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Alrahahleh D, Thoma Y, Van Daele R, Nguyen T, Halena S, Luig M, Stocker S, Kim HY, Alffenaar JW. Bayesian Vancomycin Model Selection for Therapeutic Drug Monitoring in Neonates. Clin Pharmacokinet 2024; 63:367-380. [PMID: 38416322 PMCID: PMC10954945 DOI: 10.1007/s40262-024-01353-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND AND OBJECTIVE Pharmacokinetic models can inform drug dosing of vancomycin in neonates to optimize therapy. However, the model selected needs to describe the intended population to provide appropriate dose recommendations. Our study aims to identify the population pharmacokinetic (PopPK) model(s) with the best performance to predict vancomycin exposure in neonates in our hospital. METHODS Relevant published PopPK models for vancomycin in neonates were selected based on demographics and vancomycin dosing strategy. The predictive performance of the models was evaluated in Tucuxi using a local cohort of 69 neonates. Mean absolute error (MAE), relative bias (rBias) and relative root mean square error (rRMSE) were used to quantify the accuracy and precision of the predictive performance of each model for three different approaches: a priori, a posteriori, and Bayesian forecasting for the next course of therapy based on the previous course predictions. A PopPK model was considered clinically acceptable if rBias was between ± 20 and 95% confidence intervals included zero. RESULTS A total of 25 PopPK models were identified and nine were considered suitable for further evaluation. The model of De Cock et al. 2014 was the only clinically acceptable model based on a priori [MAE 0.35 mg/L, rBias 0.8 % (95% confidence interval (CI) - 7.5, 9.1%), and rRMSE 8.9%], a posteriori [MAE 0.037 mg/L, rBias - 0.23% (95% CI - 1.3, 0.88%), and rRMSE 6.02%] and Bayesian forecasting for the next courses [MAE 0.89 mg/L, rBias 5.45% (95% CI - 8.2, 19.1%), and rRMSE 38.3%) approaches. CONCLUSIONS The De Cock model was selected based on a comprehensive approach of model selection to individualize vancomycin dosing in our neonates.
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Affiliation(s)
- Dua'a Alrahahleh
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- Westmead Hospital, Westmead, NSW, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
| | - Yann Thoma
- School of Engineering and Management Vaud, HES-SO University of Applied Sciences and Arts Western Switzerland, 1400, Yverdon-les-Bains, Switzerland
| | - Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, 3000, Leuven, Belgium
| | - Thi Nguyen
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- Westmead Hospital, Westmead, NSW, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
| | - Stephanie Halena
- Department of Pharmacy, Westmead Hospital, NSW, Westmead, Australia
| | - Melissa Luig
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
| | - Sophie Stocker
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- Westmead Hospital, Westmead, NSW, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
| | - Hannah Yejin Kim
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
- Department of Pharmacy, Westmead Hospital, NSW, Westmead, Australia
| | - Jan-Willem Alffenaar
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia.
- Westmead Hospital, Westmead, NSW, Australia.
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia.
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Haag H, Lau A. Correlation of Calculated Vancomycin Trough Concentrations and Exposure: A Monte Carlo Simulation. Ann Pharmacother 2023; 57:1410-1414. [PMID: 36999486 DOI: 10.1177/10600280231160571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Current recommendations are to dose vancomycin to target 24-hour area under the curve (AUC) of 400-600 mg·h/L to optimize efficacy and safety. Limited data support AUC monitoring, and some centers continue to use trough concentrations. A target of 10-20 mg/L has been proposed to reduce nephrotoxicity risk. OBJECTIVE To use previously published pharmacokinetic equations in a Monte Carlo simulation relating AUC exposure to trough concentrations when targeting an AUC between 400 and 600 mg·h/L. METHODS Previously published pharmacokinetic data were used as input parameters for a Monte Carlo simulation using previously published formulae to correlate AUC to simulated trough concentrations. Pharmacokinetic parameters were assumed to occur in a normal distribution pattern. We excluded irrelevant simulated cases. Maintenance doses of 15 mg/kg were rounded to the nearest 250 mg. Calculated trough concentrations for AUCs of both 400 and 600 mg·h/L were evaluated in each simulation. RESULTS A total of 10 000 Monte Carlo simulations were performed. Targeting an AUC of 400 mg·h/L resulted in a mean trough concentration of 10.3 ± 0.8 mg/L. Targeting an AUC of 600 mg·h/L resulted in a mean trough concentration of 15.4 ± 1.2 mg/L. CONCLUSION AND RELEVANCE We demonstrate that a lower trough concentration range may be supported by an AUC of 400-600 mg·h/L, which may reduce risk and rates of nephrotoxicity without compromising previously established efficacious target trough concentrations.
