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Tesfamariam NS, Aboelezz A, Mahmoud SH. The Impact of Augmented Renal Clearance on Vancomycin Pharmacokinetics and Pharmacodynamics in Critically Ill Patients. J Clin Med 2024; 13:2317. [PMID: 38673590 PMCID: PMC11051385 DOI: 10.3390/jcm13082317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/06/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Augmented renal clearance (ARC), defined as a creatinine clearance (CrCl) > 130 mL/min/1.73 m2, is observed in 30-65% of critically ill patients. When following standard dosage guidelines, patients with ARC often experience subtherapeutic vancomycin levels, resulting in treatment failure due to accelerated drug elimination. This review aims to explore ARC's impact on vancomycin pharmacokinetics and pharmacodynamics (PK/PD) indices in ARC patients, seeking to identify an accurate dose adjustment method for this patient population. In September 2023, a comprehensive literature search was conducted on the MEDLINE and EMBASE databases to include all available studies providing information on the impact of ARC on vancomycin therapy in critically ill adults. Articles that studied the pediatric population and those with insufficient PK data were excluded. A total of 21 articles met the inclusion criteria. The findings revealed a positive correlation between CrCl and vancomycin clearance, indicating low serum concentrations. Therefore, upward dosing adjustments are necessary to improve treatment success. Younger age consistently emerged as a major contributor to ARC and vancomycin PK/PD alterations. This study summarizes the PK/PD alterations, current dosage recommendations and proposes preliminary recommendations on possible dosing approaches to decrease the risk of subtherapeutic exposure in this patient population.
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Affiliation(s)
| | - Asma Aboelezz
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB T6G 2E1, Canada;
| | - Sherif Hanafy Mahmoud
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB T6G 2E1, Canada;
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2
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Viertel K, Feles E, Schulte M, Annecke T, Mattner F. Serum concentration of continuously administered vancomycin influences efficacy and safety in critically ill adults: a systematic review. Int J Antimicrob Agents 2023; 62:107005. [PMID: 37839714 DOI: 10.1016/j.ijantimicag.2023.107005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/12/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES Vancomycin is used to treat Gram-positive infections in critically ill adults. For vancomycin administered by continuous infusion (CI), various target ranges have been used, ranging from 15-20 mg/L to 30-40 mg/L. This systematic literature review was conducted to investigate the impact of steady-state serum concentration (Css) of CI on safety and efficacy of therapy in critically ill adults. METHODS Relevant literature was identified by searching two electronic databases (PubMed, Cochrane Library) and Google Scholar from inception until July 2023, focusing on studies reporting measured Css and treatment outcomes (e.g. mortality, nephrotoxicity) with CI. Due to study heterogeneity, a narrative synthesis of the evidence was performed. RESULTS Twenty-one publications were included with a total of 2949 patients. Mortality was higher (two studies, n = 388 patients) and clinical cure was lower (one study, n = 40 patients) with Css < 15 mg/L measured 24 h after initiation of CI (C24). An adequate loading dose appeared most important for maintaining higher C24. Generally, higher Css was associated with higher rates of acute kidney injury (AKI) (15 studies, n = 2331 patients). It was calculated that Css < 25 mg/L (versus ≥25 mg/L) was preferable for reducing nephrotoxicity (three studies, n = 515 patients). CONCLUSIONS Despite sparse data availability, the target range of 15-25 mg/L in CI may increase clinical cure and reduce mortality and AKI. In future research, vancomycin Css cohorts should be formed to allow evaluation of the impact of Css of CI on treatment outcomes.
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Affiliation(s)
- Katrin Viertel
- Central Pharmacy, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Institute of Hygiene, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Division of Hygiene and Environmental Medicine, Department of Human Medicine, Faculty of Health, Witten/Herdecke University, Witten, Alfred-Herrhausen-Straße 50, 58455 Witten, Germany.
| | - Elisabeth Feles
- Central Pharmacy, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Institute of Hygiene, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Division of Hygiene and Environmental Medicine, Department of Human Medicine, Faculty of Health, Witten/Herdecke University, Witten, Alfred-Herrhausen-Straße 50, 58455 Witten, Germany
| | - Melanie Schulte
- Central Pharmacy, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Thorsten Annecke
- Department of Anaesthesiology and Intensive Care Medicine, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Frauke Mattner
- Institute of Hygiene, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Division of Hygiene and Environmental Medicine, Department of Human Medicine, Faculty of Health, Witten/Herdecke University, Witten, Alfred-Herrhausen-Straße 50, 58455 Witten, Germany
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Monteiro E, Dias CC, Czosnyka M, Paiva JA, Dias C. Measured Creatinine Clearance: Still a Good Surrogate of Glomerular Filtration Rate in Neurocritically Ill Patients! Neurocrit Care 2023; 39:545-546. [PMID: 37634179 DOI: 10.1007/s12028-023-01805-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Elisabete Monteiro
- Department of Intensive Care Medicine, Centro Hospitalar e Universitário São João, Porto, Portugal.
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | - Cláudia Camila Dias
- Knowledge Management Unit and Department of Community Medicine, Information and Health Decision Sciences, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Porto, Portugal
- RISE Health Research Network: From the Lab to the Community, Porto, Portugal
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - José Artur Paiva
- Department of Intensive Care Medicine, Centro Hospitalar e Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Celeste Dias
- Department of Intensive Care Medicine, Centro Hospitalar e Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Williams P, Cotta MO, Abdul-Aziz MH, Wilks K, Farkas A, Roberts JA. In silico Evaluation of a Vancomycin Dosing Guideline Among Adults with Serious Infections. Ther Drug Monit 2023; 45:631-636. [PMID: 37199397 DOI: 10.1097/ftd.0000000000001102] [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: 11/21/2022] [Accepted: 03/14/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND This study aimed to compare the achievement of pharmacokinetic-pharmacodynamic (PK-PD) exposure targets for vancomycin using a newly developed dosing guideline with product-information-based dosing in the treatment of adult patients with serious infections. METHODS In silico product-information- and guideline-based dosing simulations for vancomycin were performed across a range of doses and patient characteristics, including body weight, age, and renal function at 36-48 and 96 hours, using a pharmacokinetic model derived from a seriously ill patient population. The median simulated concentration and area under the 24-hour concentration-time curve (AUC 0-24 ) were used to measure predefined therapeutic, subtherapeutic, and toxicity PK-PD targets. RESULTS Ninety-six dosing simulations were performed. The pooled median trough concentration target with guideline-based dosing at 36 and 96 hours was achieved in 27.1% (13/48) and 8.3% (7/48) of simulations, respectively. The pooled median AUC 0-24 /minimum inhibitory concentration ratio with guideline-based dosing at 48 and 96 hours was attained in 39.6% (19/48) and 27.1% (13/48) of simulations, respectively. Guideline-based dosing simulations yielded improved trough target attainment compared with product-information-based dosing at 36 hours and significantly less subtherapeutic drug exposure. The toxicity threshold was exceeded in 52.1% (25/48) and 0% (0/48) for guideline- and product-information-information-based dosing, respectively ( P < 0.001). CONCLUSIONS A Critical care vancomycin dosing guideline appeared slightly more effective than standard dosing, as per product information, in achieving PK-PD exposure associated with an increased likelihood of effectiveness. In addition, this guideline significantly reduced the risk of subtherapeutic exposure. The risk of exceeding toxicity thresholds, however, was greater with the guideline, and further investigation is suggested to improve dosing accuracy and sensitivity.
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Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Kathryn Wilks
- Infectious Diseases Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Andras Farkas
- Department of Pharmacy, Mount Sinai West, New York, New York
- Optimum Dosing Strategies, Bloomingdale, New Jersey
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
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Coste A, Bellouard R, Deslandes G, Jalin L, Roger C, Ansart S, Dailly E, Bretonnière C, Grégoire M. Development of a Predictive Dosing Nomogram to Achieve PK/PD Targets of Amikacin Initial Dose in Critically Ill Patients: A Non-Parametric Approach. Antibiotics (Basel) 2023; 12:antibiotics12010123. [PMID: 36671324 PMCID: PMC9854650 DOI: 10.3390/antibiotics12010123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/30/2022] [Accepted: 01/04/2023] [Indexed: 01/10/2023] Open
Abstract
French guidelines recommend reaching an amikacin concentration of ≥8 × MIC 1 h after beginning infusion (C1h), with MIC = 8 mg/L for probabilistic therapy. We aimed to elaborate a nomogram guiding clinicians in choosing the right first amikacin dose for ICU patients in septic shock. A total of 138 patients with 407 observations were prospectively recruited. A population pharmacokinetic model was built using a non-parametric, non-linear mixed-effects approach. The total body weight (TBW) influenced the central compartment volume, and the glomerular filtration rate (according to the CKD-EPI formula) influenced its clearance. A dosing nomogram was produced using Monte Carlo simulations of the amikacin amount needed to achieve a C1h ≥ 8 × MIC. The dosing nomogram recommended amikacin doses from 1700 mg to 4200 mg and from 28 mg/kg to 49 mg/kg depending on the patient's TBW and renal clearance. However, a Cthrough ≤ 2.5 mg/L 24 h and 48 h after an optimal dose of amikacin was obtained with probabilities of 0.20 and 0.81, respectively. Doses ≥ 30 mg/kg are required to achieve a C1h ≥ 8 × MIC with MIC = 8 mg/L. Targeting a MIC = 8 mg/L should depend on local ecology.
