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Leegwater E, Wewerinke L, de Grauw AM, van Veen M, Storm BN, Kruizinga MD. Optimization of β-Lactam Dosing Regimens in Neonatal Infections: Continuous and Extended Administration versus Intermittent Administration. Clin Pharmacokinet 2023; 62:715-724. [PMID: 36972008 DOI: 10.1007/s40262-023-01230-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND OBJECTIVE In neonates, β-Lactam antibiotics are almost exclusively administered by intermittent infusion. However, continuous or prolonged infusion may be more beneficial because of the time-dependent antibacterial activity. In this pharmacokinetic/pharmacodynamic simulation study, we aimed to compare treatment with continuous, extended and intermittent infusion of β-lactam antibiotics for neonates with infectious diseases. METHODS We selected population pharmacokinetic models of penicillin G, amoxicillin, flucloxacillin, cefotaxime, ceftazidime and meropenem, and performed a Monte Carlo simulation with 30,000 neonates. Four different dosing regimens were simulated: intermittent infusion in 30 min, prolonged infusion in 4 h, continuous infusion, and continuous infusion with a loading dose. The primary endpoint was 90% probability of target attainment (PTA) for 100% ƒT>MIC during the first 48 h of treatment. RESULTS For all antibiotics except cefotaxime, continuous infusion with a loading dose resulted in a higher PTA compared with other dosing regimens. Sufficient exposure (PTA >90%) using continuous infusion with a loading dose was reached for amoxicillin (90.3%), penicillin G (PTA 98.4%), flucloxacillin (PTA 94.3%), cefotaxime (PTA 100%), and ceftazidime (PTA 100%). Independent of dosing regimen, higher meropenem (PTA for continuous infusion with a loading dose of 85.5%) doses might be needed to treat severe infections in neonates. Ceftazidime and cefotaxime dose might be unnecessarily high, as even with dose reductions, a PTA > 90% was retained. CONCLUSIONS Continuous infusion after a loading dose leads to a higher PTA compared with continuous, intermittent or prolonged infusion, and therefore has the potential to improve treatment with β-lactam antibiotics in neonates.
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Affiliation(s)
- Emiel Leegwater
- The Hague Hospital Pharmacy, The Hague, The Netherlands.
- Department of Hospital Pharmacy, Haga Teaching Hospital, The Hague, The Netherlands.
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden University, Leiden, The Netherlands.
| | - Leo Wewerinke
- Juliana Children's Hospital, Haga Teaching Hospital, The Hague, The Netherlands
| | - Anne M de Grauw
- Juliana Children's Hospital, Haga Teaching Hospital, The Hague, The Netherlands
| | - Mirjam van Veen
- Juliana Children's Hospital, Haga Teaching Hospital, The Hague, The Netherlands
| | - Bert N Storm
- Department of Hospital Pharmacy, Haga Teaching Hospital, The Hague, The Netherlands
| | - Matthijs D Kruizinga
- Juliana Children's Hospital, Haga Teaching Hospital, The Hague, The Netherlands
- Department of Paediatrics, Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
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2
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Le J, Greenberg RG, Yoo Y, Clark RH, Benjamin DK, Zimmerman KO, Cohen-Wolkowiez M, Wade KC. Ampicillin dosing in premature infants for early-onset sepsis: exposure-driven efficacy, safety, and stewardship. J Perinatol 2022; 42:959-964. [PMID: 35210541 PMCID: PMC9262754 DOI: 10.1038/s41372-022-01344-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/06/2022] [Accepted: 02/03/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Define optimal ampicillin dosing for empiric early-onset sepsis (EOS) therapy in preterm neonates. STUDY DESIGN We simulated ampicillin concentrations in newborns (birthweight < 1500 g; gestational age 22-27 weeks), summarizing three 48 h regimens: high 100 mg/kg Q8hr, medium 100 mg/kg Q12hr, and standard 50 mg/kg Q12hr. Concentration data were analyzed for concentration above minimum inhibitory concentration (MIC), below neurotoxicity threshold (Cmax ≤ 140 mcg/mL), and duration limited to 48 h. RESULTS Among 34,689 newborns, all dosing regimens provided concentrations above MIC through 48 h, but Cmax exceeded the neurotoxicity threshold. With the 4-dose standard regimen, >90% maintained concentrations >MIC beyond 48 h. With the 2-dose regimen, newborns maintained the mean concentration >MIC within the 48 h culture window and below neurotoxicity level. Infants 22-24 weeks' gestation had higher drug concentrations and more prolonged exposure duration than 25-27 weeks' gestation. CONCLUSIONS For EOS in preterm infants, two ampicillin doses (50 mg/kg) provided optimal bactericidal exposures, while minimizing potential toxicity.
