing of antimicrobials has been attributed to poorer clinical outcomes, clinical cure and mortality advantages have been demonstrated when target pharmacokinetic (PK) and pharmacodynamic (PD) indices for various classes of antimicrobials were achieved to maximise antibiotic activity. Dosing optimisation requires a good knowledge of PK/PD principles. This review serves to provide a foundation in PK/PD principles for the commonly prescribed antibiotics (β-lactams, vancomycin, fluoroquinolones and aminoglycosides), as well as dosing considerations in special populations (critically ill and obese patients). PK principles determine whether an appropriate dose of antimicrobial reaches the intended pathogen(s). It involves the fundamental processes of absorption, distribution, metabolism and elimination, and is affected by the antimicrobial's physicochemical properties. Antimicrobial pharmacodynamics define the relationship between the drug concentration and its observed effect on the pathogen. The major indicator of the effect of the antibiotics is the minimum inhibitory concentration. The quantitative relationship between a PK and microbiological parameter is known as a PK/PD index, which describes the relationship between dose administered and the rate and extent of bacterial killing. Improvements in clinical outcomes have been observed when antimicrobial agents are dosed optimally to achieve their respective PK/PD targets. With the rising rates of antimicrobial resistance and a limited drug development pipeline, PK/PD concepts can foster more rational and individualised dosing regimens, improving outcomes while simultaneously limiting the toxicity of antimicrobials.
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Affiliation(s)
| | - Yi Xin Liew
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Andrea Lay-Hoon Kwa
- Department of Pharmacy, Singapore General Hospital; Emerging Infectious Diseases, Duke-National University of Singapore; Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
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16
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Lee C, Walker SAN, Walker SE, Seto W, Simor A, Jeschke M. A prospective study evaluating tobramycin pharmacokinetics and optimal once daily dosing in burn patients. Burns 2017. [PMID: 28647460 DOI: 10.1016/j.burns.2017.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Once-daily aminoglycoside dosing (ODA) is used in most patient populations to optimize antibacterial activity and reduce toxicity. Unfortunately, burn patients are excluded from ODA due to concerns over altered pharmacokinetics resulting in a shortened half-life and low peak aminoglycoside concentrations. Retrospective studies suggest that ODA may be appropriate if higher milligram/kilogram doses are used. However, no prospective clinical trials in burn patients exist to confirm these findings. OBJECTIVE To determine the adequacy of once daily tobramycin dosed at 10mg/kg in adult burn patients. METHODS This prospective single dose pharmacokinetic clinical trial was conducted at the Ross Tilley Burn Centre. Patients with a total burn surface area (TBSA) of <20% and creatinine clearance ≥50mL/min were eligible. A first-order one compartment model was used to determine the pharmacokinetic profile from 3 or 5 tobramycin levels over a 24h period per patient. Monte Carlo simulation (MCS) was performed to determine the probability of target level attainment. RESULTS The mean percent TBSA, partial, and full thickness burn were 10%, 6%, and 4%, respectively. Nine of the ten patients recruited achieved peak concentrations of ≥20mg/L (mean of 29.4±5.7mg/L) and all patients had a trough level ≤0.5mg/L. The mean half-life, volume of distribution, and clearance were 2.58h, 0.33L/kg, and 7.40L/h, respectively. The MCS determined probability of attaining target peak concentrations with the 10mg/kg dose was 97%, which almost doubled that predicted with the usual 7mg/kg dose. CONCLUSION Burn patients with adequate renal function and <20% TBSA are candidates for ODA. Tobramycin half-life was similar to healthy, non-burn patients. The larger than normal volume of distribution supports the use of the higher empiric dose of 10mg/kg total body or adjusted weight in non-obese and obese patients, respectively, with further dose adjustment based on therapeutic drug monitoring.
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Affiliation(s)
- Colin Lee
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada
| | - Sandra A N Walker
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada; SHSC, Division of Infectious Diseases, Canada; SHSC, Sunnybrook Research Institute, Canada.
| | - Scott E Walker
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada
| | - Winnie Seto
- University of Toronto, Leslie Dan Faculty of Pharmacy, Canada; Hospital for Sick Children (HSC), Department of Pharmacy, Canada
| | - Andrew Simor
- SHSC, Division of Infectious Diseases, Canada; SHSC, Sunnybrook Research Institute, Canada; University of Toronto, Faculty of Medicine, Canada
| | - Marc Jeschke
- University of Toronto, Faculty of Medicine, Canada; SHSC, Ross Tilley Burn Centre, Canada
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Seng P, Amrane S, Million M, Stein A. Old antimicrobials and Gram-positive cocci through the example of infective endocarditis and bone and joint infections. Int J Antimicrob Agents 2017; 49:558-564. [PMID: 28365430 DOI: 10.1016/j.ijantimicag.2017.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/09/2017] [Accepted: 03/11/2017] [Indexed: 01/20/2023]
Abstract
The management of some serious infections such as infective endocarditis (IE) and bone and joint infections (BJIs) caused by Gram-positive cocci (GPC) is complex and requires great responsiveness and effective antimicrobials with high bioavailability in heart valves or bone tissues. Treatment of these infections requires the use of a higher dosage that may result in increased toxicity or the use of new promising antimicrobials to control the infection. However, use of these new antimicrobials could still bring about new toxicity and resistance. Another approach may be the 'comeback' of old antimicrobials, which is evaluated in this review in the treatment of IE and BJIs caused by GPC.