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Affiliation(s)
- Anne Coste
- Service de Maladies Infectieuses et Tropicales, CHU de Brest, 29200 Brest, France
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Laboratoire de Traitement de l’Information Médicale, INSERM, UMR1101, Brest Université, 29200 Brest, France
- Correspondence:
| | - Ronan Bellouard
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Service de Pharmacologie Clinique, CHU Nantes, 44000 Nantes, France
| | | | - Laurence Jalin
- Unité de Neuro-Anesthésie-Réanimation, Groupe Hospitalier Pitié-Salpétrière, AP-HP, 75013 Paris, France
| | - Claire Roger
- Département d’anesthésie et réanimation, douleur et médecine d’urgence, CHU Carémeau, 30029 Nîmes, France
- UR UM 103 IMAGINE, Faculté de Médecine, Montpellier Université, 30029 Nîmes, France
| | - Séverine Ansart
- Service de Maladies Infectieuses et Tropicales, CHU de Brest, 29200 Brest, France
- Laboratoire de Traitement de l’Information Médicale, INSERM, UMR1101, Brest Université, 29200 Brest, France
| | - Eric Dailly
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Service de Pharmacologie Clinique, CHU Nantes, 44000 Nantes, France
| | - Cédric Bretonnière
- Service des Soins Intensifs de Pneumologie, CHU Nantes, 44000 Nantes, France
| | - Matthieu Grégoire
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Service de Pharmacologie Clinique, CHU Nantes, 44000 Nantes, France
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Critically Ill Patients with Renal Hyperfiltration: Optimizing Antibiotic Dose. Int J Nephrol 2023; 2023:6059079. [PMID: 36896122 PMCID: PMC9991472 DOI: 10.1155/2023/6059079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/09/2022] [Accepted: 02/18/2023] [Indexed: 03/06/2023] Open
Abstract
Renal hyperfiltration (RHF) is a prevalent phenomenon in critically ill patients characterized by augmented renal clearance (ARC) and increased of elimination of renally eliminated medications. Multiple risk factors had been described and potential mechanisms may contribute to the occurrence of this condition. RHF and ARC are associated with the risk of suboptimal exposure to antibiotics increasing the risk of treatment failure and unfavorable patient outcomes. The current review discusses the available evidence related to the RHF phenomenon, including definition, epidemiology, risk factors, pathophysiology, pharmacokinetic variability, and considerations for optimizing the dosage of antibiotics in critically ill patients.
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Bing E, Archambault K, Sananikone A, Nguyen KD, Fang YT, Jabamikos C, Gras C, Marsot A, Duceppe MA, Perreault MM. Risk factors associated with augmented renal clearance in a mixed intensive care unit population: a retrospective study. Int J Clin Pharm 2022; 44:1277-1286. [PMID: 35834093 DOI: 10.1007/s11096-022-01458-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Augmented renal clearance is increasingly recognized in critically ill patients. This condition may lead to suboptimal dosing of renally excreted medications. AIM Our primary objective was to identify demographic and clinical factors associated with augmented renal clearance in a mixed critically ill population. METHOD This retrospective single center observational cohort study evaluated patients admitted in a mixed adult intensive care unit for augmented renal clearance, defined as a creatinine clearance of ≥ 130 ml/min/1.73m2, through weekly 24-h urine collection. Variables associated with augmented renal clearance were identified using univariate analysis, then served as covariates in a backward stepwise logistic regression. Goodness-of-fit of the model was assessed and receiver operating characteristic curve was generated. RESULTS Augmented renal clearance was observed in 25.3% of the study cohort (n = 324). Age below 50 years (adjusted odds ratio 7.32; 95% CI 4.03-13.29, p < 0.001), lower serum creatinine at intensive care admission (adjusted odds ratio 0.97; 95% CI 0.96-0.99, p < 0.001) and trauma admission (adjusted odds ratio 2.26; 95% CI 1.12-4.54, p = 0.022) were identified as independent risk factors. Our model showed acceptable discrimination in predicting augmented renal clearance (Area under receiver operating characteristic curve (0.810; 95% CI 0.756-0.864, p < 0.001)). CONCLUSION We identified age below 50 years, lower serum creatinine upon intensive care admission and trauma as independent risk factors for augmented renal clearance, consistent with the literature suggesting that patients with low serum creatinine upon admission could have a higher risk of developing augmented renal clearance.
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Affiliation(s)
- Emily Bing
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Kym Archambault
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Alice Sananikone
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Kim-Dan Nguyen
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Yi Tong Fang
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Caren Jabamikos
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Cécile Gras
- Département de Pharmacie, Centre Hospitalier de Montpellier, 91 av. du Doyen Giraud, 34295, Montpellier cedex 5, France
| | - Amélie Marsot
- Faculté de Pharmacie de L'Université de Montréal, Pavillon Jean-Coutu 2940, Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Marc-Alexandre Duceppe
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Marc M Perreault
- Faculté de Pharmacie de L'Université de Montréal, Pavillon Jean-Coutu 2940, Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada. .,Department of Pharmacy, McGill University Health Center, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
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8
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Hefny F, Sambhi S, Morris C, Kung JY, Stuart A, Mahmoud SH. Drug Dosing in Critically Ill Adult Patients with Augmented Renal Clearance. Eur J Drug Metab Pharmacokinet 2022; 47:607-620. [PMID: 35763238 DOI: 10.1007/s13318-022-00779-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/03/2022]
Abstract
Augmented renal clearance (ARC) is a phenomenon of enhanced renal function seen in critically ill patients. ARC alters the disposition of renally eliminated medications currently used in the intensive care unit, resulting in underdosing and potential therapy failure. Our review addresses the rising concern of inadequate dosing in patients with ARC by summarizing the currently available evidence. To our knowledge, this guide is the first to provide clinicians with dose recommendation insights for renally eliminated agents in adult critically ill patients with ARC. A comprehensive literature search using MEDLINE, Embase, Cochrane Library, CINAHL, Scopus, and ProQuest Dissertations and Theses Global was conducted until 3 November 2021. Screening and data extraction were conducted in two steps: title and abstract screening followed by full-text review. Full text review resulted in a total of 51 studies included in this review. The results demonstrated the need for higher-than-standard doses for meropenem, imipenem, and vancomycin and reduced dosing intervals for ceftriaxone in patients with ARC. The potential need for increased dosing frequency in patients with ARC was also found for both enoxaparin and levetiracetam. In conclusion, ARC has been shown to influence the probability of target attainment in several medications requiring dosing changes to mitigate the risk of therapeutic failure.
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Affiliation(s)
- Fatma Hefny
- Katz Group Centre for Pharmacy and Health Research, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-142H, Edmonton, AB, T6G 2E1, Canada
| | - Sukhvir Sambhi
- Katz Group Centre for Pharmacy and Health Research, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-142H, Edmonton, AB, T6G 2E1, Canada
| | - Cassidy Morris
- Katz Group Centre for Pharmacy and Health Research, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-142H, Edmonton, AB, T6G 2E1, Canada
| | - Janice Y Kung
- Public Services Librarian, John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Anna Stuart
- Katz Group Centre for Pharmacy and Health Research, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-142H, Edmonton, AB, T6G 2E1, Canada
| | - Sherif Hanafy Mahmoud
- Katz Group Centre for Pharmacy and Health Research, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-142H, Edmonton, AB, T6G 2E1, Canada.
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9
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Jabamikos C, Fang YT, Nguyen KD, Sananikone A, Archambault K, Bing E, Chagnon M, Husainalamoodi O, Marsot A, Duceppe MA, Perreault MM. Validation of the Augmented Renal Clearance in Trauma Intensive Care scoring system for augmented renal clearance prediction in a trauma subgroup of a mixed ICU population. J Clin Pharm Ther 2022; 47:1517-1524. [PMID: 35633117 DOI: 10.1111/jcpt.13695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/24/2022] [Accepted: 05/04/2022] [Indexed: 01/25/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Augmented renal clearance is prevalent in trauma patients and leads to subtherapeutic levels of renally eliminated medications with potentially unfavourable clinical outcomes. The Augmented Renal Clearance of Trauma in Intensive Care (ARCTIC) score has been developed to predict augmented renal clearance in critically ill trauma patients. Our primary objective was to validate this score among the trauma subgroup of a mixed intensive care patient cohort. METHODS This single-centre, retrospective, observational cohort study assessed augmented renal clearance using a timed 24-h urine collection performed weekly. ARC was defined as a measured creatinine clearance of ≥130 ml/min/1.73 m2 . ARCTIC score performance was evaluated through a receiver operator characteristic curves and analysis of sensitivities and specificities for the trauma subgroup, the medical/surgical subgroup and the pooled cohort. RESULTS AND DISCUSSION Augmented renal clearance was observed in 33.9% (n = 58) of trauma patients (n = 171) and 15.7% (n = 24) of medical/surgical patients (n = 153). Examination of different cutoffs for the ARCTIC score in our trauma population confirmed that the optimal cutoff score was ≥6. Comparison between ROC curves for ARCTIC score and for regression model based upon our data in trauma patients indicated validation of the score in this subgroup. Comparison of sensitivities and specificities for ARCTIC score between trauma (93.1% and 41.6%, respectively) and medical/surgical subjects (87.5% and 49.6%, respectively) showed no clinical nor statistical difference, suggesting validation for the medical/surgical subgroup as well. WHAT IS NEW AND CONCLUSION In our mixed ICU population, the ARCTIC score was validated in the trauma subgroup. We also found that the score performed well in the medical/surgical population. Future studies should assess the performance of the ARCTIC score prospectively.
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Affiliation(s)
- Caren Jabamikos
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Yi Tong Fang
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Kim-Dan Nguyen
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Alice Sananikone
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Kym Archambault
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Emily Bing
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, University of Montreal, Montreal, Quebec, Canada
| | - Omar Husainalamoodi
- Department of Critical Care, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada
| | - Amélie Marsot
- Faculté de pharmacie de l'Université de Montréal, Montreal, Quebec, Canada
| | - Marc-Alexandre Duceppe
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Marc M Perreault
- Faculté de pharmacie de l'Université de Montréal, Montreal, Quebec, Canada.,Department of Pharmacy, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada
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Xiao Q, Zhang H, Wu X, Qu J, Qin L, Wang C. Augmented Renal Clearance in Severe Infections-An Important Consideration in Vancomycin Dosing: A Narrative Review. Front Pharmacol 2022; 13:835557. [PMID: 35387348 PMCID: PMC8979486 DOI: 10.3389/fphar.2022.835557] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/25/2022] [Indexed: 12/15/2022] Open
Abstract
Vancomycin is a hydrophilic antibiotic widely used in severe infections, including bacteremia and central nervous system (CNS) infections caused by Gram-positive bacteria such as methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative staphylococci and enterococci. Appropriate antimicrobial dosage regimens can help achieve the target exposure and improve clinical outcomes. However, vancomycin exposure in serum and cerebrospinal fluid (CSF) is challenging to predict due to rapidly changing pathophysiological processes and patient-specific factors. Vancomycin concentrations may be decreased for peripheral infections due to augmented renal clearance (ARC) and increased distribution caused by systemic inflammatory response syndrome (SIRS), increased capillary permeability, and aggressive fluid resuscitation. Additionally, few studies on vancomycin’s pharmacokinetics (PK) in CSF for CNS infections. The relationship between exposure and clinical response is unclear, challenging for adequate antimicrobial therapy. Accurate prediction of vancomycin pharmacokinetics/pharmacodynamics (PK/PD) in patients with high interindividual variation is critical to increase the likelihood of achieving therapeutic targets. In this review, we describe the interaction between ARC and vancomycin PK/PD, patient-specific factors that influence the achievement of target exposure, and recent advances in optimizing vancomycin dosing schedules for severe infective patients with ARC.