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Affiliation(s)
- Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California, San Diego, La Jolla, CA, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - YoungJun Yoo
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California, San Diego, La Jolla, CA, USA
| | | | - Daniel K Benjamin
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kanecia O Zimmerman
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kelly C Wade
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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3
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Chen XK, Shi HY, Huang X, Zhao W, Zhao H, Khan W, Zheng Y, Hao GX, Kou C, Li LW. A Suitable Therapeutic Drug Monitoring Method for Amoxicillin in Plasma by High Performance Liquid Chromatography–UV (HPLC–UV) in Neonates. LCGC NORTH AMERICA 2022. [DOI: 10.56530/lcgc.na.tx2790t9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Amoxicillin, a broad-spectrum β-lactam antibiotic, is widely used for treatment of neonatal infections. Despite the unmet need in neonates, an adapted analytical method is still missing in clinical practice. The purpose of this study was to develop and test an easy and credible high performance liquid chromatography–UV (HPLC–UV) method to determine amoxicillin in small volumes of human plasma and use it in routine therapeutic drug monitoring (TDM) of neonates. After a protein precipitation, amoxicillin for standards, quality control samples, and patient samples were separated by LC and measured by UV detection, and tinidazole was used as the internal standard. The calibration range was 0.50–20.0 μg/mL. Intra- and inter-day precisions were less than 4.7%. The acceptance criteria of accuracy (between 85–115%) were met in all cases. A plasma volume of 50 μL was required to achieve the limit of quantification of 0.50 μg/mL. Thus, a simple, rapid, and accurate HPLC–UV method has been developed to detect the concentration of amoxicillin in human plasma. This method was adapted to do TDM of amoxicillin in neonates.
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Affiliation(s)
| | | | - Xin Huang
- First Affiliated Hospital of Shandong
| | - Wei Zhao
- First Affiliated Hospital of Shandong
| | | | | | | | | | - Chen Kou
- Beijing Obstetrics and Gynecology Hospital
| | - Li-Wen Li
- First Affiliated Hospital of Shandong
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4
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Hurkacz M, Dobrek L, Wiela-Hojeńska A. Antibiotics and the Nervous System-Which Face of Antibiotic Therapy Is Real, Dr. Jekyll (Neurotoxicity) or Mr. Hyde (Neuroprotection)? Molecules 2021; 26:7456. [PMID: 34946536 PMCID: PMC8708917 DOI: 10.3390/molecules26247456] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 12/13/2022] Open
Abstract
Antibiotics as antibacterial drugs have saved many lives, but have also become a victim of their own success. Their widespread abuse reduces their anti-infective effectiveness and causes the development of bacterial resistance. Moreover, irrational antibiotic therapy contributes to gastrointestinal dysbiosis, that increases the risk of the development of many diseases, including neurological and psychiatric. One of the potential options for restoring homeostasis is the use of oral antibiotics that are poorly absorbed from the gastrointestinal tract (e.g., rifaximin alfa). Thus, antibiotic therapy may exert neurological or psychiatric adverse drug reactions which are often considered to be overlooked and undervalued issues. Drug-induced neurotoxicity is mostly observed after beta-lactams and quinolones. Penicillin may produce a wide range of neurological dysfunctions, including encephalopathy, behavioral changes, myoclonus or seizures. Their pathomechanism results from the disturbances of gamma-aminobutyric acid-GABA transmission (due to the molecular similarities between the structure of the β-lactam ring and GABA molecule) and impairment of the functioning of benzodiazepine receptors (BZD). However, on the other hand, antibiotics have also been studied for their neuroprotective properties in the treatment of neurodegenerative and neuroinflammatory processes (e.g., Alzheimer's or Parkinson's diseases). Antibiotics may, therefore, become promising elements of multi-targeted therapy for these entities.
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Affiliation(s)
- Magdalena Hurkacz
- Department of Clinical Pharmacology, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.H.); (L.D.)
- Clinical Pharmacy Service, Jan Mikulicz-Radecki University Clinical Hospital, 50-556 Wroclaw, Poland
| | - Lukasz Dobrek
- Department of Clinical Pharmacology, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.H.); (L.D.)
| | - Anna Wiela-Hojeńska
- Department of Clinical Pharmacology, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.H.); (L.D.)
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5
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Paradoxical Antibiotic Effect of Ampicillin: Use of a Population Pharmacokinetic Model to Evaluate a Clinical Correlate of the Eagle Effect in Infants With Bacteremia. Pediatr Infect Dis J 2020; 39:725-729. [PMID: 32235247 PMCID: PMC8628496 DOI: 10.1097/inf.0000000000002663] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND High doses of ampicillin are often used to achieve therapeutic drug concentrations in infants. A paradoxical antibiotic effect, often called the Eagle effect, occurs when increasing concentrations of antibiotic above a threshold results in decreased efficacy. It is unknown if infants treated with ampicillin are at risk for this paradoxical effect. METHODS We identified infants <28 days of age with Escherichia coli, Enterococcus or Streptococcus agalactiae (group B streptococcus) bloodstream infections from 1997 to 2012 and previously included in an ampicillin pharmacokinetic (PK) modeling study. We compared the odds of death for ampicillin dose, estimated time above the minimum inhibitory concentration (T > MIC) and PK parameters using separate logistic regression models. Adjusted logistic regression and Poisson models were used to calculate the odds of prolonged bacteremia ≥3 days and the duration of bacteremia, respectively, for dose, T > MIC and multiple PK parameters. RESULTS Among 1272 infants meeting inclusion criteria, odds of death 7 or 30 days after the positive blood culture were not consistent with a paradoxical effect across any of the dosing regimens or PK parameters evaluated. The odds of prolonged bacteremia was lowest at the lowest dose category and the lowest daily dose category but not associated with the area-under-the-concentration time curve from 0 to 24 hours, or the maximum or minimum concentrations at steady state. T > MIC of ≥50% of the dosing interval was associated with decreased duration of bacteremia and odds of prolonged bacteremia. CONCLUSIONS It is unlikely that a paradoxical antibiotic effect will have a clinical correlate when ampicillin is used for neonatal bacteremia. A T > MIC ≥50% decreased both duration of bacteremia and odds of prolonged bacteremia.