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Affiliation(s)
- Piseth Seng
- Centre de Référence des Infections Ostéo-Articulaires (CRIOA) Sud-Méditerranée, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005 Marseille, France; Service de Maladies Infectieuses Tropicales et Infections Chroniques, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005 Marseille, France; Aix-Marseille Université, Unité de recherche sur les maladies infectieuses et tropicales émergentes (URMITE), UM63, CNRS 7278, IRD 198, INSERM 1095, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005 Marseille, France.
| | - Sophie Amrane
- Aix-Marseille Université, Unité de recherche sur les maladies infectieuses et tropicales émergentes (URMITE), UM63, CNRS 7278, IRD 198, INSERM 1095, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005 Marseille, France
| | - Matthieu Million
- Aix-Marseille Université, Unité de recherche sur les maladies infectieuses et tropicales émergentes (URMITE), UM63, CNRS 7278, IRD 198, INSERM 1095, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005 Marseille, France
| | - Andreas Stein
- Centre de Référence des Infections Ostéo-Articulaires (CRIOA) Sud-Méditerranée, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005 Marseille, France; Service de Maladies Infectieuses Tropicales et Infections Chroniques, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005 Marseille, France; Aix-Marseille Université, Unité de recherche sur les maladies infectieuses et tropicales émergentes (URMITE), UM63, CNRS 7278, IRD 198, INSERM 1095, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005 Marseille, France
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Abd-Elfattah R, Elhdad AM, Khames A, Abdelrahim ME, Shouman SA. Efficacy and toxicity of once versus twice daily regimens of amikacin in febrile neutropenic pediatric cancer patients. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2017. [DOI: 10.1016/j.bjbas.2017.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Rao SC, Srinivasjois R, Moon K. One dose per day compared to multiple doses per day of gentamicin for treatment of suspected or proven sepsis in neonates. Cochrane Database Syst Rev 2016; 12:CD005091. [PMID: 27921299 PMCID: PMC6464017 DOI: 10.1002/14651858.cd005091.pub4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Animal studies and trials in older children and adults suggest that a 'one dose per day' regimen of gentamicin is superior to a 'multiple doses per day' regimen. OBJECTIVES To compare the efficacy and safety of one dose per day compared to multiple doses per day of gentamicin in suspected or proven sepsis in neonates. SEARCH METHODS Eligible studies were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3) in the Cochrane Library (searched 8 April 2016), MEDLINE (1966 to 8 April 2016), Embase (1980 to 8 April 2016), and CINAHL (December 1982 to 8 April 2016). SELECTION CRITERIA All randomised or quasi-randomised controlled trials comparing one dose per day ('once a day') compared to multiple doses per day ('multiple doses a day') of gentamicin to newborn infants. DATA COLLECTION AND ANALYSIS Data collection and analysis was performed according to the standards of the Cochrane Neonatal Review Group. MAIN RESULTS Eleven RCTs were included (N = 574) and 28 excluded. All except one study enrolled infants of more than 32 weeks' gestation. Limited information suggested that infants in both 'once a day' as well as 'multiple doses a day' regimens showed adequate clearance of sepsis (typical RR 1.00, 95% CI 0.84 to 1.19; typical RD 0.00, 95% CI -0.19 to 0.19; 3 trials; N = 37). 'Once a day' gentamicin regimen was associated with fewer failures to attain peak level of at least 5 µg/ml (typical RR 0.22, 95% CI 0.11 to 0.47; typical RD -0.13, 95% CI -0.19 to -0.08; number needed to treat for an additional beneficial outcome (NNTB) = 8; 9 trials; N = 422); and fewer failures to achieve trough levels of 2 µg/ml or less (typical RR 0.38, 95% CI 0.27 to 0.55; typical RD -0.22, 95% CI -0.29 to -0.15; NNTB = 4; 11 trials; N = 503). 'Once a day' gentamicin achieved higher peak levels (MD 2.58, 95% CI 2.26 to 2.89; 10 trials; N = 440) and lower trough levels (MD -0.57, 95% CI -0.69 to -0.44; 10 trials; N = 440) than 'multiple doses a day' regimen. There was no significant difference in ototoxicity between two groups (typical RR 1.69, 95% CI 0.18 to 16.25; typical RD 0.01, 95% CI -0.04 to 0.05; 5 trials; N = 214). Nephrotoxicity was not noted with either of the treatment regimens. Overall, the quality of evidence was considered to be moderate on GRADE analysis, given the small sample size and unclear/high risk of bias in some of the domains in a few of the included studies. AUTHORS' CONCLUSIONS There is insufficient evidence from the currently available RCTs to conclude whether a 'once a day' or a 'multiple doses a day' regimen of gentamicin is superior in treating proven neonatal sepsis. However, data suggest that pharmacokinetic properties of a 'once a day' gentamicin regimen are superior to a 'multiple doses a day' regimen in that it achieves higher peak levels while avoiding toxic trough levels. There was no change in nephrotoxicity or auditory toxicity. Based on the assessment of pharmacokinetics, a 'once a day regimen' may be superior in treating sepsis in neonates of more than 32 weeks' gestation.