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Affiliation(s)
- Qile Xiao
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Hainan Zhang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiaomei Wu
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Jian Qu
- Department of Pharmacy, Second Xiangya Hospital, Central South University, Changsha, China
| | - Lixia Qin
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Chunyu Wang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
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Yu YX, Lu J, Lu HD, Li L, Li JJ, Shi L, duan LF, Zhuang ZW, Xue SD, Shen Y, Tang L. Predictive performance of reported vancomycin population pharmacokinetic model in patients with different renal function status, especially those with augmented renal clearance. Eur J Hosp Pharm 2022; 29:e6-e14. [PMID: 33414258 PMCID: PMC8899683 DOI: 10.1136/ejhpharm-2020-002477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/30/2020] [Accepted: 12/08/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND There is a significant correlation between augmented renal clearance (ARC) and lower serum trough concentrations of vancomycin (VCM) during therapy. There is a need to evaluate the predictive performance of the population pharmacokinetic (PPK) model used for individual calculation of dosage regimens in ARC patients. OBJECTIVE Our study aimed to estimate the predictive performance differences of the reported VCM PPK software JPKD-vancomycin and SmartDose in patients with varying renal function status, especially those with ARC. METHODS Patients receiving VCM treatment from May 2014 to December 2019 were enrolled, and divided into the ARC group, the normal renal function (NRF) group, and the impaired renal function (IRF) group. VCM dosage, trough concentration, area under the curve (AUC) and pharmacokinetic parameters were compared among the three groups. The predictive performance of PPK software was expressed using absolute prediction error (APE), sensitivity, specificity, and regression coefficient (r2) of linear regression analysis between the measured VCM trough concentration and the predicted trough concentration. RESULTS A total of 388 patients were included: 86 patients in the ARC group, 241 patients in the NRF group, and 61 patients in the IRF group. The daily dose of the adjusted regimen in the ARC group was higher than in the NRF group, but the trough concentration was significantly lower than in the NRF group (2.8±0.6 g vs 1.9±0.6 g, p<0.001; 10.5±5.1 mg/L vs 12.9±6.8 mg/L, p=0.030). The percentage of trough concentrations lower than 10 mg/L was 84.9% in the ARC group. Compared with the APE of the initial dosage regimen, the APE of the adjusted regimen calculated by JPKD was lower in the ARC group (p=0.041) and the NRF group (p<0.001). Specificity of JPKD and SmartDose in the ARC group was higher than in the NRF group (p<0.001; p<0.001). According to the linear regression analysis, the coefficients of determination (r2) were all >0.6 for the initial regimen and adjusted regimen of VCM in the ARC and NRF groups, and the r2 of the adjusted regimen of JPKD was >0.8 in the ARC and NRF groups. In the IRF group, 31.1% of patients had a change in serum creatinine (Scr) level of >50%. The r2 increased from 0.527 to 0.7347 in SmartDose and from 0.55 to 0.7802 in JPKD when using Scr at the sampling time. The ARC group showed a significant decrease in AUC (p<0.001) and an increase in clearance rate (p<0.001) when compared to the NRF group. CONCLUSION ARC was significantly associated with subtherapeutic serum VCM concentration. The pharmacokinetic parameters of VCM were diverse in patients with different renal function status. The PPK model JPKD and SmartDose had a good predictive performance for predicting VCM trough concentrations of the ARC and NRF patients, especially using JPKD for prediction of the adjusted regimen. The change of Scr is a main factor affecting the accuracy of software prediction.
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Affiliation(s)
- Yan-xia Yu
- GCP office, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Jian Lu
- Intensive Care Unit, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Hao-di Lu
- Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Lan Li
- Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Jing-jing Li
- Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Lu Shi
- Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Lu-fen duan
- Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Zhi-wei Zhuang
- Emergency intensive care unit, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Su-dong Xue
- Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Yi Shen
- Intensive Care Unit, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Lian Tang
- Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
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12
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Silva CM, Baptista JP, Santos I, Martins P. Recommended Antibiotic Dosage Regimens in Critically Ill Patients with Augmented Renal Clearance: A Systematic Review. Int J Antimicrob Agents 2022; 59:106569. [DOI: 10.1016/j.ijantimicag.2022.106569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 02/15/2022] [Accepted: 03/06/2022] [Indexed: 12/17/2022]
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13
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Prevalence and Risk Factors of Augmented Renal Clearance: A Systematic Review and Meta-Analysis. Pharmaceutics 2022; 14:pharmaceutics14020445. [PMID: 35214177 PMCID: PMC8878755 DOI: 10.3390/pharmaceutics14020445] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 02/04/2023] Open
Abstract
Kidney function assessment in the critically ill overlooks the possibility for hyperfunctioning kidneys, known as augmented renal clearance (ARC), which could contribute to therapeutic failures in the intensive care unit (ICU). The aim of this research is to conduct a systematic review and meta-analysis of prevalence and risk factors of ARC in the critically ill. MEDLINE, Embase, Cochrane Library, CINAHL, Scopus, ProQuest Dissertations and Theses Global databases were searched on 27 October 2020. We included studies conducted in critically ill adults who reported the prevalence and/or risk factors of ARC. We evaluated study quality using the Joanna Briggs Institute appraisal tool. Case reports, reviews, editorials and commentaries were excluded. We generated a random-effects meta-analytic model using the inverse variance method and visualized the pooled estimates using forest plots. Seventy studies were included. The pooled prevalence (95% CI) was 39% (34.9–43.3). Prevalence for neuro, trauma, mixed and sepsis ICUs were 74 (55–87), 58 (48–67), 36 (31–41) and 33 (21–48), respectively. Age, male sex and trauma were associated with ARC with pooled OR (95% CI) of 0.95 (0.93–0.96), 2.36 (1.28–4.36), 2.60 (1.21–5.58), respectively. Limitations included variations in ARC definition, inclusion and exclusion criteria and studies design. In conclusion, ARC is prevalent in critically ill patients, especially those in the neurocritical care and trauma ICU population. Young age, male sex and trauma are risk factors for ARC in those with apparently normal renal function. Further research on optimal dosing of drugs in the setting of ARC is warranted. (Prospero registration: CRD42021246417).
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14
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Sistanizad M, Hassanpour R, Pourheidar E. Are Antibiotics Appropriately Dosed in Critically Ill Patients with Augmented Renal Clearance? A Narrative Review. Int J Clin Pract 2022; 2022:1867674. [PMID: 35685541 PMCID: PMC9159163 DOI: 10.1155/2022/1867674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/17/2021] [Accepted: 12/03/2021] [Indexed: 11/18/2022] Open
Abstract
AIMS Augmented renal clearance (ARC), which is commonly defined as increased renal clearance above 130 ml/min/1.73 m2, is a common phenomenon among critically ill patients. The increased elimination rate of drugs through the kidneys in patients with ARC can increase the risk of treatment failure due to the exposure to subtherapeutic serum concentrations of medications and affect the optimal management of infections, length of hospital stay, and outcomes. The main goal of this review article is to summarize the recommendations for appropriate dosing of antibiotics in patients with ARC. METHODS This article is a narrative review of the articles that evaluated different dosing regimens of antibiotics in patients with ARC. The keywords "Augmented Renal Clearance," "Critically ill patients," "Drug dosing," "Serum concentration," "Beta-lactams," "Meropenem," "Imipenem," "Glycopeptide," "Vancomycin," "Teicoplanin," "Linezolid," "Colistin," "Aminoglycosides," "Amikacin," "Gentamycin," "Fluoroquinolones," "Ciprofloxacin," and "Levofloxacin" were searched in Scopus, Medline, PubMed, and Google Scholar databases, and pediatric, nonhuman, and non-English studies were excluded. RESULTS PK properties of antibiotics including lipophilicity or hydrophilicity, protein binding, the volume of distribution, and elimination rate that affect drug concentration should be considered along with PD parameters for drug dosing in critically ill patients with ARC. CONCLUSION This review recommends a dosing protocol for some antibiotics to help the appropriate dosing of antibiotics in ARC and decrease the risk of subtherapeutic exposure that may be observed while receiving conventional dosing regimens in critically ill patients with ARC.
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Affiliation(s)
- Mohammad Sistanizad
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rezvan Hassanpour
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elham Pourheidar
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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15
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Avedissian SN, Rhodes NJ, Kim Y, Bradley J, Valdez JL, Le J. Augmented renal clearance of aminoglycosides using population-based pharmacokinetic modelling with Bayesian estimation in the paediatric ICU. J Antimicrob Chemother 2021; 75:162-169. [PMID: 31648297 DOI: 10.1093/jac/dkz408] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/21/2019] [Accepted: 08/24/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate augmented renal clearance (ARC) using aminoglycoside clearance (CLAMINO24h) derived from pharmacokinetic (PK) modelling. METHODS A retrospective study at two paediatric hospitals of patients who received tobramycin or gentamicin from 1999 to 2016 was conducted. Compartmental PK models were constructed using the Pmetrics package, and Bayesian posteriors were used to estimate CLAMINO24h. ARC was defined as a CLAMINO24h of ≥130 mL/min/1.73 m2. Risk factors for ARC were identified using multivariate logistic regression. RESULTS The final population model was fitted to 275 aminoglycoside serum concentrations. Overall clearance (L/h) was=CL0×(TBW/70)0.75×AGEH/(TMH + AGEH) + CL1 (0.5/SCr), where TBW is total body weight, H is the Hill coefficient, TM is a maturation term and SCr is serum creatinine. Median CLAMINO24h in those with versus without ARC was 157.36 and 93.42 mL/min/1.73 m2, respectively (P<0.001). ARC was identified in 19.5% of 118 patients. For patients with ARC, median baseline SCr was lower than for those without ARC (0.38 versus 0.41 mg/dL, P=0.073). Risk factors for ARC included sepsis [adjusted OR (aOR) 3.77, 95% CI 1.01-14.07, P=0.048], increasing age (aOR 1.11, 95% CI 1-1.23, P=0.04) and low log-transformed SCr (aOR 0.16, 95% CI 0.05-0.52, P=0.002). Median 24 h AUC (AUC24h) was significantly lower in patients with ARC at 45.27 versus 56.95 mg·h/L, P<0.01. CONCLUSIONS ARC was observed in one of every five patients. Sepsis, increasing age and low SCr were associated with ARC. Increased clearance was associated with an attenuation of AUC24h in this population. Future studies are needed to define optimal dosing in paediatric patients with ARC.