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6
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van Donge T, Fuchs A, Leroux S, Pfister M, Rodieux F, Atkinson A, Giannoni E, van den Anker J, Bielicki J. Amoxicillin Dosing Regimens for the Treatment of Neonatal Sepsis: Balancing Efficacy and Neurotoxicity. Neonatology 2020; 117:619-627. [PMID: 32841941 DOI: 10.1159/000509751] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 06/21/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Large variability in neonatal amoxicillin dosing recommendations may reflect uncertainty about appropriate efficacy and toxicity targets. OBJECTIVE The aim of this study was to model efficacious and safe exposure for current neonatal amoxicillin dosing regimens, given a range of assumptions for minimal inhibitory concentration (MIC), targeted %fT > MIC, and potential for aminopenicillin-related neurotoxicity. METHODS Individual intravenous amoxicillin exposures based on 6 international and 9 Swiss neonatal dosing recommendations, reflecting the range of current dosing approaches, were assessed by a previously developed population pharmacokinetic model informed by neonatal data from an international cohort. Exposure was simulated by attributing each dosing regimen to each patient cohort. End points of interest were %fT > MIC and potential neurotoxicity using Cmax > 140 mg/L as threshold. RESULTS None of the dosing regimens achieved targets of ≥100%fT > MIC at any of the relevant MICs for a desired probability of target attainment (PTA) of ≥90%. All regimens achieved a PTA ≥90% for Streptococcus agalactiae (MIC 0.25 mg/L) and Listeria monocytogenes (MIC 1 mg/L) when targeting ≤70%fT > MIC. In contrast, none of the regimens resulted in a PTA ≥90% targeting ≥70%fT > MIC for enterococci (MIC 4 mg/L). The maximum amoxicillin concentration associated with potential neurotoxicity was exceeded using 4 dosing regimens (100 mg/kg q12, 60/30 mg/kg q12/8, 50 mg/kg q12/8/6, and 50 mg/kg q12/8/4) for ≥10% of neonates. CONCLUSIONS The acceptability of regimens is highly influenced by efficacy and toxicity targets, the selection of which is challenging. Novel randomized trial designs combined with pharmacometric modeling and simulation could assist in selecting optimal dosing regimens in this understudied population.
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Affiliation(s)
- Tamara van Donge
- Paediatric Pharmacology and Pharmacometrics Research, University Children's Hospital Basel, Basel, Switzerland,
| | - Aline Fuchs
- Paediatric Pharmacology and Pharmacometrics Research, University Children's Hospital Basel, Basel, Switzerland.,Medicines for Malaria Venture, Geneva, Switzerland
| | - Stéphanie Leroux
- Paediatric Pharmacology and Pharmacometrics Research, University Children's Hospital Basel, Basel, Switzerland
| | - Marc Pfister
- Paediatric Pharmacology and Pharmacometrics Research, University Children's Hospital Basel, Basel, Switzerland
| | - Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anaesthesiology, Pharmacology, Intensive care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Andrew Atkinson
- Paediatric Pharmacology and Pharmacometrics Research, University Children's Hospital Basel, Basel, Switzerland
| | - Eric Giannoni
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - John van den Anker
- Paediatric Pharmacology and Pharmacometrics Research, University Children's Hospital Basel, Basel, Switzerland.,Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Clinical Pharmacology, Children's National Hospital, Washington, District of Columbia, USA
| | - Julia Bielicki
- Medicines for Malaria Venture, Geneva, Switzerland.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
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7
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Evaluation of a System-Specific Function To Describe the Pharmacokinetics of Benzylpenicillin in Term Neonates Undergoing Moderate Hypothermia. Antimicrob Agents Chemother 2018; 62:AAC.02311-17. [PMID: 29378710 DOI: 10.1128/aac.02311-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/21/2018] [Indexed: 12/24/2022] Open
Abstract
The pharmacokinetic (PK) properties of intravenous (i.v.) benzylpenicillin in term neonates undergoing moderate hypothermia after perinatal asphyxia were evaluated, as they have been unknown until now. A system-specific modeling approach was applied, in which our recently developed covariate model describing developmental and temperature-induced changes in amoxicillin clearance (CL) in the same patient study population was incorporated into a population PK model of benzylpenicillin with a priori birthweight (BW)-based allometric scaling. Pediatric population covariate models describing the developmental changes in drug elimination may constitute system-specific information and may therefore be incorporated into PK models of drugs cleared through the same pathway. The performance of this system-specific model was compared to that of a reference model. Furthermore, Monte-Carlo simulations were performed to evaluate the optimal dose. The system-specific model performed as well as the reference model. Significant correlations were found between CL and postnatal age (PNA), gestational age (GA), body temperature (TEMP), urine output (UO; system-specific model), and multiorgan failure (reference model). For a typical patient with a GA of 40 weeks, BW of 3,000 g, PNA of 2 days (TEMP, 33.5°C), and normal UO (2 ml/kg/h), benzylpenicillin CL was 0.48 liter/h (interindividual variability [IIV] of 49%) and the volume of distribution of the central compartment was 0.62 liter/kg (IIV of 53%) in the system-specific model. Based on simulations, we advise a benzylpenicillin i.v. dose regimen of 75,000 IU/kg/day every 8 h (q8h), 150,000 IU/kg/day q8h, and 200,000 IU/kg/day q6h for patients with GAs of 36 to 37 weeks, 38 to 41 weeks, and ≥42 weeks, respectively. The system-specific model may be used for other drugs cleared through the same pathway accelerating model development.