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Affiliation(s)
- Hans Haag
- Vancouver General Hospital, Vancouver, BC, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Anthony Lau
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
- Emergency Medicine, Vancouver General Hospital, Vancouver, BC, Canada
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Treshchalin MI, Polozkova VA, Moiseenko EI, Shchekotikhin AE, Dovzhenko SA, Kobrin MB, Pereverzeva ER. Experimental Evaluation of the Hypersensitivity Reactions of a New Glycopeptide Antibiotic Flavancin in Animal Models. Pharmaceuticals (Basel) 2023; 16:1569. [PMID: 38004435 PMCID: PMC10675777 DOI: 10.3390/ph16111569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
Glycopeptide antibiotics are still in demand in clinical practice for treating infections caused by resistant gram-positive pathogens; however, their use is limited due to severe adverse reactions. Their predominant types of side effects are immunoglobulin E-mediated or nonmediated hypersensitivity reactions. Therefore, the development of new glycopeptide antibiotics with improved toxicity profiles remains an important objective in advancing modern antimicrobial agents. We investigated a new eremomycin aminoalkylamide flavancin, its anaphylactogenic properties, influence on histamine levels in blood plasma, pseudoallergic inflammatory reaction on concanavalin A and the change in the amount of flavancin in the blood plasma after administration. It has been shown that flavancin does not demonstrate anaphylactogenic properties. The injection of flavancin resulted in a level of histamine in the blood three times lower than that caused by vancomycin. The therapeutic dose of vancomycin led to a statistically significant increase in the concanavalin A response index compared to flavancin (54% versus 3.7%). Thus, flavancin does not cause a pseudo-allergic reaction. The rapid decrease in flavancin concentration in the blood and the low levels of histamine in the plasma lead us to assume that any pseudoallergic reactions resulting from flavancin application, if they do occur in clinical practice, will be significantly less compared to the use of vancomycin.
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Affiliation(s)
- Michael I. Treshchalin
- Gause Institute of New Antibiotics, 11 B. Pirogovskaya Street, 119021 Moscow, Russia; (V.A.P.); (E.I.M.); (A.E.S.); (S.A.D.); (M.B.K.); (E.R.P.)
| | - Vasilisa A. Polozkova
- Gause Institute of New Antibiotics, 11 B. Pirogovskaya Street, 119021 Moscow, Russia; (V.A.P.); (E.I.M.); (A.E.S.); (S.A.D.); (M.B.K.); (E.R.P.)
| | - Elena I. Moiseenko
- Gause Institute of New Antibiotics, 11 B. Pirogovskaya Street, 119021 Moscow, Russia; (V.A.P.); (E.I.M.); (A.E.S.); (S.A.D.); (M.B.K.); (E.R.P.)
| | - Andrey E. Shchekotikhin
- Gause Institute of New Antibiotics, 11 B. Pirogovskaya Street, 119021 Moscow, Russia; (V.A.P.); (E.I.M.); (A.E.S.); (S.A.D.); (M.B.K.); (E.R.P.)
- Organic Chemistry Department, Mendeleyev University of Chemical Technology of Russia, 9 Miusskaya Square, 125047 Moscow, Russia
| | - Svetlana A. Dovzhenko
- Gause Institute of New Antibiotics, 11 B. Pirogovskaya Street, 119021 Moscow, Russia; (V.A.P.); (E.I.M.); (A.E.S.); (S.A.D.); (M.B.K.); (E.R.P.)
| | - Mikhail B. Kobrin
- Gause Institute of New Antibiotics, 11 B. Pirogovskaya Street, 119021 Moscow, Russia; (V.A.P.); (E.I.M.); (A.E.S.); (S.A.D.); (M.B.K.); (E.R.P.)
| | - Eleonora R. Pereverzeva
- Gause Institute of New Antibiotics, 11 B. Pirogovskaya Street, 119021 Moscow, Russia; (V.A.P.); (E.I.M.); (A.E.S.); (S.A.D.); (M.B.K.); (E.R.P.)
