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Hambrick HR, Cervantes F, Dong M, Tang P, Arbough T, Vinks AA, Mizuno T, Goldstein SL, Kaplan J, Girdwood, ST. Ceftriaxone Pharmacokinetics and Pharmacodynamic Target Attainment for Three Pediatric Patients Receiving Continuous Kidney Replacement Therapy. J Pediatr Pharmacol Ther 2024; 29:180-187. [PMID: 38596427 PMCID: PMC11001209 DOI: 10.5863/1551-6776-29.2.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/16/2023] [Indexed: 04/11/2024]
Abstract
Ceftriaxone is used commonly for sepsis, including in children requiring continuous kidney replacement therapy (CKRT). No reports exist of pharmacokinetic (PK) parameters for children receiving ceftriaxone on CKRT. We enrolled children admitted to our pediatric intensive care unit (PICU) who received CKRT for >24 hours and received >1 dose of ceftriaxone while on and off CKRT. We measured free ceftriaxone -concentrations from residual blood samples then used Bayesian estimation with PK modeling software to generate concentration-time profiles and determine PK parameters and the percentage of time free ceftriaxone concentrations were above 1× or 4× MIC (% fT >MIC). Three patients aged 2 to 17 years were included; all were anuric at CKRT initiation and received 50 mg/kg (max 2000 mg) ceftriaxone every 12 to 24 hours. Total ceftriaxone clearance (CL) was 0.50 to 3.67 L/hr while receiving CKRT and 0.29 to 2.71 L/hr while off, indicating CKRT provided 25% to 42% of total ceftriaxone CL. All achieved 100% fT >1× and 4× MIC using an estimated MIC (1 mg/L) for patients 1 to 2 (no culture data) and a measured MIC (0.016 mg/L) for patient 3. Therefore, CKRT contributed significantly to total ceftriaxone clearance in 3 children though the dosing strategies used in each patient attained PD targets.
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Affiliation(s)
- H. Rhodes Hambrick
- Division of Nephrology and Hypertension (HRH, SLG), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Division of Clinical Pharmacology (HRH, MD, AAV, TM, STG), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Francisco Cervantes
- Department of Medical Education (FC), University of Cincinnati College of Medicine, Cincinnati, OH
| | - Min Dong
- Division of Clinical Pharmacology (HRH, MD, AAV, TM, STG), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics (MD, PT, AAV, TM, SLG, JK, STG), University of Cincinnati College of Medicine, Cincinnati, OH
| | - Peter Tang
- Department of Pediatrics (MD, PT, AAV, TM, SLG, JK, STG), University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Pathology and Laboratory Medicine (PT), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Trent Arbough
- Department of Anesthesiology (TA), University of Kentucky College of Medicine, Lexington, KY
| | - Alexander A. Vinks
- Division of Clinical Pharmacology (HRH, MD, AAV, TM, STG), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics (MD, PT, AAV, TM, SLG, JK, STG), University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology (HRH, MD, AAV, TM, STG), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics (MD, PT, AAV, TM, SLG, JK, STG), University of Cincinnati College of Medicine, Cincinnati, OH
| | - Stuart L. Goldstein
- Division of Nephrology and Hypertension (HRH, SLG), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Division of Clinical Pharmacology (HRH, MD, AAV, TM, STG), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics (MD, PT, AAV, TM, SLG, JK, STG), University of Cincinnati College of Medicine, Cincinnati, OH
- Center for Acute Care Nephrology (SLG), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jennifer Kaplan
- Department of Pediatrics (MD, PT, AAV, TM, SLG, JK, STG), University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Critical Care Medicine (JK), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Sonya Tang Girdwood,
- Department of Pediatrics (MD, PT, AAV, TM, SLG, JK, STG), University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Hospital Medicine (STG), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Thy M, Naudin J, Genuini M, Leteurtre S, Recher M, Oualha M. Anti-infective prescribing practices in critically ill children on continuous renal replacement therapy: a multicenter survey of French-speaking countries. J Nephrol 2023; 36:2541-2547. [PMID: 37698831 DOI: 10.1007/s40620-023-01762-1] [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: 04/18/2023] [Accepted: 08/13/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Use of continuous renal replacement therapy in children receiving anti-infective drugs may lead to inappropriate concentrations with risks related to treatment