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8
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Bijleveld YA, Mathôt R, van der Lee JH, Groenendaal F, Dijk PH, van Heijst A, Simons S, Dijkman KP, van Straaten H, Rijken M, Zonnenberg IA, Cools F, Zecic A, Nuytemans D, van Kaam AH, de Haan TR. Population Pharmacokinetics of Amoxicillin in Term Neonates Undergoing Moderate Hypothermia. Clin Pharmacol Ther 2017; 103:458-467. [PMID: 28555724 DOI: 10.1002/cpt.748] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 05/15/2017] [Indexed: 12/23/2022]
Abstract
The pharmacokinetics (PK) of amoxicillin in asphyxiated newborns undergoing moderate hypothermia were quantified using prospective data (N = 125). The population PK was described by a 2-compartment model with a priori birthweight (BW) based allometric scaling. Significant correlations were observed between clearance (Cl) and postnatal age (PNA), gestational age (GA), body temperature (TEMP), and urine output (UO). For a typical patient with GA 40 weeks, BW 3,000 g, 2 days PNA (i.e., TEMP 33.5°C), and normal UO, Cl was 0.26 L/h (interindividual variability (IIV) 41.9%) and volume of distribution of the central compartment was 0.34 L/kg (IIV of 114.6%). For this patient, Cl increased to 0.41 L/h at PNA 5 days and TEMP 37.0°C. The respective contributions of both covariates were 23% and 27%. Based on Monte Carlo simulations we recommend 50 and 75 mg/kg/24h amoxicillin in three doses for patients with GA 36-37 and 38-42 weeks, respectively.
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Affiliation(s)
- Y A Bijleveld
- Department of Pharmacy, Academic Medical Center, Amsterdam, The Netherlands
| | - Raa Mathôt
- Department of Pharmacy, Academic Medical Center, Amsterdam, The Netherlands
| | - J H van der Lee
- Paediatric Clinical Research Office, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, The Netherlands
| | - F Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P H Dijk
- Department of Neonatology, University of Groningen, Groningen, The Netherlands
| | - A van Heijst
- Department of Neonatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Shp Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - K P Dijkman
- Department of Neonatology, Máxima Medical Center Veldhoven, Veldhoven, The Netherlands
| | - Hlm van Straaten
- Department of Neonatology, Isala Clinics, Zwolle, The Netherlands
| | - M Rijken
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - I A Zonnenberg
- Department of Neonatology, VU University Medical Center, Amsterdam, The Netherlands
| | - F Cools
- Department of Neonatology, Vrije Universiteit Brussel, Brussels, Belgium
| | - A Zecic
- Department of Neonatology, Academic Medical Center, Gent, Belgium
| | | | - A H van Kaam
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - T R de Haan
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
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9
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Esposito S, Canevini MP, Principi N. Complications associated with antibiotic administration: neurological adverse events and interference with antiepileptic drugs. Int J Antimicrob Agents 2017; 50:1-8. [PMID: 28414069 DOI: 10.1016/j.ijantimicag.2017.01.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 01/28/2017] [Indexed: 11/19/2022]
Abstract
Antibiotic use is associated with toxic effects involving the peripheral and central nervous systems and it may interfere with antiepileptic drugs, causing significant variations in their serum levels and activity. Prompt identification of neurological complications during antibiotic therapy is important in order to make appropriate modifications to medication. Characteristics of the drug and the patient, including age and underlying diseases, may favour these complications. The main aim of this study was to review the neurological adverse events that may follow antibiotic administration, the mechanisms that cause them, and the possibility of prevention and treatment. Moreover, the interference of antibiotics with serum levels and the activity of antiepileptic drugs are discussed. The results demonstrate that antibiotic-associated adverse events involving the nervous system are relatively uncommon and are only rarely severe and irreversible, although neurotoxicity has been reported for several antibiotics. Moreover, for patients receiving antiepileptic drugs, monitoring of drug serum levels to avoid the risk of toxicity or inadequate therapy is mandatory during antibiotic treatment. Areas for future research include the effects of combined antibiotic therapies as well as multiple antiepileptic drugs in study populations with an adequate sample size, including neonates and infants, patients with pharmacoresistant epilepsy and elderly patients.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Università degli Studi di Perugia, Perugia, Italy.