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Affiliation(s)
- Sean N Avedissian
- Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA.,Midwestern University Chicago College of Pharmacy Center of Pharmacometric Excellence, Midwestern University, Downers Grove, IL, USA.,Antiviral Pharmacology Laboratory, University of Nebraska Medical Center (UNMC) Center for Drug Discovery, UNMC, Omaha, NE, USA.,University of Nebraska Medical Center, College of Pharmacy, Omaha, NE, USA
| | - Nathaniel J Rhodes
- Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA.,Midwestern University Chicago College of Pharmacy Center of Pharmacometric Excellence, Midwestern University, Downers Grove, IL, USA
| | - Yuna Kim
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA
| | - John Bradley
- Division of Infectious Diseases, University of California San Diego School of Medicine and Rady Children's Hospital San Diego, CA, USA
| | - Joshua L Valdez
- Kaiser Permanente San Diego Medical Center, San Diego, CA, USA
| | - Jennifer Le
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA.,Miller Children's and Women's Hospital of Long Beach, Long Beach, CA, USA
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16
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Huang X, Yu Z, Wei X, Shi J, Wang Y, Wang Z, Chen J, Bu S, Li L, Gao F, Zhang J, Xu A. Prediction of vancomycin dose on high-dimensional data using machine learning techniques. Expert Rev Clin Pharmacol 2021; 14:761-771. [PMID: 33835879 DOI: 10.1080/17512433.2021.1911642] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Despite therapeutic vancomycin is regularly monitored, its dose requirements vary considerably between individuals. Various innovative vancomycin dosing strategies have been developed for dose optimization; however, the utilization of individual factors and extensibility is insufficient. We aimed to develop an optimal dosing algorithm for vancomycin based on the high-dimensional data using the proposed variable engineering and machine-learning methods. METHODS This study proposed a variable engineering process that automatically generates second-order variable interactions. We performed an initial examination of independent variables and interactive variables using eXtreme Gradient Boosting. The vancomycin dose prediction model was established based on the derived variables. RESULTS Based on the evaluation of the model performance in the validation cohort, our algorithm accounted for 67.5% of variations in the vancomycin doses. Subgroup analysis showed better performance in patients with medium and high body weight (with the ideal predictive percentage of 72.7% and 73.7%), and low and medium levels of serum creatinine (with the ideal predictive percentage of 77.8% and 73.1%) than in other groups. CONCLUSION The new vancomycin dose prediction model is potentially useful for patients whose population profiles are similar to those of our patients and yielded desired reference of clinical indicators with specific breakpoints.
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Affiliation(s)
- Xiaohui Huang
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ze Yu
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Xin Wei
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Junfeng Shi
- Department of Nephrology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yu Wang
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Zeyuan Wang
- Beijing Medicinovo Technology Co. Ltd., Beijing, China.,School of Computer Science, The University of Sydney, Sydney, Australia
| | - Jihui Chen
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shuhong Bu
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lixia Li
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fei Gao
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Jian Zhang
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ajing Xu
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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17
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Tomasa-Irriguible TM, Sabater-Riera J, Pérez-Carrasco M, Ortiz-Ballujera P, Díaz-Buendía Y, Navas-Pérez A, Betbesé-Roig A, Rodríguez-López M, Ibarz-Vilamayor M, Olmo-Isasmendi A, Oliva-Zelaya I, Rovira-Anglès C, Cano-Hernández S, Vendrell-Torra E, Catalan-Ibars RM, Miralbés-Torner M, González de Molina J, Xirgu-Cortacans J, Marcos-Neira P. Augmented renal clearance. An unnoticed relevant event. Sci Prog 2021; 104:368504211018580. [PMID: 34078190 PMCID: PMC10359677 DOI: 10.1177/00368504211018580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Augmented renal clearance (ARC) is a phenomenon that can lead to a therapeutic failure of those drugs of renal clearance. The purpose of the study was to ascertain the prevalence of ARC in the critically ill patient, to study the glomerular filtration rate (GFR) throughout the follow-up and analyze the concordance between the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimation formula and measured GFR. Observational, prospective, multicenter study. ARC was defined as a creatinine clearance greater than 130 ml/min/1.73 m2. Eighteen hospitals were recruited. GFR measurements carried out twice weekly during a 2-month follow-up period. A total of 561 patients were included. ARC was found to have a non-negligible prevalence of 30%. More even, up to 10.7% already had ARC at intensive care unit (ICU) admission. No specific pattern of GFR was found during the follow-up. Patients in the ARC group were younger 56.5 (53.5-58.5) versus 66 (63.5-68.5) years than in the non-ARC group, p < 0.001. ICU mortality was lower in the ARC group, 6.9% versus 14.5%, p = 0.003. There was no concordance between the estimation of GFR by the CKD-EPI formula and GFR calculated from the 4-h urine. ARC is found in up to 30% of ICU patients, so renal removal drugs could be under dosed by up to 30%. And ARC is already detected on admission in 10%. It is a dynamic phenomenon without an established pattern that usually occurs in younger patients that can last for several weeks. And the CKD-EPI formula does not work to estimate the real creatinine clearance of these patients.
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Affiliation(s)
| | | | | | | | | | - Ana Navas-Pérez
- Intensive Care Department, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | | | | | | | - Aitor Olmo-Isasmendi
- Intensive Care Department, General de Catalunya Hospital, Sant Cugat del Vallès, Spain
| | | | | | - Silvia Cano-Hernández
- Intensive Care Department, Fundació Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | | | | | | | | | | | - Pilar Marcos-Neira
- Intensive Care Department, Germans Trias i Pujol Hospital, Barcelona, Spain
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18
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Shahrami B, Najmeddin F, Ghaffari S, Najafi A, Rouini MR, Mojtahedzadeh M. Area under the Curve-Based Dosing of Vancomycin in Critically Ill Patients Using 6-Hour Urine Creatinine Clearance Measurement. Crit Care Res Pract 2020; 2020:8831138. [PMID: 33425384 PMCID: PMC7775160 DOI: 10.1155/2020/8831138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/27/2020] [Accepted: 12/16/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The area under the curve- (AUC-) guided vancomycin dosing is the best strategy for individualized therapy in critical illnesses. Since AUC can be calculated directly using drug clearance (CLvan), any parameter estimating CLvan will be able to achieve the goal of 24-hour AUC (AUC24 h). The present study was aimed to determine CLvan based on 6-hour urine creatinine clearance measurement in critically ill patients with normal renal function. METHOD 23 adult critically ill patients with an estimated glomerular filtration rate (eGFR) ≥60 mL/min who received vancomycin infusion were enrolled in this pilot study. Vancomycin pharmacokinetic parameters were determined for each patient using serum concentration data and a one-compartment model provided by MONOLIX software using stochastic approximation expectation-maximization (SAEM) algorithm. Correlation of CLvan with the measured creatinine clearance in 6-hour urine collection (CL6 h) and estimated creatinine clearance by the Cockcroft-Gault formula (CLCG) was investigated. RESULTS Data analysis revealed that CL6 h had a stronger correlation with CLvan rather than CLCG (r = 0.823 vs. 0.594; p < 0.001 vs. 0.003). The relationship between CLvan and CL6 h was utilized to develop the following equation for estimating CLvan: CLvan (mL/min) = ─137.4 + CL6 h (mL/min) + 2.5 IBW (kg) (R 2 = 0.826, p < 0.001). Regarding the described model, the following equation can be used to calculate the empirical dose of vancomycin for achieving the therapeutic goals in critically ill patients without renal impairment: total daily dose of vancomycin (mg) = (─137.4CL6-h (mL/min) + 2.5 IBW (kg)) × 0.06 AUC24 h (mg.hr/L). CONCLUSION For AUC estimation, CLvan can be obtained by collecting urine in a 6-hour period with good approximation in critically ill patients with normal renal function.
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Affiliation(s)
- Bita Shahrami
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Najmeddin
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeideh Ghaffari
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabak Najafi
- Department of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Rouini
- Department of Pharmaceutics, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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19
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Perin N, Roger C, Marin G, Molinari N, Evrard A, Lavigne JP, Barbar S, Claret PG, Boutin C, Muller L, Lipman J, Lefrant JY, Jaber S, Roberts JA. Vancomycin Serum Concentration after 48 h of Administration: A 3-Years Survey in an Intensive Care Unit. Antibiotics (Basel) 2020; 9:antibiotics9110793. [PMID: 33182613 PMCID: PMC7698174 DOI: 10.3390/antibiotics9110793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022] Open
Abstract
The present study assessed the proportion of intensive care unit (ICU) patients who had a vancomycin serum concentration between 20 and 25 mg/L after 24–48 h of intravenous vancomycin administration. From 2016 to 2018, adult ICU patients with vancomycin continuous infusion (CI) for any indication were included. The primary outcome was the proportion of patients with a first-available vancomycin serum concentration between 20–25 mg/L at 24 h (D2) or 48 h (D3). Of 3894 admitted ICU patients, 179 were included. A median loading dose of 15.6 (interquartile range (IQR) = (12.5–20.8) mg/kg) was given in 151/179 patients (84%). The median daily doses of vancomycin infusion for D1 and D2 were 2000 [(IQR (1600–2000)) and 2000 (IQR (2000–2500)) mg/d], respectively. The median duration of treatment was 4 (2–7) days. At D2 or D3, the median value of first serum vancomycin concentration was 19.8 (IQR (16.0–25.1)) with serum vancomycin concentration between 20–25 mg/L reported in 43 patients (24%). Time spent in the ICU before vancomycin initiation was the only risk factor of non-therapeutic concentration at D2 or D3. Acute kidney injury occurred significantly more when vancomycin concentration was supra therapeutic at D2 or D3. At D28, 44 (26%) patients had died. These results emphasize the need of appropriate loading dose and regular monitoring to improve vancomycin efficacy and avoid renal toxicity.