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Affiliation(s)
- Shripada C Rao
- King Edward Memorial Hospital for Women and Princess Margaret Hospital for ChildrenCentre for Neonatal Research and EducationPerth, Western AustraliaAustralia6008
| | - Ravisha Srinivasjois
- University of Western Australia, Joondalup Health CampusNeonatology and PaediatricsJoondalupWAAustralia
| | - Kwi Moon
- Princess Margaret Hospital for ChildrenPerthAustralia
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Kale-Pradhan PB, Habowski SR, Chase HC, Castronova FC. Once-Daily Aminoglycosides: A Meta-Analysis of Nonneutropenic and Neutropenic Adults. J Pharm Technol 2016. [DOI: 10.1177/875512259801400109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To compare the efficacy, nephrotoxicity, and ototoxicity of once-daily dosing of aminoglycosides versus conventional dosing. Design: Meta-analysis of 14 randomized trials identified through a MEDLINE search (January 1965-May 1996). Patients: Neutropenic and nonneutropenic adults. Interventions: Patients were randomly selected to receive an aminoglycoside once daily or in multiple daily doses. Measurements and Main Outcomes: The outcomes considered were clinical cure, bacteriologic cure, nephrotoxicity, auditory toxicity, and vestibular toxicity. The data were analyzed in the following subgroups: (1) all trials, (2) nonneutropenic patients, (3) neutropenic patients, and (4) patients with undefined neutrophil status. For all trials the pooled risk ratio was 1.268 (95% CI 0.828 to 1.939) for clinical cure, and was 1.390 (95% CI 1.350 to 1.392) for bacteriologic cure. Nephrotoxicity had a pooled risk ratio of 0.765 (95% CI 0.468 to 1.252), that for auditory toxicity was 1.117 (95% CI 0.151 to 5.636), and that for vestibular toxicity was 1.155 (95% CI 0.221 to 6.039). Analysis of the subgroups, including a separate analysis of neutropenic patients, demonstrated similar results. Conclusions: When all trials were considered, once-daily administration of aminoglycosides had similar efficacy and no increase in nephrotoxicity or ototoxicity compared with conventional aminoglycoside dosing.
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Abstract
Although aminoglycosides remain an essential part of therapy of severe gram-negative infections in critically ill patients, the use of extended-interval aminoglycoside dosing (EIAD) in this population is highly controversial. The rationale for EIAD is based on major pharmacodynamic characteristics of the aminoglycosides, which include concentration-dependent bactericidal effects, postantibiotic effect, and adaptive resistance. Alterations in the pharmacokinetics of aminoglycosides in the critically ill have been well documented, including changes in both drug distribution and elimination. These pharmacokinetic alterations may prevent critically ill patients from realizing the potential benefits of EIAD by reducing serum concentrations achieved by recommended EIAD regimens and may perhaps place patients at risk of therapeutic failure. Although numerous studies of EIAD have been conducted, there is a lack of data specifically concerning the efficacy and safety of EIAD in the critically ill. The most appropriate methods for monitoring EIAD in this population are also not clearly established. There are thus many questions regarding the suitability of EIAD in the critically ill. This article briefly reviews the rationale for EIAD and data related to the pharmacokinetics, efficacy, safety, and clinical monitoring of EIAD in critically ill patients. Considerations and recommendations for use of EIAD in the critically ill are provided.
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Affiliation(s)
- Douglas N. Fish
- Department of Pharmacy Practice, University of Colorado School of Pharmacy, Department of Pharmacy, University of Colorado Hospital, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Campus Box C- 238, Denver, CO 80262,
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22
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Antimicrobial Agent Dosing in Infants. Clin Ther 2016; 38:1948-60. [DOI: 10.1016/j.clinthera.2016.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 11/19/2022]
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Jenkins A, Thomson AH, Brown NM, Semple Y, Sluman C, MacGowan A, Lovering AM, Wiffen PJ. Amikacin use and therapeutic drug monitoring in adults: do dose regimens and drug exposures affect either outcome or adverse events? A systematic review. J Antimicrob Chemother 2016; 71:2754-9. [DOI: 10.1093/jac/dkw250] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/24/2016] [Indexed: 11/14/2022] Open
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The effectiveness and safety of two prophylactic antibiotic regimes in hip-fracture surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:483-92. [PMID: 27193753 DOI: 10.1007/s00590-016-1794-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Abstract
Antibiotic prophylaxis with cefuroxime can reduce the incidence of deep wound infection (DWI) in hip-fracture surgery, but may increase the risk of C. difficile infection (CDI). An alternative is gentamicin with beta-lactam for which a question exists around clinical effectiveness and safety, given the gentamicin-associated nephrotoxicity particularly in the elderly and narrower sensitivity spectrum. We compared 744 consecutive patients (group I-cefuroxime) with 756 in group II (gentamicin + flucloxacillin) who were well matched. There were 4 cases of CDI in the cefuroxime prophylaxis, whereas none in flucloxacillin plus gentamicin (group II). There was a statistically significant (p = 0.036) increased DWI rate in group II (2.5 %) as compared to group I (1.1 %). However, after controlling for age, gender, ASA grade, surgeon grade, implant type and type of anaesthesia, there was no statistically significant difference between the two groups (p = 0.146). 8.5 % of group I and 16.5 % of group II developed AKI post-operatively (p = 0.023); however, 79 % of group I and 80 % of in group II had complete resolution of AKI prior to their discharge. Further, a significant increase in inpatient deaths (p = 0.057) in group II was observed, but not at 30 days (p = 0.378).
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Can we transfer pharmacokinetics/pharmacodynamics of antimicrobials into clinical practice? Int J Antimicrob Agents 2015; 46 Suppl 1:S40-2. [DOI: 10.1016/j.ijantimicag.2015.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Bowsher B. Sensorineural deafness following routine transurethral resection of the prostate. BMJ Case Rep 2015; 2015:bcr-2015-212933. [PMID: 26564118 DOI: 10.1136/bcr-2015-212933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
A man in his 50s presented to a rural Australian emergency department with complete unilateral hearing loss following transurethral resection of the prostate. His hearing impairment progressed from 'muffled hearing' with tinnitus on emergence from anaesthesia, to total sensorineural deafness by day three. His surgery and anaesthesia were uncomplicated and he had remained normotensive throughout. He had no pre-existing auditory disease. He had received 240 mg of intravenous gentamicin intraoperatively for surgical prophylaxis. Renal function was normal. Brain imaging was negative for structural pathology, stroke and circulatory insufficiency. Ear nose and throat advised 7 days of oral corticosteroids, transtympanic dexamethasone and hyperbaric oxygen therapy. A working diagnosis of gentamicin-induced ototoxicity was applied. Intervention has proven unsuccessful and there is no possibility for rehabilitation. The patient is permanently disabled.