| | - Maria Paola Canevini
- Child Neurology Unit-Epilepsy Center, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Nicola Principi
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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10
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Cies JJ, Fugarolas KN, Moore WS, Mason RW, Menkiti OR. Population Pharmacokinetics and Pharmacodynamic Target Attainment of Ampicillin in Neonates with Hypoxemic-Ischemic Encephalopathy in the Setting of Controlled Hypothermia. Pharmacotherapy 2017; 37:456-463. [DOI: 10.1002/phar.1916] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Jeffrey J. Cies
- The Center for Pediatric Pharmacotherapy LLC; Pottstown Pennsylvania
- St. Christopher's Hospital for Children; Philadelphia Pennsylvania
- Drexel University College of Medicine; Philadelphia Pennsylvania
| | - Keri N. Fugarolas
- St. Christopher's Hospital for Children; Philadelphia Pennsylvania
- Drexel University College of Medicine; Philadelphia Pennsylvania
| | - Wayne S. Moore
- The Center for Pediatric Pharmacotherapy LLC; Pottstown Pennsylvania
| | - Robert W. Mason
- Alfred I. DuPont Hospital for Children; Wilmington Delaware
- Nemours Biomedical Research; Wilmington Delaware
| | - Ogechukwu R. Menkiti
- St. Christopher's Hospital for Children; Philadelphia Pennsylvania
- Drexel University College of Medicine; Philadelphia Pennsylvania
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11
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Hornik CP, Benjamin DK, Smith PB, Pencina MJ, Tremoulet AH, Capparelli EV, Ericson JE, Clark RH, Cohen-Wolkowiez M. Electronic Health Records and Pharmacokinetic Modeling to Assess the Relationship between Ampicillin Exposure and Seizure Risk in Neonates. J Pediatr 2016; 178:125-129.e1. [PMID: 27522443 PMCID: PMC5085855 DOI: 10.1016/j.jpeds.2016.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/27/2016] [Accepted: 07/08/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the relationship between ampicillin dosing, exposure, and seizures. STUDY DESIGN This was a retrospective observational cohort study of electronic health record (EHR) data combined with pharmacokinetic model derived drug exposure predictions. We used the EHR from 348 Pediatrix Medical Group neonatal intensive care units from 1997 to 2012. We included all infants 24-41 weeks gestational age, 500-5400 g birth weight, first exposed to ampicillin prior to 25 days postnatal age. Using a 1-compartment pharmacokinetic model and EHR data, we simulated maximum ampicillin concentration at steady state (Cmaxss, µg/mL) and area under the concentration time curve from 0 to 24 hours (AUC24, µg*h/dL). Using multivariable logistic regression, we evaluated association between ampicillin dosing, exposure, and seizures as documented in the EHR. RESULTS We identified 131 723 infants receiving 134 041 courses of ampicillin for 653 506 infant-days of exposure. The median daily dose was 200 mg/kg/d (25th, 75th percentile; 100, 200). Median Cmaxss and AUC24 were 256.6 µg/mL (164.3, 291.5) and 2593 µg*h/dL (1917, 3334). On multivariable analysis, dosing was not associated with seizures. However increasing Cmaxss (OR = 1.10, 95% CI 1.03, 1.17) and AUC24 (OR 1.11, 95% CI 1.05, 1.18) were associated with increased odds of seizures. CONCLUSIONS In this cohort of hospitalized infants, higher ampicillin exposure was associated with seizures as documented in the EHR.
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Affiliation(s)
- Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Pediatrics, Duke University School of Medicine, Durham, NC.
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Michael J Pencina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Edmund V Capparelli
- Deparment of Biostatistics and Bioinformatics, Duke University, Durham, NC; Skaggs School of Pharmacy, University of California, San Diego, La Jolla, CA
| | | | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Pediatrics, Duke University School of Medicine, Durham, NC
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12
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Serum concentrations of amoxicillin in neonates during continuous intravenous infusion. Eur J Clin Microbiol Infect Dis 2016; 35:1007-12. [DOI: 10.1007/s10096-016-2630-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/18/2016] [Indexed: 12/17/2022]
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El-Ansary A, Bhat RS, Al-Daihan S, Al Dbass AM. The neurotoxic effects of ampicillin-associated gut bacterial imbalances compared to those of orally administered propionic acid in the etiology of persistent autistic features in rat pups: effects of various dietary regimens. Gut Pathog 2015; 7:7. [PMID: 25852770 PMCID: PMC4387705 DOI: 10.1186/s13099-015-0054-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 02/20/2015] [Indexed: 12/31/2022] Open
Abstract
HYPOTHESIS A healthy gut with normal intestinal microflora is completely disrupted by oral antibiotics. The byproducts of harmful gut bacteria can interfere with brain development and may contribute to autism. Strategies to improve the gut microflora profile through dietary modification may help to alleviate gut disorders in autistic patients. METHOD Sixty young male western albino rats were divided into six equal groups. The first group served as the control; the second group was given an oral neurotoxic dose of propionic (PPA) (250 mg/kg body weight/day) for three days. The third group received an orogastric dose of ampicillin (50 mg/kg for three weeks) with a standard diet. Groups 4, 5 and 6 were given an orogastric dose of ampicillin and fed high-carbohydrate, high-protein and high-lipid diets, respectively, for 10 weeks. Biochemical parameters related to oxidative stress were investigated in brain homogenates from each group. RESULT The microbiology results revealed descriptive changes in the fecal microbiota of rats treated with ampicillin either alone or with the three dietary regimens. The results of PPA acid and ampicillin treatment showed significant increases in lipid peroxidation and catalase with decreases in glutathione and potassium compared with levels in the control group. A protein-rich diet was effective at restoring the glutathione level, while the carbohydrate-rich diet recovered lipid peroxidation and catalase activity. In addition, the three dietary regimens significantly increase the potassium level in the brain tissue of the test animals. Lactate dehydrogenase was remarkably elevated in all groups relative to the control. No outstanding effects were observed in glutathione S-transferase and creatine kinase. CONCLUSION The changes observed in the measured parameters reflect the neurotoxic effects of PPA and ampicillin. Lipid peroxide and catalase activity and the levels of glutathione and potassium are satisfactory biomarkers of PPA and ampicillin neurotoxicity. Based on the effects of the three dietary regimens, a balanced diet can protect against PPA or ampicillin-induced neurotoxicity that might induce autistic traits. These outcomes will help efforts directed at controlling the prevalence of autism, a disorder that has recently been associated with PPA neurotoxicity.