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Affiliation(s)
- Nicolas Perin
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
- Correspondence:
| | - Claire Roger
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Grégory Marin
- IMAG, CNRS, Université de Montpellier, Department of Statistics, CHU Montpellier, 34295 Montpellier, France; (G.M.); (N.M.)
| | - Nicolas Molinari
- IMAG, CNRS, Université de Montpellier, Department of Statistics, CHU Montpellier, 34295 Montpellier, France; (G.M.); (N.M.)
| | - Alexandre Evrard
- Laboratoire de Biochimie, Centre Hospitalier Universitaire (CHU) de Nîmes, Hôpital Carémeau, 30029 Nîmes, France;
| | - Jean-Philippe Lavigne
- VBMI, INSERM U1047, Université de Montpellier, Laboratoire de Microbiologie, CHU de Nîmes, 30029 Nîmes, France;
| | - Saber Barbar
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Pierre Géraud Claret
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Caroline Boutin
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Laurent Muller
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Jeffrey Lipman
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
- VBMI, INSERM U1047, Université de Montpellier, Laboratoire de Microbiologie, CHU de Nîmes, 30029 Nîmes, France;
- Department of Intensive Care Medicine, Royal Brisbane and Womens’ Hospital, Brisbane 4029, QLD, Australia
- UQ Centre for Clinical Research, The University of Queensland, Brisbane 4029, QLD, Australia
| | - Jean-Yves Lefrant
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Samir Jaber
- Département d’Anesthésie Réanimation B, Saint Eloi ICU, Montpellier University Hospital, 34295 Montpellier, France;
| | - Jason A. Roberts
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
- UQ Centre for Clinical Research, The University of Queensland, Brisbane 4029, QLD, Australia
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane 4029, QLD, Australia
- Pharmacy Department, Royal Brisbane and Womens’ Hospital, Brisbane 4029, QLD, Australia
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Mohd Tahir NA, Mohd Saffian S, Islahudin FH, Abdul Gafor AH, Makmor-Bakry M. A Meta-Analysis on the Performance of Cystatin C- versus Creatinine-based eGFR Equations in Predicting Vancomycin Clearance. J Korean Med Sci 2020; 35:e306. [PMID: 32959542 PMCID: PMC7505726 DOI: 10.3346/jkms.2020.35.e306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/25/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The objective of this study was to compare the performance of cystatin C- and creatinine-based estimated glomerular filtration rate (eGFR) equations in predicting the clearance of vancomycin. METHODS MEDLINE and Embase databases were searched from inception up to September 2019 to identify all studies that compared the predictive performance of cystatin C- and/or creatinine-based eGFR in predicting the clearance of vancomycin. The prediction errors (PEs) (the value of eGFR equations minus vancomycin clearance) were quantified for each equation and were pooled using a random-effects model. The root mean squared errors were also quantified to provide a metric for imprecision. RESULTS This meta-analysis included evaluations of seven different cystatin C- and creatinine-based eGFR equations in total from 26 studies and 1,234 patients. The mean PE (MPE) for cystatin C-based eGFR was 4.378 mL min-1 (95% confidence interval [CI], -29.425, 38.181), while the creatinine-based eGFR provided an MPE of 27.617 mL min-1 (95% CI, 8.675, 46.560) in predicting clearance of vancomycin. This indicates the presence of unbiased results in vancomycin clearance prediction by the cystatin C-based eGFR equations. Meanwhile, creatinine-based eGFR equations demonstrated a statistically significant positive bias in vancomycin clearance prediction. CONCLUSION Cystatin C-based eGFR equations are better than creatinine-based eGFR equations in predicting the clearance of vancomycin. This suggests that utilising cystatin C-based eGFR equations could result in better accuracy and precision to predict vancomycin pharmacokinetic parameters.
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Affiliation(s)
| | | | | | - Abdul Halim Abdul Gafor
- Nephrology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Malaysia
| | - Mohd Makmor-Bakry
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
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Chai MG, Cotta MO, Abdul-Aziz MH, Roberts JA. What Are the Current Approaches to Optimising Antimicrobial Dosing in the Intensive Care Unit? Pharmaceutics 2020; 12:pharmaceutics12070638. [PMID: 32645953 PMCID: PMC7407796 DOI: 10.3390/pharmaceutics12070638] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/29/2022] Open
Abstract
Antimicrobial dosing in the intensive care unit (ICU) can be problematic due to various challenges including unique physiological changes observed in critically ill patients and the presence of pathogens with reduced susceptibility. These challenges result in reduced likelihood of standard antimicrobial dosing regimens achieving target exposures associated with optimal patient outcomes. Therefore, the aim of this review is to explore the various methods for optimisation of antimicrobial dosing in ICU patients. Dosing nomograms developed from pharmacokinetic/statistical models and therapeutic drug monitoring are commonly used. However, recent advances in mathematical and statistical modelling have resulted in the development of novel dosing software that utilise Bayesian forecasting and/or artificial intelligence. These programs utilise therapeutic drug monitoring results to further personalise antimicrobial therapy based on each patient’s clinical characteristics. Studies quantifying the clinical and cost benefits associated with dosing software are required before widespread use as a point-of-care system can be justified.
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Affiliation(s)
- Ming G. Chai
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Woollongabba 4102, Australia
| | - Menino O. Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Woollongabba 4102, Australia
| | - Mohd H. Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Woollongabba 4102, Australia
- Departments of Pharmacy and Intensive Care, Royal Brisbane and Women’s Hospital, Brisbane 4006, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nimes University Hospital, University of Montpellier, 30021 Nimes, France
- Correspondence:
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Colin PJ, Eleveld DJ, Thomson AH. Genetic Algorithms as a Tool for Dosing Guideline Optimization: Application to Intermittent Infusion Dosing for Vancomycin in Adults. CPT Pharmacometrics Syst Pharmacol 2020; 9:294-302. [PMID: 32383808 PMCID: PMC7239335 DOI: 10.1002/psp4.12512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/05/2020] [Indexed: 11/10/2022] Open
Abstract
This paper demonstrates the use of a genetic algorithm (GA) for the optimization of a dosing guideline. GAs are well‐suited to derive combinations of doses and dosing intervals that go into a dosing guideline when the number of possible combinations rule out the calculation of all possible outcomes. GAs also allow for different constraints to be imposed on the optimization process to safeguard the clinical feasibility of the dosing guideline. In this work, we demonstrate the use of a GA for the optimization of intermittent vancomycin administration in adult patients. Constraints were placed on the dose strengths, the length of the dosing intervals, and the maximum infusion rate. In addition, flexibility with respect to the timing of the first maintenance dose was included in the optimization process. The GA‐based optimal solution is compared with the Scottish Antimicrobial Prescribing Group vancomycin guideline.
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Affiliation(s)
- Pieter J. Colin
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Douglas J. Eleveld
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Alison H. Thomson
- Strathclyde Institute of Pharmacy and Biomedical Sciences University of Strathclyde Glasgow UK
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Dhont E, Van Der Heggen T, De Jaeger A, Vande Walle J, De Paepe P, De Cock PA. Augmented renal clearance in pediatric intensive care: are we undertreating our sickest patients? Pediatr Nephrol 2020; 35:25-39. [PMID: 30374606 DOI: 10.1007/s00467-018-4120-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/04/2018] [Accepted: 10/16/2018] [Indexed: 10/28/2022]
Abstract
Many critically ill patients display a supraphysiological renal function with enhanced renal perfusion and glomerular hyperfiltration. This phenomenon described as augmented renal clearance (ARC) may result in enhanced drug elimination through renal excretion mechanisms. Augmented renal clearance seems to be triggered by systemic inflammation and therapeutic interventions in intensive care. There is growing evidence that ARC is not restricted to the adult intensive care population, but is also prevalent in critically ill children. Augmented renal clearance is often overlooked due to the lack of reliable methods to assess renal function in critically ill children. Standard equations to calculate glomerular filtration rate (GFR) are developed for patients who have a steady-state creatinine production and a stable renal function. Those formulas are not reliable in critically ill patients with acutely changing GFR and tend to underestimate true GFR in patients with ARC. Tools for real-time, continuous, and non-invasive measurement of fluctuating GFR are most needed to identify changes in kidney function during critical illness and therapeutic interventions. Such devices are currently being validated and hold a strong potential to become the standard of practice. In the meantime, urinary creatinine clearance is considered the most reliable method to detect ARC in critically ill patients. Augmented renal clearance is clearly associated with subtherapeutic antimicrobial concentrations and subsequent therapeutic failure. This warrants the need for adjusted dosing regimens to optimize pharmacokinetic and pharmacodynamic target attainment. This review aims to summarize current knowledge on ARC in critically ill children, to give insight into its possible pathophysiological mechanism, to evaluate screening methods for ARC in the pediatric intensive care population, and to illustrate the effect of ARC on drug exposure, therapeutic efficacy, and clinical outcome.
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Affiliation(s)
- Evelyn Dhont
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium. .,Pediatric Intensive Care 1K12D, Ghent University Hospital, Heymanslaan 10, 9000, Ghent, Belgium.
| | | | - Annick De Jaeger
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Johan Vande Walle
- Department of Pediatrics, Ghent University Hospital, Ghent, Belgium.,Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Pieter A De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium.,Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
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Attainment of therapeutic vancomycin level within the first 24 h: Authors' response. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:354. [PMID: 31722733 PMCID: PMC6852771 DOI: 10.1186/s13054-019-2639-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022]
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25
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He CY, Qin YR, Liu CJ, Ren J, Fan JS. [Effect of augmented renal clearance on plasma concentration of vancomycin and treatment outcome in children with methicillin-resistant Staphylococcus aureus infection]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:904-909. [PMID: 31506151 PMCID: PMC7390248 DOI: 10.7499/j.issn.1008-8830.2019.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate the effect of augmented renal clearance (ARC) on plasma concentration of vancomycin, bacteriological outcome, and clinical outcome in children with methicillin-resistant Staphylococcus aureus (MRSA) infection treated by vancomycin. METHODS A retrospective analysis was performed for the clinical data of 60 critically ill children who were treated with vancomycin due to MRSA infection from January 2013 to July 2017 and underwent plasma concentration monitoring. According to estimated glomerular filtration rate, these children were divided into an ARC group with 19 children and a normal renal function group with 41 children. The two groups were compared in terms of the use of vancomycin, plasma concentration of vancomycin, and treatment outcome. RESULTS The children in the ARC group had an age of 1-12 years, and the ARC group had significantly higher body weight and body surface area than the normal renal function group (P<0.05). Compared with the normal renal function group, the ARC group had a significantly lower initial trough concentration of vancomycin and a significantly lower proportion of children who achieved the effective trough concentration of vancomycin (10-20 mg/L) (P<0.05). There were no significant differences in bacteriological outcome and clinical outcome between the two groups (P>0.05), but the ARC group had significantly longer length of stay in the pediatric intensive care unit (PICU) and length of hospital stay than the normal renal function group (P<0.05). CONCLUSIONS ARC can significantly reduce the trough concentration of vancomycin and prolong the length of PICU stay and the length of hospital stay in children with MRSA infection. Idividualized medication should be administered to children with ARC.