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Affiliation(s)
- Benjamin Bowsher
- Emergency Department, Northern NSW Local Health District, Tweed Heads, New South Wales, Australia
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Diasinos N, Baysari M, Kumar S, Day RO. Does the availability of therapeutic drug monitoring, computerised dose recommendation and prescribing decision support services promote compliance with national gentamicin prescribing guidelines? Intern Med J 2015; 45:55-62. [PMID: 25371347 DOI: 10.1111/imj.12627] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 10/24/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gentamicin is an aminoglycoside antibiotic that is highly effective in treating Gram-negative infections, but inappropriate use leads to toxicity. In 2010, the Australian Therapeutic Guidelines (Antibiotic) were revised to recommend the use of computerised methods to individualise dosing of gentamicin and optimise therapy, rather than traditional nomogram approaches. AIM To determine whether gentamicin prescribing was compliant with the Australian Therapeutic Guidelines, version 14 (2010) in a setting where computerised dose recommendation resources and computerised decision support were available, and to determine why the resources were effective or ineffective in achieving compliance to guidelines. METHODS During phase 1, a retrospective audit of gentamicin prescribing from 1 January 2012 to 31 December 2012 (n = 826) at a 320-bed teaching hospital in Sydney was undertaken. In phase 2, 12 doctors from specialties with high-volume prescribing of gentamicin were interviewed. RESULTS Intravenous gentamicin was used in 545 cases, 81% of which were for short-term therapy (≤48 h). Doctors feared inducing toxicity in patients, but limited the dose rather than altering the dosing interval according to renal function. Of the 'continued' dosing cases, 55% went unmonitored and the computerised dose recommendation service was rarely used. Doctors were unaware of its availability despite electronic alerts accompanying prescriptions of gentamicin. CONCLUSIONS In comparison with the national guidelines, there was significant under-dosing and monitoring practices were haphazard. Computerised electronic alerts were ineffective in informing users. To improve prescribing practices, we recommend exploring alternative computerised decision support approaches (e.g. pre-written orders) and more pervasive and persuasive implementation strategies.
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Affiliation(s)
- N Diasinos
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia; Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
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Mustafa S, Pai RS, Singh G, Kusum Devi V. Nanocarrier-based interventions for the management of MDR/XDR-TB. J Drug Target 2015; 23:287-304. [PMID: 25766078 DOI: 10.3109/1061186x.2015.1009076] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Emergence of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB over the past decade presents an unprecedented public health challenge to which countries of concern are responding far too slowly. Global Tuberculosis Report 2014 marks the 20th anniversary of the Global Project on Anti-Tuberculosis Drug Resistance Surveillance, indicating the highest global level of drug-resistance ever recorded detection of 97 000 patients with MDR-TB resulting in 170 000 deaths in 2013. Treatment of MDR-TB is expensive, complex, prolonged (18-24 months) and associated with a higher incidence of adverse events. In this context, nanocarrier delivery systems (NDSs) efficiently encapsulating considerable amounts of second-line anti tubercular drugs ((s)ATDs), eliciting controlled, sustained and more profound effect to trounce the need to administer (s)ATDs at high and frequent doses, would assist in improving patient compliance and avoid hepatotoxicity and/or nephrotoxicity/ocular toxicity/ototoxicity associated with the prevalent (s)ATDs. Besides, NDSs are also known to inhibit the P-glycoprotein efflux, reduce metabolism by gut cytochrome P-450 enzymes and circumnavigate the hepatic first-pass effect, facilitating absorption of drugs via intestinal lymphatic pathways. This review first provides a holistic account on MDR-TB and discusses the molecular basis of Mycobacterium tuberculosis resistance to anti-tubercular drugs. It also provides an updated bird's eye view on current treatment strategies and laboratory diagnostic test for MDR-TB. Furthermore, a relatively pithy view on patent studies on second-line chemotherapy using NDSs will be discussed.
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Affiliation(s)
- Sanaul Mustafa
- Department of Pharmaceutics, Al-Ameen College of Pharmacy , Bangalore, Karnataka , India
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Chronopharmacokinetics of once daily dosed aminoglycosides in hospitalized infectious patients. Int J Clin Pharm 2015; 37:342-7. [PMID: 25616626 PMCID: PMC4375292 DOI: 10.1007/s11096-015-0066-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 01/07/2015] [Indexed: 01/05/2023]
Abstract
Background hospitalized patients with serious infections treated with aminoglycosides are at risk of developing nephrotoxicity. Previous clinical studies have shown that the pharmacokinetics of aminoglycosides in humans follow a circadian rhythm. Therefore, the time of administration could have important clinical implications with respect to the risk of developing aminoglycoside-associated nephrotoxicity in patients treated with once daily dosing regimens. Objective To examine the effect of the time period of administration on aminoglycoside exposure and the incidence of nephrotoxicity in a large population of hospitalized patients with serious infections. Setting General ward and intensive care unit of a teaching hospital. Method In this retrospective cohort study, patients treated with intravenous tobramycin or gentamicin were eligible for inclusion. Patients were divided into three groups by time of administration: morning, afternoon and night. Main outcome measure Pharmacokinetic parameters and the incidences of nephrotoxicity were compared between the morning, afternoon and evening groups. Results 310 general ward and 411 intensive care unit patients were included. No significant differences were found in patient characteristics between the morning, afternoon and night groups. The time period of administration did not affect aminoglycoside pharmacokinetics or the incidence of nephrotoxicity. Conclusion The time of administration has no effect on the pharmacokinetics or nephrotoxicity of once daily dosed aminoglycosides in hospitalized patients. Consequently, we advise aminoglycosides to be administered as soon as possible in case of (suspected) severe hospital-acquired infections and subsequent dosages to be based on therapeutic drug monitoring to optimize the efficacy/toxicity balance.