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Affiliation(s)
- Afaf El-Ansary
- />Biochemistry Department, Science College, King Saud University, P.O.Box 22452, , Zip code 11495 Riyadh, Saudi Arabia
- />Medicinal Chemistry Department, National Research Centre, Dokki, Cairo Egypt
| | - Ramesa Shafi Bhat
- />Biochemistry Department, Science College, King Saud University, P.O.Box 22452, , Zip code 11495 Riyadh, Saudi Arabia
| | - Sooad Al-Daihan
- />Biochemistry Department, Science College, King Saud University, P.O.Box 22452, , Zip code 11495 Riyadh, Saudi Arabia
| | - Abeer M Al Dbass
- />Biochemistry Department, Science College, King Saud University, P.O.Box 22452, , Zip code 11495 Riyadh, Saudi Arabia
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Mattappalil A, Mergenhagen KA. Neurotoxicity with Antimicrobials in the Elderly: A Review. Clin Ther 2014; 36:1489-1511.e4. [DOI: 10.1016/j.clinthera.2014.09.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 09/24/2014] [Accepted: 09/17/2014] [Indexed: 02/07/2023]
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Tremoulet A, Le J, Poindexter B, Sullivan JE, Laughon M, Delmore P, Salgado A, Ian-U Chong S, Melloni C, Gao J, Benjamin DK, Capparelli EV, Cohen-Wolkowiez M. Characterization of the population pharmacokinetics of ampicillin in neonates using an opportunistic study design. Antimicrob Agents Chemother 2014; 58:3013-20. [PMID: 24614374 PMCID: PMC4068432 DOI: 10.1128/aac.02374-13] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 03/01/2014] [Indexed: 11/20/2022] Open
Abstract
Although ampicillin is the most commonly used drug in neonates, developmental pharmacokinetic (PK) data to guide dosing are lacking. Ampicillin is primarily renally eliminated, and developmental changes are expected to influence PK. We conducted an open-label, multicenter, opportunistic, prospective PK study of ampicillin in neonates stratified by gestational age (GA) (≤ 34 or >34 weeks) and postnatal age (PNA) (≤ 7 or >7 days). Drug concentrations were measured by tandem mass spectrometry. PK data were analyzed using population nonlinear mixed-effects modeling in NONMEM 7.2. Monte Carlo simulations were conducted to determine the probability of target attainment for the time in which the total steady-state ampicillin concentrations remained above the MIC (T>MIC) for 50%, 75%, and 100% of the dosing interval. A total of 142 PK samples from 73 neonates were analyzed (median [range] GA, 36 [24 to 41] weeks; PNA, 5 [0 to 25] days). The median ampicillin dose was 200 (100 to 350) mg/kg/day. Postmenstrual age and serum creatinine were covariates for ampicillin clearance (CL). A simplified dosing regimen of 50 mg/kg every 12 h for GA of ≤ 34 weeks and PNA of ≤ 7 days, 75 mg/kg every 12 h for GA of ≤ 34 weeks and PNA of ≥ 8 and ≤ 28 days, and 50 mg/kg every 8 h for GA of >34 weeks and PNA of ≤ 28 days achieved the prespecified surrogate efficacy target in 90% of simulated subjects. Ampicillin CL was associated with neonatal development. A simplified dosing regimen stratified by GA and PNA achieves the desired surrogate therapeutic target in the vast majority of neonates.