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Affiliation(s)
- Cui-Yao He
- Department of Pharmacy, Children's Hospital of Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Clinical Research Center for Child Health and Disorders (Chongqing)/China International Science and Technology Cooperation Base of Child Development and Critical Disorders/Chongqing Key Laboratory of Pediatrics, Chongqing 400014,
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Risk Factors and Clinical Outcomes Associated With Augmented Renal Clearance in Trauma Patients. J Surg Res 2019; 244:477-483. [PMID: 31330291 DOI: 10.1016/j.jss.2019.06.087] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/21/2019] [Accepted: 06/20/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Augmented renal clearance (ARC; i.e., creatinine clearance [CLCr] ≥ 130 mL/min) has an incidence of 14%-80% in critically ill patients and has been associated with therapy failures for renally cleared drugs. However, the clinical implications of ARC are poorly defined. We hypothesize that modifiable risk factors that contribute to ARC can be identified in severely injured trauma patients and that these risk factors influence clinical outcome. METHODS In 207 trauma intensive care unit patients, 24-h CLCr was correlated with clinical estimates of glomerular filtration rate (by Cockroft-Gault, modification of diet in renal disease, or chronic kidney disease epidemiology), and clinical outcomes (infection, venous thromboembolism [VTE], length of stay, and mortality). RESULTS The population was 45 ± 20 y, 68% male, 77% blunt injury with injury severity score of 24 (17-30). Admission serum creatinine was 1.02 ± 0.35 mg/dL, CLCr was 154 ± 77 mL/min, VTE incidence was 15%, ARC incidence was 57%, and mortality was 11%. Clinical estimates of glomerular filtration rate by Cockroft-Gault, modification of diet in renal disease, chronic kidney disease epidemiology underestimated actual CLCr by 20%, 22%, or 15% (all P < 0.01). CLCr was higher in males and those who survived, and lower in those with hypertension, diabetes, positive cultures, receiving transfusions, or pressors (all P < 0.05). On multivariate analysis, male gender (odds ratio [OR] 2.9 [1.4-6.1]), age (OR 0.97 [0.95-0.99]), and packed red blood cells transfusion (OR 0.31 [0.15-0.66]) were the only independent predictors of ARC. CONCLUSIONS ARC occurs in more than half of all high-risk trauma intensive care unit patients and is underestimated by standard clinical equations. ARC was not associated with increased incidence of VTE or infection but rather is associated with younger healthier males and reduced mortality. ARC seems to be a beneficial compensatory response to trauma.
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Honore PM, De Bels D, Attou R, Redant S, Gallerani A, Kashani K. Attainment of therapeutic vancomycin level within the first 24 h. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:228. [PMID: 31227005 PMCID: PMC6588930 DOI: 10.1186/s13054-019-2515-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/12/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann, Brugmann University Hospital, 4 Place Arthur Van Gehuchten, 1020, Brussels, Belgium.
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann, Brugmann University Hospital, 4 Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann, Brugmann University Hospital, 4 Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - Sebastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann, Brugmann University Hospital, 4 Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - Andrea Gallerani
- ICU Department, Centre Hospitalier Universitaire Brugmann, Brugmann University Hospital, 4 Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, USA
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Abraham J, Sinnollareddy MG, Roberts MS, Williams P, Peake SL, Lipman J, Roberts JA. Plasma and interstitial fluid population pharmacokinetics of vancomycin in critically ill patients with sepsis. Int J Antimicrob Agents 2018; 53:137-142. [PMID: 30296581 DOI: 10.1016/j.ijantimicag.2018.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 09/26/2018] [Accepted: 09/29/2018] [Indexed: 01/16/2023]
Abstract
Vancomycin is a commonly prescribed antibiotic in the intensive care unit. However, there are limited data describing its distribution into the interstitial fluid (ISF) of tissues. The aim of this study was to describe the plasma and tissue ISF population pharmacokinetics of vancomycin in critically ill patients with sepsis. Serial vancomycin blood and ISF samples were collected at pre-specified time intervals in critically ill patients with sepsis. ISF sampling occurred using a subcutaneously inserted microdialysis catheter. Bioanalysis was undertaken using a validated spectrometric assay method. Population pharmacokinetic analysis was performed using Pmetrics®. Seven patients were recruited and pharmacokinetic data were available for six of them. The median (interquartile range) age, weight, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Sequential Organ Failure Assessment (SOFA) score and measured creatinine clearance (CLCr) were 55 (44-67) years, 85 (81-102) kg, 20 (16-29), 5 (4-8) and 90 (83-98) mL/min, respectively. Vancomycin pharmacokinetics was best described by a three-compartment linear model. Measured CLCr (on vancomycin clearance) and weight (on volume of distribution of the central compartment) were the only patient covariates that improved the model fit. Coefficients of variation for the vancomycin rate constants into and out of the peripheral and tissue ISF compartments were also high, ranging from 47% to 134%. There is significant variability of vancomycin distribution into tissue ISF, which it was not possible to explain with patient characteristics.
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Affiliation(s)
- Jacob Abraham
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Mahipal G Sinnollareddy
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia; Therapeutics Research Centre, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
| | - Michael S Roberts
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia; Therapeutics Research Centre, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Patricia Williams
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia; The School of Medicine, University of Adelaide, Adelaide, South Australia, Australia; School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sandra L Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia; The School of Medicine, University of Adelaide, Adelaide, South Australia, Australia; School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jason A Roberts
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
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Sin JH, Newman K, Elshaboury RH, Yeh DD, de Moya MA, Lin H. Prospective evaluation of a continuous infusion vancomycin dosing nomogram in critically ill patients undergoing continuous venovenous haemofiltration. J Antimicrob Chemother 2018; 73:199-203. [PMID: 29040561 DOI: 10.1093/jac/dkx356] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/31/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives The most optimal method of attaining therapeutic vancomycin concentrations during continuous venovenous haemofiltration (CVVH) remains unclear. Studies have shown continuous infusion vancomycin (CIV) achieves target concentrations more rapidly and consistently when compared with intermittent infusion. Positive correlations between CVVH intensity and vancomycin clearance (CLvanc) have been noted. This study is the first to evaluate a CIV regimen in patients undergoing CVVH that incorporates weight-based CVVH intensity (mL/kg/h) into the dosing nomogram. Methods This was a prospective, observational study of patients undergoing CVVH and receiving CIV based on the nomogram. The primary outcome was achievement of a therapeutic vancomycin concentration (15-25 mg/L) at 24 h. Secondary outcomes included the achievement of therapeutic concentrations at 48 and 72 h. Results The nomogram was analysed in 52 critically ill adults. Vancomycin concentrations were therapeutic in 43/52 patients (82.7%) at 24 h. Of the nine patients who were not therapeutic at 24 h, seven were supratherapeutic and two were subtherapeutic. The mean (SD) concentration was 20.1 (4.2) mg/L at 24 h, 20.7 (3.7) mg/L at 48 h and 21.9 (3.5) mg/L at 72 h. Patients with CVVH intensity >20 mL/kg/h experienced higher CLvanc at 24 h compared with patients with CVVH intensity <20 mL/kg/h (3.1 versus 2.6 L/h; P = 0.013). Conclusions By incorporating CVVH intensity into the CIV dosing nomogram, the majority of patients achieved therapeutic concentrations at 24 h and maintained them within range at 48 and 72 h. Additional studies are required to validate this nomogram before widespread implementation may be considered.
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Affiliation(s)
- Jonathan H Sin
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Kelly Newman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Ramy H Elshaboury
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - D Dante Yeh
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Marc A de Moya
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Hsin Lin
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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Declercq P, Gijsen M, Meijers B, Schetz M, Nijs S, D'Hoore A, Wauters J, Spriet I. Reliability of serum creatinine-based formulae estimating renal function in non-critically ill surgery patients: Focus on augmented renal clearance. J Clin Pharm Ther 2018; 43:695-706. [PMID: 29733108 DOI: 10.1111/jcpt.12695] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 03/28/2018] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Formulae estimating glomerular filtration rate (GFR) are frequently used to guide drug dosing. The objectives of this prospective single-center study were to evaluate agreement between these equations and measured creatinine clearance (CrCl) in non-critically ill surgery patients with normal kidney function and augmented renal clearance (ARC, CrCl ≥ 130 mL/min/1.73 m²), to determine predictors for disagreement, define a GFR estimator cut-off value identifying ARC and determine the ARC prevalence and duration in non-critically ill surgical patients. METHODS Hospitalized adult non-critically ill abdominal and trauma surgery patients were eligible for inclusion. Measured CrCl based on an 8-hour urinary collection (CrCl8h ) was used as the primary method for determining kidney function. Agreement between equations and measured CrCl8h was assessed in terms of precision, defined as a bias within ±10 mL/min/1.73 m². Predictors for disagreement were identified for the most precise estimator using an ordinal logistic regression model with negative bias, agreement and positive bias as outcome variables. A receiver operating characteristic (ROC) analysis was performed to identify an estimator cut-off predicting ARC, which was subsequently applied for the daily proportion of patients displaying ARC and ARC duration. RESULTS AND DISCUSSION During the study period (14/11/2013 - 13/05/2014), in 232 adult non-critically ill abdominal and trauma surgery patients, all estimators tend to underestimate CrCl8h (mean bias ranging from 17 to 22 mL/min/1.73 m²), especially in patients displaying ARC (mean bias ranging from 44 to 56 mL/min/1.73 m²). eGFRCKD-EPI performed the best. Younger age and low ASA score independently predicted underestimation of CrCl8h . Three different eGFRCKD-EPI cut-offs with decreasing sensitivity and increasing specificity (84, 95 and 112 mL/min/1.73 m²) identified, respectively, 65%, 44% and 14% patients displaying ARC. The median ARC duration was 4, 4 and 3 days, respectively. WHAT IS NEW AND CONCLUSION In surgical patients, eGFR frequently underestimates measured CrCl, especially in young patients with low ASA score. eGFR cut-offs predicting ARC were identified.