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Dose derivation of once-daily dosing guidelines for gentamicin in critically ill pediatric patients. Ther Drug Monit 2015; 36:288-94. [PMID: 24695354 DOI: 10.1097/ftd.0000000000000016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To determine dose and eligibility criteria for once-daily dosing (ODD) of gentamicin in critically ill pediatric patients. METHODS Retrospective chart review of patients admitted to the Pediatric Intensive Care Unit or Cardiac Critical Care Unit at The Hospital for Sick Children (SickKids) who received traditionally dosed intravenous (IV) gentamicin (January 2008 to June 2010). Statistically significant patient characteristics associated with gentamicin pharmacokinetic (PK) parameters were determined by multiple linear regression. Binary partitioning was used to set critical values for these characteristics to derive dose for ODD of gentamicin. Feasibility of implementing ODD of gentamicin in critically ill children was assessed using individualized PK parameters to simulate area under the concentration-time curves and drug-free intervals while targeting a maximum concentration (C(max)) of 16-20 mg/L. Eligibility criteria were determined by patient characteristics that had a statistically significant impact on gentamicin PK. RESULTS Volume of distribution (V(d)) and elimination rate constant (k(e)) were calculated for 140 patients. Weight and admission unit were significantly associated with weight-normalized V(d) (Vd/kg), whereas age and serum creatinine (SCr) were significantly associated with k(e). Weight <5 kg and SCr ≥20% over age-specific upper normal limit before gentamicin initiation were associated with prolonged gentamicin elimination. Gentamicin 6 mg/kg IV every 24 hours, the dose at which the highest percentage of patients achieved C(max), area under the curve, and drug-free interval within target ranges simultaneously, was selected as the proposed ODD regimen. CONCLUSIONS A regimen of gentamicin 6 mg/kg IV every 24 hours for Pediatric Intensive Care Unit/Cardiac Critical Care Unit patients at SickKids weighing ≥5 kg with SCr <20% above age-specific upper normal limit before initiation of gentamicin is proposed.
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Abstract
Aminoglycosides are among the oldest antibiotics available to treat serious infections caused by primarily, Gram-negative bacteria. The most commonly utilized parenteral agents in this class include gentamicin, tobramycin and amikacin. Aminoglycosides are concentration-dependent, bactericidal agents that undergo active transport into the cell where they inhibit protein synthesis on the 30S subunit of the bacterial ribosome. As the use of aminoglycosides became more widespread, the toxic effects of these agents, most notably ototoxicity and nephrotoxicity, became more apparent. When other, safer, antimicrobial agents became available, the use of aminoglycosides sharply declined. The development of multi-drug resistance among bacteria has now lead clinicians to reexamine the role of the aminoglycosides in the treatment of serious infections. This review will revisit the mechanism and risk factors for the development of aminoglycoside-induced nephrotoxicity, as well as strategies to prevent patients from developing nephrotoxicity.
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Affiliation(s)
- Kurt A Wargo
- Division of Internal Medicine, Auburn University Harrison School of Pharmacy, Huntsville, AL, USA
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Kitamura Y, Yoshida K, Kusama M, Sugiyama Y. A proposal of a pharmacokinetic/pharmacodynamic (PK/PD) index map for selecting an optimal PK/PD index from conventional indices (AUC/MIC, Cmax/MIC, and TAM) for antibiotics. Drug Metab Pharmacokinet 2014; 29:455-62. [PMID: 25008846 DOI: 10.2133/dmpk.dmpk-14-rg-013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A pharmacokinetic/pharmacodynamic (PK/PD) analysis is important in antibiotic chemotherapy. Basically, the in vivo efficacy of antibiotics that exert concentration-dependent effects can be predicted using conventional PK/PD indices such as the ratio of the area under the curve to the minimum inhibitory concentration (AUC/MIC) and/or the ratio of the maximum plasma concentration to MIC (Cmax/MIC), whereas that of antibiotics with time-dependent effects can be determined using the period of time for which the drug concentration exceeds the MIC (time above MIC [TAM]). However, an optimal PK/PD index remains to be established for some antibiotics. Thus, a PK/PD model which describes the PK profile and effect of an antibiotic was developed, and the results obtained from this model were interpreted to form a PK/PD index map to assess the optimal PK/PD index for the antibiotic. The findings from the map were generally consistent with clinical outcomes even for the antibiotics which proved to be exceptions to the conventional classification. For example, AUC/MIC was an optimal index for azithromycin despite its time-dependent bactericidal activity, and Cmax/MIC was a poor index for arbekacin despite its concentration-dependent profile. Thus, the map would be useful for selecting the appropriate PK/PD index for an antibiotic.
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Velissaris D, Karamouzos V, Marangos M, Pierrakos C, Karanikolas M. Pharmacokinetic changes and dosing modification of aminoglycosides in critically ill obese patients: a literature review. J Clin Med Res 2014; 6:227-33. [PMID: 24883145 PMCID: PMC4039091 DOI: 10.14740/jocmr1858w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2014] [Indexed: 01/21/2023] Open
Abstract
The objective of the paper is to review the literature and provide recommendations for use of aminoglycoside antibiotics in critically ill obese patients. Literature search in PubMed for all articles on the use of aminoglycosides in critically ill obese patients was conducted, and all articles related to pharmacokinetics in obesity were reviewed. Bibliographies of all searched manuscripts were also reviewed in an attempt to find additional references. Although aminoglycoside pharmacokinetics have been described in detail, data on aminoglycoside use and appropriate dose modification in critically ill obese patients are very limited. Knowledge on aminoglycoside pharmacokinetics and use in critically ill obese patients is incomplete. Pathophysiologic changes in obesity can result in sub- or supra-therapeutic aminoglycoside plasma concentrations, especially in the presence of sepsis. Rigorous clinical studies are needed to establish aminoglycoside dosing guidelines in critically ill obese patients with sepsis.