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Affiliation(s)
- Adriana Tremoulet
- University of California, San Diego, School of Medicine, San Diego, California, USA Rady Children's Hospital, San Diego, California, USA
| | - Jennifer Le
- University of California, San Diego, Skaggs School of Pharmacy, San Diego, California, USA
| | | | - Janice E Sullivan
- University of Louisville & Kosair Children's Hospital, Louisville, Kentucky, USA
| | - Matthew Laughon
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Andrea Salgado
- University of California, San Diego, School of Medicine, San Diego, California, USA
| | - Sandy Ian-U Chong
- University of California, San Diego, Skaggs School of Pharmacy, San Diego, California, USA
| | - Chiara Melloni
- Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Jamie Gao
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Edmund V Capparelli
- University of California, San Diego, School of Medicine, San Diego, California, USA University of California, San Diego, Skaggs School of Pharmacy, San Diego, California, USA
| | - Michael Cohen-Wolkowiez
- Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA
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16
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Campbell SC, Spigarelli MG, Courter J, Sherwin CMT. Metabolic and toxicological considerations for sepsis drug treatments. Expert Opin Drug Metab Toxicol 2012; 9:79-89. [DOI: 10.1517/17425255.2012.727396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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17
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Grill MF, Maganti RK. Neurotoxic effects associated with antibiotic use: management considerations. Br J Clin Pharmacol 2011; 72:381-93. [PMID: 21501212 DOI: 10.1111/j.1365-2125.2011.03991.x] [Citation(s) in RCA: 222] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The clinical manifestations of antibiotic-induced neurotoxic effects, the underlying mechanisms and management strategies have been reviewed. PubMed and OVID searches (January 1960-June 2010) were conducted using search terms such as antibiotics, side effects, neurotoxicity and encephalopathy which yielded approximately 300 articles. All relevant case reports, case series, letters and retrospective reviews describing neurotoxic effects and those discussing mechanisms of neurotoxicity were included. Antibiotic-induced neurotoxic side effects can have a myriad of neurologic presentations. Patients with prior central nervous system (CNS) disease, renal insufficiency and advanced age may be particularly vulnerable. Treatment consists of discontinuation of the offending agent, use of antiepileptic drugs in the case of seizures or status epilepticus and haemodialysis in certain cases. The risk of CNS toxicity may be reduced via dosage adjustments in high risk populations. Awareness of the potential neurotoxic clinical manifestations of various antibiotics and high degree of vigilance in critically ill patients is essential in identifying a potentially serious, though reversible complications of antibiotic therapy particularly with the advent of newer antimicrobial agents.
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Affiliation(s)
- Marie F Grill
- University of California San Francisco, San Francisco General Hospital, 1001 Potrero Avenue, 4M62, San Francisco, CA 94110, USA
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18
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Pacifici GM, Labatia J, Mulla H, Choonara I. Clinical pharmacokinetics of penicillins in the neonate: a review of the literature. Eur J Clin Pharmacol 2008; 65:191-8. [DOI: 10.1007/s00228-008-0562-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Accepted: 08/26/2008] [Indexed: 11/30/2022]
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Pullen J, Driessen M, Stolk LML, Degraeuwe PLJ, van Tiel FH, Neef C, Zimmermann LJI. Amoxicillin Pharmacokinetics in (Preterm) Infants Aged 10 to 52 Days: Effect of Postnatal Age. Ther Drug Monit 2007; 29:376-80. [PMID: 17529898 DOI: 10.1097/ftd.0b013e318067de5c] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The pharmacokinetic parameters of amoxicillin were determined in 32 newborn infants aged 10 to 52 days (mean postnatal age, 24.7 +/- 12.4 days) to improve amoxicillin dosing in this age group. Amoxicillin plasma concentrations were determined using reversed-phase high-performance liquid chromatography in surplus plasma samples from routine gentamicin assays. Amoxicillin pharmacokinetic parameters (mean +/- SD) were as follows: first-order elimination constant (K(el)) = 0.27 +/- 0.10 h(-1), volume of distribution corrected for body weight (V/W) = 0.66 +/- 0.27 L/kg, total body clearance corrected for body weight (CL/W) = 0.18 +/- 0.10 Lkg(-1)h(-1), and elimination half-life (t(1/2)) = 3.0 +/- 1.3 hours. Amoxicillin body clearance was approximately twofold greater in our patients compared with published values in younger neonates (mean postnatal age, 0.76 +/- 1.57 days). Simulation studies using the observed amoxicillin pharmacokinetic data suggest an amoxicillin dose of 40 mg/kg administered every 8 hours in infants older than 9 days postnatal age, independent of gestational age and postconceptional age, to achieve satisfactory target plasma amoxicillin concentrations less than 140 mg/L and time above minimum inhibitory concentration of at least 40%. Prospective evaluation of this suggested new dosage regimen is necessary before implementation in the care of ill neonates.
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Affiliation(s)
- J Pullen
- Department of Clinical Pharmacy and Toxicology, University Hospital of Maastricht, Maastricht, The Netherlands.