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Affiliation(s)
- Peter Declercq
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Matthias Gijsen
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | - Björn Meijers
- Division of Internal Medicine, Nephrology Unit, UZ Leuven and Department of Immunology and Microbiology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Marie Schetz
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Faculty of Medicine, Department of Traumatology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - André D'Hoore
- Faculty of Medicine, Department of Abdominal Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Joost Wauters
- Faculty of Medicine, Department of General Internal Medicine, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
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Tomasa Irriguible TM. Augmented renal clearance: Much more is better? Med Intensiva 2018; 42:500-503. [PMID: 29551234 DOI: 10.1016/j.medin.2018.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/04/2018] [Accepted: 02/09/2018] [Indexed: 11/27/2022]
Affiliation(s)
- T M Tomasa Irriguible
- Servicio de Medicina Intensiva, Hospital Germans Trias i Pujol, Badalona, Barcelona, España.
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Augmented Renal Clearance in Critically Ill Patients: A Systematic Review. Clin Pharmacokinet 2018; 57:1107-1121. [DOI: 10.1007/s40262-018-0636-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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May CC, Erwin BL, Childress M, Cortopassi J, Curtis G, Kilpatrick T, Taylor J, Vance B, Wylie D. Assessment of acute kidney injury in neurologically and traumatically injured intensive care patients receiving large vancomycin doses. Int J Crit Illn Inj Sci 2018; 8:194-200. [PMID: 30662865 PMCID: PMC6311967 DOI: 10.4103/ijciis.ijciis_39_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background: Previous reports note that in a mixed patient population, vancomycin doses >4 g/day are associated with increased rates of acute kidney injury (AKI). Objective: The objective of the study is to determine if vancomycin regimens >4 g/day are associated with a higher incidence of AKI in neurocritical care unit (NCCU) and trauma/burn Intensive Care Unit (TBICU) patients. Materials and Methods: This single-centered, retrospective study enrolled adult patients initiated on vancomycin in the NCCU and TBICU at an academic medical center during 2016. Based on maximum steady-state dose exposure, patients were separated into two groups: ≤4 g/day and >4 g/day. The primary outcome of incidence of AKI was defined by the AKI Network criteria. Results: A total of 284 patients were screened for eligibility; 165 patients met inclusion criteria, 98 patients received ≤4 g/day and 67 patients received >4 g/day. The >4 g/day group had a lower mean age (32.6±11.1 vs. 47.8±16.2, P < 0.001), included more male patients (81% vs. 60%, P = 0.008), were more often treated for a central nervous system infection (31% vs. 11%, P = 0.001), had, on average, more concomitant use of nephrotoxic drugs (2.2±1.2 vs. 1.8±0.9, P = 0.02) and had a higher exposure to contrast (94% vs. 79%, P < 0.001). The primary outcome of AKI occurred in 14 patients receiving ≤4 g/day and five patients receiving >4 g/day which was not statistically significant (14% vs. 7%, P = 0.22). Conclusions: Our results indicate that administering >4 g/day of vancomycin to achieve therapeutic vancomycin troughs does not appear to lead to an increased incidence of AKI in a mixed NCCU and TBICU population.
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Affiliation(s)
- Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Beth L Erwin
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Margaret Childress
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Josh Cortopassi
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Garrett Curtis
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Tyson Kilpatrick
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Jennifer Taylor
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Bonnie Vance
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Doug Wylie
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
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Influence of Mechanical Ventilation on the Pharmacokinetics of Vancomycin Administered by Continuous Infusion in Critically Ill Patients. Antimicrob Agents Chemother 2017; 61:AAC.01249-17. [PMID: 28893792 DOI: 10.1128/aac.01249-17] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/04/2017] [Indexed: 12/15/2022] Open
Abstract
Pathophysiological changes involved in drug disposition in critically ill patients should be considered in order to optimize the dosing of vancomycin administered by continuous infusion, and certain strategies must be applied to reach therapeutic targets on the first day of treatment. The aim of this study was to develop a population pharmacokinetic model of vancomycin to determine clinical covariates, including mechanical ventilation, that influence the wide variability of this antimicrobial. Plasma vancomycin concentrations from 54 critically ill patients were analyzed simultaneously by a population pharmacokinetic approach. A nomogram for dosing recommendations was developed and was internally evaluated through stochastic simulations. The plasma vancomycin concentration-versus-time data were best described by a one-compartment open model with exponential interindividual variability associated with vancomycin clearance and the volume of distribution. Residual error followed a homoscedastic trend. Creatinine clearance and body weight significantly dropped the objective function value, showing their influence on vancomycin clearance and the volume of distribution, respectively. Characterization based on the presence of mechanical ventilation demonstrated a 20% decrease in vancomycin clearance. External validation (n = 18) was performed to evaluate the predictive ability of the model; median bias and precision values were 0.7 mg/liter (95% confidence interval [CI], -0.4, 1.7) and 5.9 mg/liter (95% CI, 5.4, 6.4), respectively. A population pharmacokinetic model was developed for the administration of vancomycin by continuous infusion to critically ill patients, demonstrating the influence of creatinine clearance and mechanical ventilation on vancomycin clearance, as well as the implications for targeting dosing rates to reach the therapeutic range (20 to 30 mg/liter).
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Mahmoud SH, Shen C. Augmented Renal Clearance in Critical Illness: An Important Consideration in Drug Dosing. Pharmaceutics 2017; 9:E36. [PMID: 28926966 PMCID: PMC5620577 DOI: 10.3390/pharmaceutics9030036] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/12/2017] [Accepted: 09/14/2017] [Indexed: 12/16/2022] Open
Abstract
Augmented renal clearance (ARC) is a manifestation of enhanced renal function seen in critically ill patients. The use of regular unadjusted doses of renally eliminated drugs in patients with ARC might lead to therapy failure. The purpose of this scoping review was to provide and up-to-date summary of the available evidence pertaining to the phenomenon of ARC. A literature search of databases of available evidence in humans, with no language restriction, was conducted. Databases searched were MEDLINE (1946 to April 2017), EMBASE (1974 to April 2017) and the Cochrane Library (1999 to April 2017). A total of 57 records were included in the present review: 39 observational studies (25 prospective, 14 retrospective), 6 case reports/series and 12 conference abstracts. ARC has been reported to range from 14-80%. ARC is currently defined as an increased creatinine clearance of greater than 130 mL/min/1.73 m² best measured by 8-24 h urine collection. Patients exhibiting ARC tend to be younger (<50 years old), of male gender, had a recent history of trauma, and had lower critical illness severity scores. Numerous studies have reported antimicrobials treatment failures when using standard dosing regimens in patients with ARC. In conclusion, ARC is an important phenomenon that might have significant impact on outcome in critically ill patients. Identifying patients at risk, using higher doses of renally eliminated drugs or use of non-renally eliminated alternatives might need to be considered in ICU patients with ARC. More research is needed to solidify dosing recommendations of various drugs in patients with ARC.
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Affiliation(s)
- Sherif Hanafy Mahmoud
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB T6G 1C9, Canada.
| | - Chen Shen
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB T6G 1C9, Canada.
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Augmented Renal Clearance Using Population-Based Pharmacokinetic Modeling in Critically Ill Pediatric Patients. Pediatr Crit Care Med 2017. [PMID: 28640009 DOI: 10.1097/pcc.0000000000001228] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this study were to: 1) evaluate the prevalence of augmented renal clearance in critically ill pediatric patients using vancomycin clearance; 2) derive the pharmacokinetic model that best describes vancomycin clearance in critically ill pediatric patients; and 3) correlate vancomycin clearance with creatinine clearance estimated by modified Schwartz or Cockcroft-Gault. DESIGN Retrospective, two-center, cohort study from 2003 to 2016. SETTING Clinical drug monitoring services in the PICUs at two tertiary care, teaching hospitals. PATIENTS Children from 1 to 21 years old. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Identify patients with augmented renal clearance (vancomycin clearance ≥ 130 mL/min/1.73 m used as definition of augmented renal clearance). Derive final population-based pharmacokinetic model and estimate individual patient pharmacokinetic parameters. Compare estimated glomerular filtration rate (modified Schwartz or Cockcroft-Gault depending on age < or ≥ 17 yr) with vancomycin clearance. Augmented renal clearance was identified in 12% of 250 total subjects. The final population-based pharmacokinetic model for vancomycin clearance (L/hr) was 0.118 × weight (e). Median vancomycin clearance in those with versus without augmented renal clearance were 141.3 and 91.7 mL/min/1.73 m, respectively (p < 0.001). By classification and regression tree analysis, patients who were more than 7.9 years old were significantly more likely to experience augmented renal clearance (17% vs 4.6% in those ≤ 7.9 yr old; p = 0.002). In patients with augmented renal clearance, 79% of 29 had vancomycin trough concentrations less than 10 µg/mL, compared with 52% of 221 in those without augmented renal clearance (p < 0.001). Vancomycin clearance was weakly correlated to the glomerular filtration rate estimated by the modified Schwartz or Cockcroft-Gault method (Spearman R = 0.083). CONCLUSIONS Augmented renal clearance was identified in one of 10 critically ill pediatric patients using vancomycin clearance, with an increase of approximately 50 mL/min/1.73 m in those with augmented renal clearance. As augmented renal clearance results in subtherapeutic antibiotic concentrations, optimal dosing is essential in those exhibiting augmented renal clearance.
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38
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Yoon S, Park KR, Lee S, Song SH, Park WB, Jang IJ, Yu KS. Assessment of Appropriateness of an Initial Dosing Regimen of Vancomycin and Development of a New Dosing Nomogram. Basic Clin Pharmacol Toxicol 2017; 122:233-238. [PMID: 28834212 DOI: 10.1111/bcpt.12873] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/01/2017] [Indexed: 11/28/2022]
Abstract
Vancomycin is a glycopeptide antibiotic used to treat Gram-positive infections including methicillin-resistant Staphylococcus aureus (MRSA). The objectives of this study were to evaluate the appropriateness of the initial dosing regimen of vancomycin, identify factors to be considered in regimen selection and develop a new dosing nomogram. Therapeutic drug monitoring (TDM) data of vancomycin obtained from Seoul National University Hospital from 2011 to 2013 were included in this analysis. The vancomycin trough concentrations at steady-state were estimated using Abbott's PKS software program and then categorized into three levels: subtherapeutic, therapeutic and toxic. The newly developed nomograms were evaluated by analysing the percentage of patients with target vancomycin trough concentration using the data of 2,570 patients of the first TDM cases. Therapeutic level was achieved only in approximately one-fifth of the cases, while 56.0% and 23.8% of the TDMs were considered subtherapeutic and toxic, respectively. As body-weight and creatinine clearance (CrCL) increased, the proportion of patients with a subtherapeutic level increased. Using the newly developed nomogram increased the proportion of patients who achieved therapeutic levels from 23.1% to 45.0% or 13.8% to 36.2% (target, 10-15 and 15-20 mg/L, respectively). These results suggest that the vancomycin concentrations fail to reach the therapeutic level or exceed the safe upper margin of the therapeutic level depending on age, body-weight and CrCL. Considering these factors, the new nomograms provide a strategy to achieve target concentrations of vancomycin more rapidly than existing regimens.