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Affiliation(s)
| | - Vasilios Karamouzos
- Internal Medicine Department, University Hospital of Patras, Rion 26500, Greece
| | - Markos Marangos
- Internal Medicine Department, University Hospital of Patras, Rion 26500, Greece
| | | | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Roberts JA, Abdul-Aziz MH, Lipman J, Mouton JW, Vinks AA, Felton TW, Hope WW, Farkas A, Neely MN, Schentag JJ, Drusano G, Frey OR, Theuretzbacher U, Kuti JL. Individualised antibiotic dosing for patients who are critically ill: challenges and potential solutions. THE LANCET. INFECTIOUS DISEASES 2014; 14:498-509. [PMID: 24768475 DOI: 10.1016/s1473-3099(14)70036-2] [Citation(s) in RCA: 659] [Impact Index Per Article: 65.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Infections in critically ill patients are associated with persistently poor clinical outcomes. These patients have severely altered and variable antibiotic pharmacokinetics and are infected by less susceptible pathogens. Antibiotic dosing that does not account for these features is likely to result in suboptimum outcomes. In this Review, we explore the challenges related to patients and pathogens that contribute to inadequate antibiotic dosing and discuss how to implement a process for individualised antibiotic therapy that increases the accuracy of dosing and optimises care for critically ill patients. To improve antibiotic dosing, any physiological changes in patients that could alter antibiotic concentrations should first be established; such changes include altered fluid status, changes in serum albumin concentrations and renal and hepatic function, and microvascular failure. Second, antibiotic susceptibility of pathogens should be confirmed with microbiological techniques. Data for bacterial susceptibility could then be combined with measured data for antibiotic concentrations (when available) in clinical dosing software, which uses pharmacokinetic/pharmacodynamic derived models from critically ill patients to predict accurately the dosing needs for individual patients. Individualisation of dosing could optimise antibiotic exposure and maximise effectiveness.
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Affiliation(s)
- Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
| | - Mohd H Abdul-Aziz
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Johan W Mouton
- Nijmegen Medical Centre, Radboud University, Nijmegen, Netherlands
| | - Alexander A Vinks
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | | | - William W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Andras Farkas
- Department of Pharmacy, Nyack Hospital, Nyack, NY, USA
| | - Michael N Neely
- Laboratory of Applied Pharmacokinetics, University of Southern California, Los Angeles, CA, USA
| | | | - George Drusano
- Institute for Therapeutic Innovation, College of Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Otto R Frey
- Department of Pharmacy, Heidenheim Hospital, Heidenheim, Germany
| | | | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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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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Millan X, Muggia V, Ostrowsky B. Antimicrobial agents, drug adverse reactions and interactions, and cancer. Cancer Treat Res 2014; 161:413-62. [PMID: 24706233 DOI: 10.1007/978-3-319-04220-6_14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The intent of this chapter is to review the types of adverse drug reactions and interactions associated with antimicrobial agents, specifically in the setting of patients with malignancies. The initial sections will discuss categorizing and describing the mechanisms of adverse reactions and interactions. The later sections include a detailed discussion about adverse reactions and drug interactions associated with commonly used antibacterial, antiviral, and antifungal agents in this subpopulation. Where relevant, the clinical use and indication for the drugs will be reviewed. The antibacterial section will specifically address the emergence of antimicrobial resistance and drugs of last resort (newer agents, such as linezolid and daptomycin and novel uses of older previously retired agents, such as polymyxin B). The antifungal section will address the ramification of pharmacokinetic interactions and the need to measure drug levels. The chapter is not meant to be exhaustive and as such will not extensively address all antimicrobials or all interactions for each of these agents.
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Affiliation(s)
- Ximena Millan
- Division of Infectious Diseases, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467-2790, USA
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Boyer A, Gruson D, Bouchet S, Clouzeau B, Hoang-Nam B, Vargas F, Gilles H, Molimard M, Rogues AM, Moore N. Aminoglycosides in Septic Shock. Drug Saf 2013; 36:217-30. [DOI: 10.1007/s40264-013-0031-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kellum JA, Lameire N. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:204. [PMID: 23394211 PMCID: PMC4057151 DOI: 10.1186/cc11454] [Citation(s) in RCA: 1514] [Impact Index Per Article: 137.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute kidney injury (AKI) is a common and serious problem affecting millions and causing death and disability for many. In 2012, Kidney Disease: Improving Global Outcomes completed the first ever, international, multidisciplinary, clinical practice guideline for AKI. The guideline is based on evidence review and appraisal, and covers AKI definition, risk assessment, evaluation, prevention, and treatment. In this review we summarize key aspects of the guideline including definition and staging of AKI, as well as evaluation and nondialytic management. Contrast-induced AKI and management of renal replacement therapy will be addressed in a separate review. Treatment recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and a detailed rationale for each recommendation is provided.