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20
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Gras-Le Guen C, Boscher C, Godon N, Caillon J, Denis C, Nguyen JM, Kergueris MF, Roze JC. Therapeutic amoxicillin levels achieved with oral administration in term neonates. Eur J Clin Pharmacol 2007; 63:657-62. [PMID: 17497144 DOI: 10.1007/s00228-007-0307-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2006] [Accepted: 03/28/2007] [Indexed: 01/15/2023]
Abstract
AIMS The standard treatment of neonatal group B Streptococcus infection is intravenous amoxicillin for 10 days. We investigated whether effective serum amoxicillin concentrations could be reached by switching to oral amoxicillin after 48 h of intravenous administration in full-term neonates with group B Streptococcus infection. METHODS Over 2 years, we included 222 full-term neonates who had early onset group B streptococcal disease responsive to 48 h of intravenous amoxicillin, at which point they were asymptomatic and fed orally. They were switched to oral amoxicillin (300 or 200 mg/kg per day in four divided doses). Steady-state serum amoxicillin concentrations were determined 48 h later by high-performance liquid chromatography; values > or =5 mg/l were considered effective. RESULTS Mean gestational age was 39.32 +/- 1.5 weeks ,and mean birth weight was 3,422 +/- 533 g; 29 newborns were bacteremic. Median serum amoxicillin concentration on oral therapy was 31,.15 (range 11-118) and 25.80 (range 5-84.8) with 300 and 200 mg/kg per day, respectively. None of the infants had a concentration <5 mg/l (p < 0.001). Gastrointestinal tolerance was satisfactory; 216 patients were discharged at 5 days of age, and none was readmitted within the 3-month follow-up. CONCLUSION Early switching to the oral route in asymptomatic full-term newborns with early onset group B streptococcal disease maintained serum amoxicillin concentrations within our predefined therapeutic range (error risk<0.001). This strategy may hold potential for reducing treatment invasiveness and shortening hospital length of stay.
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Affiliation(s)
- Christele Gras-Le Guen
- Pediatric and Neonatal Critical Care Division, Department of Perinatology, Hôpital Mère Enfant, Centre Hospitalier Universitaire, 38 Bd J Monnet, 44099 Nantes, Cedex, France.
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Pullen J, Stolk LML, Nieman FHM, Degraeuwe PLJ, van Tiel FH, Zimmermann LJI. Population pharmacokinetics and dosing of amoxicillin in (pre)term neonates. Ther Drug Monit 2006; 28:226-31. [PMID: 16628135 DOI: 10.1097/01.ftd.0000198648.39751.11] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Amoxicillin plasma concentrations, pharmacokinetic parameters, and the influence of demographic, anthropometric, and clinical covariates were investigated in 150 neonates. Gestational age (GA) ranged from 25 to 42 weeks and mean postnatal age (PNA) was 0.8 days. Amoxicillin concentrations were measured with reversed-phase HPLC in surplus plasma from routine assays of coadministered gentamicin. Mean total body clearance corrected for body weight (CL/W) was 0.096 +/- 0.036 L/kg(-1)h(-1), mean elimination half-life (t(1/2)) was 5.2 +/- 1.9 hours, and mean volume of distribution corrected for body weight (V/W) was 0.65 +/- 0.13 L/kg. Multiple regression equations were calculated for the prediction of CL/W amoxicillin. CL/W gentamicin, V/W gentamicin, and GA were significant predictors of CL/W amoxicillin. Amoxicillin peak and trough concentrations after the second dose and the time the concentration exceeds the minimum inhibitory concentration (T>MIC), reached with the current dosage regimen, were evaluated. Toxic plasma concentrations were reached in several patients. Therefore, the authors have proposed a lower dosage regimen, based on GA, population pharmacokinetic parameters, bacterial susceptibility (T>MIC), and possible toxicity: 15 mg/kg per 8 hours and 20 mg/kg per 8 hours for neonates with GA < or = 34 and GA>34 weeks, respectively. Simulation with this new dosage regimen indicated that satisfactory plasma concentrations were reached in all 150 neonates. Therefore, use of therapeutic drug monitoring and pharmacokinetic calculations for dosage adjustment is generally not necessary.
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Affiliation(s)
- Joyce Pullen
- Department of Clinical Pharmacy and Toxicology, University Hospital of Maastricht, The Netherlands.
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Henry NK, Hoecker JL, Rhodes KH. Antimicrobial therapy for infants and children: guidelines for the inpatient and outpatient practice of pediatriac infectious diseases. Mayo Clin Proc 2000; 75:86-97. [PMID: 10630763 DOI: 10.4065/75.1.86] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In this article, we discuss antimicrobial regimens for both outpatient and inpatient use in infants and children. A substantial number of pediatric patient visits annually result in the prescribing of antimicrobial drugs. The emergence of bacteria resistant to commonly used antimicrobial agents is a growing concern. Information on newer drugs such as meropenem, which is active against penicillin-resistant Streptococcus pneumoniae and gram-negative bacilli, and cefepime, which has activity against gram-negative bacilli including Pseudomonas aeruginosa and against gram-positive cocci is also presented. Management of patients with congenital or acquired immunodeficiencies continues to be challenging in regard to the use of antimicrobial drugs to treat various fungal and viral infections. New formulations of older drugs such as aerosolized tobramycin and amphotericin B lipid complex are available. New antiviral agents have been approved, most of which are antiretroviral agents. Childhood tuberculosis is an ongoing concern, and regimens to treat Mycobacterium tuberculosis in children are discussed.
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Affiliation(s)
- N K Henry
- Section of Pediatric Infectious Diseases, Mayo Clinic Rochester, Minnesota 55905, USA
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