failure, toxicity and emergence of multidrug-resistant bacteria. We aimed to describe anti-infective prescribing practices in critically ill children undergoing continuous renal replacement therapy. METHODS An online survey to assess continuous renal replacement therapy, anti-infective prescribing and therapeutic drug monitoring practices was sent by e-mail to physicians working in pediatric intensive care units through the French-speaking Group of Pediatric Intensive Care and Emergency medicine (GFRUP). RESULTS From April 1st, 2021 to May 1st, 2021, 26/40 pediatric intensive care units participated in the survey, corresponding to a response rate of 65%. Twenty-one were located in France and five abroad. All pediatric intensive care units administered continuous renal replacement therapy, primarily with Prismaflex™ System. Anti-infective prescriptions were adjusted to the presence of continuous renal replacement therapy in 23 (88%) pediatric intensive care units mainly according to molecular weight in 6 (23%), molecule protein binding in 6 (23%) and elimination routes in 15 (58%) including residual diuresis in 9 (35%), to the continuous renal replacement therapy flow in 6 (23%) and to the modality of continuous renal replacement therapy used in 15 (58%), pediatric intensive care units. There was broad variability among pediatric intensive care units and among physicians within the same unit. Barriers to therapeutic drug monitoring were mainly an excessive delay in obtaining results in 11 (42%) and the lack of an on-site laboratory in 8 (31%) pediatric intensive care units. CONCLUSIONS Our survey reported wide variability in anti-infective prescribing practices in children undergoing continuous renal replacement therapy, thus highlighting a gap in knowledge and the need for education and recommendations.
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Affiliation(s)
- Michaël Thy
- Department of Intensive Care and Infectious Diseases, AP-HP, Université Paris Cité, Bichat Hospital, Paris, France.
- Pediatric Intensive Care Unit, AP-HP, Université Paris Cité, Necker-Enfants Malades Hospital, Paris, France.
- EA 7323-Pharmacology and Therapeutic Evaluation in Children and Pregnant Women, Université Paris Cité, Paris, France.
| | - Jérôme Naudin
- Pediatric Intensive Care Unit, Hôpital Robert Debré, AP-HP, Université Paris Diderot, Paris, France
| | - Mathieu Genuini
- Pediatric Intensive Care Unit, Hôpital Robert Debré, AP-HP, Université Paris Diderot, Paris, France
- Pediatric Intensive Care Transport Unit, Hôpital Robert Debré, AP-HP, Université Paris Diderot, Paris, France
| | - Stéphane Leteurtre
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Morgan Recher
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, AP-HP, Université Paris Cité, Necker-Enfants Malades Hospital, Paris, France
- EA 7323-Pharmacology and Therapeutic Evaluation in Children and Pregnant Women, Université Paris Cité, Paris, France
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Hunt JP, McKnite AM, Green DJ, Whelan AJ, Imburgia CE, Watt KM. Interaction of ceftazidime and clindamycin with extracorporeal life support. J Infect Chemother 2023; 29:1119-1125. [PMID: 37572979 PMCID: PMC11160944 DOI: 10.1016/j.jiac.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Ceftazidime and clindamycin are commonly prescribed to critically ill patients who require extracorporeal life support such as ECMO and CRRT. The effect of ECMO and CRRT on the disposition of ceftazidime and clindamycin is currently unknown. METHODS Ceftazidime and clindamycin extraction were studied with ex vivo ECMO and CRRT circuits primed with human blood. The percent recovery of these drugs over time was calculated to determine the degree of interaction between these drugs and circuit components. RESULTS Neither ceftazidime nor clindamycin exhibited measurable interactions with the ECMO circuit. In contrast, CRRT cleared 100% of ceftazidime from the experimental circuit within the first 2 h. Clearance of clindamycin from the CRRT circuit was slower, with about 20% removed after 6 h. CONCLUSION Clindamycin and ceftazidime dosing adjustments are likely required in patients who are supported with CRRT, and future studies to quantify these adjustments should consider the pathophysiology of the patient in combination with the clearance due to CRRT. Dosing adjustments to account for adsorption to ECMO circuit components are likely unnecessary and should focus instead on the pathophysiology of the patient and changes in volume of distribution. These results will help improve the safety and efficacy of ceftazidime and clindamycin in patients requiring ECMO and CRRT.