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Hanberger H, Edlund C, Furebring M, G Giske C, Melhus A, Nilsson LE, Petersson J, Sjölin J, Ternhag A, Werner M, Eliasson E. Rational use of aminoglycosides--review and recommendations by the Swedish Reference Group for Antibiotics (SRGA). ACTA ACUST UNITED AC 2012; 45:161-75. [PMID: 23270477 DOI: 10.3109/00365548.2012.747694] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The Swedish Reference Group for Antibiotics (SRGA) has carried out a risk-benefit analysis of aminoglycoside treatment based on clinical efficacy, antibacterial spectrum, and synergistic effect with beta-lactam antibiotics, endotoxin release, toxicity, and side effects. In addition, SRGA has considered optimal dosage schedules and advice on serum concentration monitoring, with respect to variability in volume of drug distribution and renal clearance. SRGA recommends that aminoglycoside therapy should be considered in the following situations: (1) progressive severe sepsis and septic shock, in combination with broad-spectrum beta-lactam antibiotics, (2) sepsis without shock, in combination with broad-spectrum beta-lactam antibiotics if the infection is suspected to be caused by multi-resistant Gram-negative pathogens, (3) pyelonephritis, in combination with a beta-lactam or quinolone until culture and susceptibility results are obtained, or as monotherapy if a serious allergy to beta-lactam or quinolone antibiotics exists, (4) serious infections caused by multi-resistant Gram-negative bacteria when other alternatives are lacking, and (5) endocarditis caused by difficult-to-treat pathogens when monotherapy with beta-lactam antibiotics is not sufficient. Amikacin is generally more active against extended-spectrum beta-lactamase (ESBL)-producing and quinolone-resistant Escherichia coli than other aminoglycosides, making it a better option in cases of suspected infection caused by multidrug-resistant Enterobacteriaceae. Based on their resistance data, local drug committees should decide on the choice of first-line aminoglycoside. Unfortunately, aminoglycoside use is rarely followed up with audiometry, and in Sweden we currently have no systematic surveillance of adverse events after aminoglycoside treatment. We recommend routine assessment of adverse effects, including hearing loss and impairment of renal function, if possible at the start and after treatment with aminoglycosides, and that these data should be included in hospital patient safety surveillance and national quality registries.
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Affiliation(s)
- Håkan Hanberger
- Department of Clinical and Experimental Medicine, Infectious Diseases, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
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Feldman L, Sherman RA, Weissgarten J. N-acetylcysteine use for amelioration of aminoglycoside-induced ototoxicity in dialysis patients. Semin Dial 2012; 25:491-4. [PMID: 22708712 DOI: 10.1111/j.1525-139x.2012.01090.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Use of aminoglycoside antibiotics is associated with significant ototoxicity, especially on patients with decreased renal function. The risk of aminoglycoside ototoxicity may approach 60%. Oxidative stress has been suggested as a general mechanism of aminoglycoside ototoxicity and is prevalent in dialysis population. N-acetylcysteine (NAC) is an effective antioxidant and has been safely used in dialysis patients. New experimental and clinical data, explored in this review, provide a good case to recommend NAC administration to all dialysis patients, receiving aminoglycosides.
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Turnidge JD, Waterston JA. Gentamicin and ototoxicity: why this drug is still in use. Med J Aust 2012; 196:665-6. [DOI: 10.5694/mja12.10733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- John D Turnidge
- Schools of Pathology, Paediatrics and Molecular and Biomedical Science, University of Adelaide, Adelaide, SA
| | - John A Waterston
- Neuroscience Department and Monash University Department of Medicine, Alfred Hospital, Melbourne, VIC
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Avent ML, Rogers BA, Cheng AC, Paterson DL. Current use of aminoglycosides: indications, pharmacokinetics and monitoring for toxicity. Intern Med J 2012; 41:441-9. [PMID: 21309997 DOI: 10.1111/j.1445-5994.2011.02452.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The new Australian Therapeutic Guidelines: Antibiotic, version 14 have revised the recommendations for the use and monitoring of aminoglycosides. The guidelines have clear distinctions between empirical and directed therapy as well as revised recommendations about the monitoring of aminoglycosides. This has led many clinicians to review their current practice with regard to the use of aminoglycosides. This review summarizes why aminoglycosides are still a valid treatment option and discusses the rationale for current dosing regimens in Gram-negative infections. In particular it focuses on the various methods for monitoring aminoglycosides that are currently being used. The aminoglycoside monitoring methods can be categorized into three groups: linear regression analysis (one compartment model), population methods and Bayesian estimation procedures. Although the population methods are easy to use and require minimal resources they can recommend clinically inappropriate doses as they have constant pharmacokinetic parameters and are not valid in special population groups, that is, renal impairment. The linear regression and Bayesian methods recommend more accurate dosage regimens; however, they require additional resources, such as information technology and healthcare personnel with background training in pharmacokinetics. The Bayesian methods offer additional advantages, such as calculation of doses based on a single serum concentration and optimization of the patient's previous pharmacokinetic data, in order to determine subsequent dosage regimens. We recommend the Bayesian estimation procedures be used, wherever feasible. However, they require the expertise of healthcare practitioners with a good understanding of pharmacokinetic principles, such as clinical pharmacists/clinical pharmacologists, in order to make appropriate recommendations.
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Affiliation(s)
- M L Avent
- The University of Queensland, UQ Centre for Clinical Research (UQCCR), Medication Services Queensland, Brisbane, Queensland, Australia.