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Affiliation(s)
- Seonghae Yoon
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Kyoung Ryun Park
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - SeungHwan Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Sang-Hoon Song
- Department of Laboratory Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - In-Jin Jang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
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Obara VY, Zacas CP, Carrilho CMDDM, Delfino VDA. Currently used dosage regimens of vancomycin fail to achieve therapeutic levels in approximately 40% of intensive care unit patients. Rev Bras Ter Intensiva 2017; 28:380-386. [PMID: 28099635 DOI: 10.5935/0103-507x.20160071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 08/22/2016] [Indexed: 11/20/2022] Open
Abstract
Objective: This study aimed to assess whether currently used dosages of vancomycin for treatment of serious gram-positive bacterial infections in intensive care unit patients provided initial therapeutic vancomycin trough levels and to examine possible factors associated with the presence of adequate initial vancomycin trough levels in these patients. Methods: A prospective descriptive study with convenience sampling was performed. Nursing note and medical record data were collected from September 2013 to July 2014 for patients who met inclusion criteria. Eighty-three patients were included. Initial vancomycin trough levels were obtained immediately before vancomycin fourth dose. Acute kidney injury was defined as an increase of at least 0.3mg/dL in serum creatinine within 48 hours. Results: Considering vancomycin trough levels recommended for serious gram-positive infection treatment (15 - 20µg/mL), patients were categorized as presenting with low, adequate, and high vancomycin trough levels (35 [42.2%], 18 [21.7%], and 30 [36.1%] patients, respectively). Acute kidney injury patients had significantly greater vancomycin trough levels (p = 0.0055, with significance for a trend, p = 0.0023). Conclusion: Surprisingly, more than 40% of the patients did not reach an effective initial vancomycin trough level. Studies on pharmacokinetic and dosage regimens of vancomycin in intensive care unit patients are necessary to circumvent this high proportion of failures to obtain adequate initial vancomycin trough levels. Vancomycin use without trough serum level monitoring in critically ill patients should be discouraged.
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Affiliation(s)
- Vitor Yuzo Obara
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Estadual de Londrina - Londrina (PR), Brasil
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Chu Y, Luo Y, Qu L, Zhao C, Jiang M. Application of vancomycin in patients with varying renal function, especially those with augmented renal clearance. PHARMACEUTICAL BIOLOGY 2016; 54:2802-2806. [PMID: 27251880 DOI: 10.1080/13880209.2016.1183684] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 04/23/2016] [Indexed: 06/05/2023]
Abstract
CONTEXT Augmented renal clearance (ARC) refers to enhanced renal elimination of circulating solute, and has attracted wide attention in recent years. OBJECTIVE This study evaluates the effects of ARC on serum vancomycin concentration in patients administered vancomycin. MATERIALS AND METHODS This was a retrospective study in patients receiving vancomycin treatment at a dose of 1000 mg in every 12 h and undergoing serum monitoring admitted over a 2-year period (May 2013 to May 2015), in order to estimate the influence of ARC on serum vancomycin concentration. In this study, statistical comparisons were made on the results from patients grouped according to creatinine clearance (CLcr). RESULTS One hundred forty-eight patients were enrolled in our study. The results showed that ARC patients were significantly younger, with a significantly lower Scr and higher GFR. The CLcr and steady-state trough concentrations of serum vancomycin exhibited a logarithmic correlation (Rs = -0.699, R2 = 0.488, p < 0.01) in the patients included in our study. The trough vancomycin concentrations of 62.9% patients in high CLcr group were under 10 μg/mL. DISCUSSION AND CONCLUSION Since ARC was significantly associated with subtherapeutic serum vancomycin concentration, it was necessary to devise adjusted dosage regimens for these patients based on their CLcr.
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Affiliation(s)
- Yang Chu
- a Department of Pharmacy , the First Affiliated Hospital of China Medical University , Shenyang , China
- b Department of the First Clinical Pharmacy , China Medical University , Shenyang , China
| | - Yifan Luo
- a Department of Pharmacy , the First Affiliated Hospital of China Medical University , Shenyang , China
- b Department of the First Clinical Pharmacy , China Medical University , Shenyang , China
| | - Lianyue Qu
- a Department of Pharmacy , the First Affiliated Hospital of China Medical University , Shenyang , China
- b Department of the First Clinical Pharmacy , China Medical University , Shenyang , China
| | - Chunyang Zhao
- a Department of Pharmacy , the First Affiliated Hospital of China Medical University , Shenyang , China
- b Department of the First Clinical Pharmacy , China Medical University , Shenyang , China
| | - Mingyan Jiang
- a Department of Pharmacy , the First Affiliated Hospital of China Medical University , Shenyang , China
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Kim AJ, Lee JY, Choi SA, Shin WG. Comparison of the pharmacokinetics of vancomycin in neurosurgical and non-neurosurgical patients. Int J Antimicrob Agents 2016; 48:381-7. [PMID: 27546217 DOI: 10.1016/j.ijantimicag.2016.06.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/28/2016] [Accepted: 06/10/2016] [Indexed: 11/29/2022]
Abstract
Although vancomycin concentrations in neurosurgical patients tend to be lower following standard dosing compared with other patient populations, factors influencing vancomycin pharmacokinetics in neurosurgical patients are poorly understood. In this study, pharmacokinetic (PK) parameters in neurosurgical and non-neurosurgical patients were compared. Furthermore, factors influencing vancomycin PK alterations, including those known to augment renal clearance, were determined. Routine therapeutic drug monitoring data from neurosurgical and non-neurosurgical patients were retrospectively collected. Vancomycin PK parameters were estimated using non-linear mixed-effects modelling (NONMEM v.7.2.0); analyses were performed for the entire population and for neurosurgical patients only. Furthermore, the final models performed a bootstrap, visual predictive check and external validation. A total of 359 serum vancomycin concentration data variables from 132 patients were used to execute the PK modelling. Neurosurgical patient factor, the early phase of treatment, underlying liver cirrhosis, co-administration of a nephrotoxic drug and estimated creatinine clearance influenced vancomycin clearance (CL). However, other factors known to augment renal clearance did not affect vancomycin pharmacokinetics. Vancomycin CL was significantly higher in neurosurgical patients than in controls (0.104 ± 0.036 L/h/kg vs. 0.073 ± 0.042 L/h/kg; P <0.01). Augmented vancomycin CL should be considered when determining vancomycin dosages in neurosurgical patients.
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Affiliation(s)
- A Jeong Kim
- Department of Pharmacy, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy, Institute of Pharmaceutical Science and Technology, Hanyang University, 55 Hanyangdaehak-ro, Sangnok-gu, Ansan, Gyeonggi-do 15588, Republic of Korea
| | - Soo An Choi
- College of Pharmacy, Korea University, 2511 Sejong-ro, Sejong-si 30019, Republic of Korea
| | - Wan Gyoon Shin
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea.
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Bedenić B, Beader N, Godič-Torkar K, Prahin E, Mihaljević L, Ćačić M, Vraneš J. Postantibiotic effect of colistin alone and combined with vancomycin or meropenem against Acinetobacter spp. with well defined resistance mechanisms. J Chemother 2016; 28:375-82. [DOI: 10.1179/1973947815y.0000000062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Branka Bedenić
- Department of Microbiology, School of Medicine, University of Zagreb, Croatia
- Department of Clinical and Molecular Microbiology, Clinical Hospital Center Zagreb, Croatia
| | - Natasa Beader
- Department of Microbiology, School of Medicine, University of Zagreb, Croatia
- Department of Clinical and Molecular Microbiology, Clinical Hospital Center Zagreb, Croatia
| | - Karmen Godič-Torkar
- Department for Sanitary Engeneering, Faculty of Health Sciences, University of Ljubljana, Slovenia
| | - Esmina Prahin
- Department of Microbiology, School of Medicine, University of Zagreb, Croatia
| | - Ljiljana Mihaljević
- Department of Gynecology and Opstetrics, Clinical Hospital Center Zagreb, Croatia
| | | | - Jasmina Vraneš
- Department of Microbiology, School of Medicine, University of Zagreb, Croatia
- Department of Microbiology, Zagreb Institute of Public Health, ‘Andrija Štampar’, Croatia
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Vancomycin dosing nomograms targeting high serum trough levels in different populations: pros and cons. Eur J Clin Pharmacol 2016; 72:777-88. [PMID: 27117446 DOI: 10.1007/s00228-016-2063-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 04/12/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE Utilization of higher doses of vancomycin to achieve the trough concentrations of 15-20 mg/L for complicated infections has been recommended by the Infectious Diseases Society of America clinical practice guideline in recent years. Concerning this recommendation, several nomograms have been constructed targeting this optimal trough level range in different populations of patients. In this review, we have collected available nomograms targeting high trough serum levels of vancomycin, particularly comparing their advantages and limitations. METHOD The data were collected by searching Scopus, PubMed, Google scholar, Medline, and Cochrane database systematic reviews. The key words used as search terms were "vancomycin", "high trough level", "dosing nomogram", "dosing strategy", "neonates", "critically ill", "pediatrics", and "hemodialysis". We have included 17 related human studies published up to the date of this publication. RESULTS & CONCLUSION Most of the available nomograms have determined the doses according to body weight and renal function. Their initial predicting success rate were 44-76 % for non-critically ill patients, 42-84 % for critically ill patients, 54 % for one nomogram specially designed for hemodialysis patients, and 71 % for the only nomogram developed for neonates. Based on validation studies, in most of cases, using a vancomycin dosing nomogram significantly improved and accelerated achievement of target trough concentrations. However, it should be noted that there are limited data about patients' clinical and microbiological outcomes and they are only validated in narrow groups of patients. Thus, their widespread application could not be encouraged for all patients before performing adequately powered, prospective randomized studies.
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