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Affiliation(s)
- J. Porter Hunt
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Autumn M. McKnite
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah, USA
| | - Danielle J. Green
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Aviva J. Whelan
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Carina E. Imburgia
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Kevin M. Watt
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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Pavia K, Hambrick HR, Paice K, Tang P, Punt N, Kaplan J, Goldstein SL, Vinks AA, Mizuno T, Tang Girdwood S. Cefepime pharmacokinetics in critically ill children and young adults undergoing continuous kidney replacement therapy. J Antimicrob Chemother 2023; 78:2140-2147. [PMID: 37466170 PMCID: PMC10477133 DOI: 10.1093/jac/dkad192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/05/2023] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES Cefepime is an antibiotic commonly used to treat sepsis and is cleared by renal excretion. Cefepime dosing requires adjustment in patients with decreased kidney function and in those receiving continuous kidney replacement therapy (CKRT). We aimed to characterize cefepime PK in a diverse cohort of critically ill paediatric patients on CKRT. METHODS Patients were identified from an ongoing pharmacokinetic/pharmacodynamic (PK/PD) study of beta-lactam antibiotics, and were included if they had received at least two cefepime doses in the ICU and were on CKRT for at least 24 h. PK parameters were estimated using MwPharm++ with Bayesian estimation and a paediatric population PK model. Target attainment was assessed as time of free cefepime concentrations above minimum inhibitory concentration (fT > 1× or 4 × MIC). RESULTS Seven patients were included in the study (ages 2 to 20 years). CKRT indications included liver failure (n = 1), renal failure (n = 4) and fluid overload (n = 2). Total effluent flow rates ranged from 1833 to 3115 (mean 2603) mL/1.73 m2/h, while clearance was 2.11-3.70 (mean 3.0) L/h/70 kg. Effluent flows were lower, but clearance and fT > MIC were similar to paediatric data published previously. Using Pseudomonas aeruginosa MIC breakpoints, all patients had 100% of dosing interval above MIC, but only one had 100% of dosing interval above 4× MIC. CONCLUSIONS Since most patients failed to attain stringent targets of 100% fT > 4× MIC, model-informed precision dosing may benefit such patients.
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Affiliation(s)
- Kathryn Pavia
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - H Rhodes Hambrick
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kelli Paice
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Tang
- Division of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nieko Punt
- University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
- Medimatics, Maastricht, The Netherlands
| | - Jennifer Kaplan
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sonya Tang Girdwood
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Tang Girdwood S, Pavia K, Paice K, Hambrick HR, Kaplan J, Vinks AA. β-lactam precision dosing in critically ill children: Current state and knowledge gaps. Front Pharmacol 2022; 13:1044683. [PMID: 36532752 PMCID: PMC9752101 DOI: 10.3389/fphar.2022.1044683] [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: 09/14/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
There has been emerging interest in implementing therapeutic drug monitoring and model-informed precision dosing of β-lactam antibiotics in critically ill patients, including children. Despite a position paper endorsed by multiple international societies that support these efforts in critically ill adults, implementation of β-lactam precision dosing has not been widely adopted. In this review, we highlight what is known about β-lactam antibiotic pharmacokinetics and pharmacodynamics in critically ill children. We also define the knowledge gaps that present barriers to acceptance and implementation of precision dosing of β-lactam antibiotics in critically ill children: a lack of consensus on which subpopulations would benefit most from precision dosing and the uncertainty of how precision dosing changes outcomes. We conclude with opportunities for further research to close these knowledge gaps.
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Affiliation(s)
- Sonya Tang Girdwood
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States,*Correspondence: Sonya Tang Girdwood,
| | - Kathryn Pavia
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Kelli Paice
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - H. Rhodes Hambrick
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Jennifer Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States,Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Alexander A. Vinks
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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