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Rao SC, Srinivasjois R, Hagan R, Ahmed M. One dose per day compared to multiple doses per day of gentamicin for treatment of suspected or proven sepsis in neonates. Cochrane Database Syst Rev 2011:CD005091. [PMID: 22071818 DOI: 10.1002/14651858.cd005091.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Animal studies and trials in older children and adults suggest that a one dose per day regimen of gentamicin is superior to a multiple doses per day regimen. OBJECTIVES To compare the efficacy and safety of one dose per day compared to multiple doses per day of gentamicin in suspected or proven sepsis in neonates. SEARCH METHODS Eligible studies were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, April 2011), MEDLINE (1966 to April 2011), EMBASE 1980 to April 2011, and CINAHL (December 1982 to April 2011). Abstracts of the Society for Pediatric Research were searched from 1980 to 2010 inclusive. SELECTION CRITERIA All randomised or quasi randomised controlled trials comparing one dose per day ( 'once a day') compared to multiple doses per day ( 'multiple doses a day') of gentamicin to newborn infants < 28 days of life. DATA COLLECTION AND ANALYSIS Data collection and analysis was performed according to the standards of the Cochrane Neonatal Review Group. MAIN RESULTS Eleven studies were included (N = 574) and nineteen excluded. All infants in both 'once a day' as well as 'multiple doses a day' regimen showed adequate clearance of sepsis [typical RD 0.00 (95% CI - 0.19 to 0.19); 3 trials; N = 36]. For the other primary outcome measures relating to gentamicin pharmacokinetics 'once a day' dosing of gentamicin was superior. 'Once a day' gentamicin regimen was associated with less failures to attain peak level of at least 5 µg/ml [typical RR 0.22 (95% CI 0.11 to 0.47); 9 trials; N = 422] and less failures to achieve trough levels of < 2 µg/ml [typical RR 0.38 (95% CI 0.27 to 0.55); 11 trials N = 503] compared to 'multiple doses a day' regimen.Ototoxicity and nephrotoxicity were not noted with either of the treatment regimens. AUTHORS' CONCLUSIONS There is insufficient evidence from the currently available RCTs to conclude whether 'once a day' or 'multiple doses a day' regimen of gentamicin is superior in treating proven neonatal sepsis. However, data suggests that pharmacokinetic properties of 'once a day' gentamicin regimen are superior to 'multiple doses a day' regimen in that it achieves higher peak levels while avoiding toxic trough levels. There is no change in nephrotoxicity or auditory toxicity. Based on this assessment of pharmacokinetics, 'once a day regimen' may be superior in treating neonatal sepsis in neonates greater than 32 weeks gestation.
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Affiliation(s)
- Shripada C Rao
- Centre for Neonatal Research and Education, King Edward Memorial Hospital for Women and Princess Margaret Hospital for Children, Perth Western Australia, Australia.
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Avent ML, Teoh J, Lees J, Eckert KA, Kirkpatrick CM. Comparing 3 Methods of Monitoring Gentamicin Concentrations in Patients With Febrile Neutropenia. Ther Drug Monit 2011; 33:592-601. [DOI: 10.1097/ftd.0b013e31822c78e9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Once-daily gentamicin in infants and children: a prospective cohort study evaluating safety and the role of therapeutic drug monitoring in minimizing toxicity. Pediatr Infect Dis J 2011; 30:827-32. [PMID: 21577177 DOI: 10.1097/inf.0b013e31821e405d] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The clinical evidence base for ototoxicity and nephrotoxicity outcomes with once-daily dosing (ODD) of gentamicin in children is suboptimal. Therapeutic drug monitoring (TDM) in once-daily gentamicin regimens is variable and its role in predicting or preventing clinical toxicity is unclear. We aimed to assess the safety of ODD of gentamicin and the usefulness of TDM in a pediatric cohort. METHODS Children with suspected sepsis were prospectively enrolled to receive ODD of gentamicin at 7 mg/kg/day. Hearing and renal function were objectively assessed at baseline, during therapy, and after therapy. TDM was performed using an interval-adjusted graphical method (Hartford nomogram). RESULTS A total of 79 children (median age: 5.6 years; range: 1 month-16 years) received 106 episodes of therapy. In all, 61% of these episodes were for febrile neutropenia. Evaluation was complete in 88% for ototoxicity and 92% for nephrotoxicity. Two patients (1.88%, 95% confidence interval: 0.10%-7.13%) experienced permanent hearing loss. One patient (0.94%, 95% confidence interval: <0.10%-5.73%) experienced transient nephrotoxicity. No abnormal serum gentamicin values were detected, even in those experiencing toxicity. Children experiencing toxicity were undergoing treatment for malignancies and had received nephrotoxic or ototoxic medicines before gentamicin. CONCLUSIONS In this pediatric cohort receiving ODD of gentamicin, nephrotoxicity was uncommon and reversible, but irreversible ototoxicity occurred more frequently. TDM using a nomogram neither predicted nor prevented toxicity, which was only observed in those with risk factors.
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Buchholtz K, Larsen CT, Schaadt B, Hassager C, Bruun NE. Once versus twice daily gentamicin dosing for infective endocarditis: a randomized clinical trial. Cardiology 2011; 119:65-71. [PMID: 21846985 DOI: 10.1159/000329842] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 05/09/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this randomized study was to investigate the effects of once versus twice daily gentamicin dosing on renal function and measures of infectious disease in a population with infective endocarditis (IE). METHODS Seventy-one IE patients needing gentamicin treatment according to guidelines were randomized to either once (n = 37) or twice daily (n = 34) doses of gentamicin. Kidney function (glomerular filtration rate, GFR) was measured with an isotope method ((51)Cr-EDTA) at the beginning of treatment and at discharge. Treatment efficacy was assessed by C-reactive protein (CRP) time to half-life, mean CRP and leukocytes. RESULTS Baseline GFR was similar in the two groups. Both groups displayed a significant fall in GFR from admission to discharge. The mean decrease in GFR was as follows: with once daily gentamicin, 17.0% (95% confidence interval 7.5-26.5), and with twice daily gentamicin, 20.4% (95% confidence interval 12.0-28.8). However, there was no significant difference in the GFR decrease between the once and twice daily regimens (p = 0.573). No difference in infection parameters was demonstrated between the two dosing regimens. CONCLUSIONS A twice daily gentamicin dosing regimen is neither less nephrotoxic nor more efficient than a once daily regimen in the treatment of IE patients. When indicated, gentamicin may therefore also be administered as a single-dose regimen in the treatment of IE patients.
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Affiliation(s)
- Kristine Buchholtz
- Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark. krisbuch @ vip.cybercity.dk
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