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Legg A, Davis JS, Roberts JA. Optimal drug therapy for Staphylococcus aureus bacteraemia in adults. Curr Opin Crit Care 2023; 29:446-456. [PMID: 37641503 DOI: 10.1097/mcc.0000000000001072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Staphylococcus aureus is a significant human pathogen, causing a variety of infections, from skin and soft tissue infections to endocarditis, bone and joint infections and deep tissue abscesses. Mortality from S. aureus bacteraemia remains high, without major therapeutic advances in recent decades. RECENT FINDINGS In recent years, optimized dosing of antibiotics is increasingly being recognized as a cornerstone of management for severe infections including S. aureus bacteraemia. This comprehensive review details the pharmacokinetics/pharmacodynamics (PK/PD) targets for commonly used antistaphylococcal antibiotics and the doses predicted to achieve them in clinical practice. Recent advances in dosing of teicoplanin and use of cefazolin in CNS infections and findings from combination therapy studies are discussed. Drug exposure relationships related to toxicity are also detailed. SUMMARY This review details the different PK/PD targets for drugs used to treat S. aureus bacteraemia and how to apply them in various scenarios. The drug doses that achieve them, and the risks of toxicity are also provided.
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Affiliation(s)
- Amy Legg
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory
- Herston Infectious Diseases Institute, Metro North Health, Brisbane, Queensland
| | - Joshua S Davis
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales
| | - Jason A Roberts
- Herston Infectious Diseases Institute, Metro North Health, Brisbane, Queensland
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
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Arensman Hannan KN, Rivera CG, Fewel N. Vancomycin AUC values estimated with trough-only data: Accuracy in an adult academic medical center population. Am J Health Syst Pharm 2023; 80:452-456. [PMID: 36525590 DOI: 10.1093/ajhp/zxac372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Vancomycin area under the concentration-time curve (AUC) can be calculated using steady-state serum peak and trough concentrations; however, compared to traditional trough-only monitoring, this approach requires an additional blood sample. Recently published data demonstrated vancomycin AUC estimations using trough-only data with a volume of distribution (Vd) model incorporating age and actual body weight were reasonably accurate and precise in a veteran population. This study sought to extend these methods to a Mayo Clinic adult population. METHODS A retrospective, observational cohort of adult patients with documented steady-state vancomycin peak and trough concentrations was evaluated. Vancomycin AUCs were estimated using trough-only data, and 4 Vd models were assessed for accuracy and precision. Estimated AUCs were compared to AUCs calculated using 1-compartment intermittent infusion equations and steady-state peak and trough ("peak-trough") data. RESULTS The study population (N = 95) was 46% female, with a median age of 59 years and a median weight of 97 kg. Using the VancoPK equation Vd = 0.29 (age in y) + 0.33 (actual weight in kg) + 11, the mean peak-trough and estimated trough-only AUC were 533 and 534, respectively, with a correlation of 0.936. The root mean square error was 47.7, meaning about 95% of AUCs were within 95 mg · h/L of peak-trough AUCs. CONCLUSIONS Accuracy and precision of Vancomycin AUC estimations using trough-only data and the described Vd model were demonstrated in a Mayo Clinic cohort. Targeting an estimated AUC of 500 mg · h/L using the VancoPK model would likely result in an actual AUC within 400 to 600 mg · h/L.
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Affiliation(s)
| | | | - Nathan Fewel
- Department of Pharmacy, Central Texas Veterans Health Care System, Temple, TX, USA
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Tochikura N, Matsumoto C, Iwabuchi S, Aso H, Fukushima S, Ootsuka S, Ooba N, Ishihara M, Nakajima H, Umemura H, Nakayama T. Pharmacokinetic/pharmacodynamic analysis of vancomycin in patients with Enterococcus faecium bacteraemia: a retrospective cohort study. Eur J Hosp Pharm 2023:ejhpharm-2022-003672. [PMID: 36868850 DOI: 10.1136/ejhpharm-2022-003672] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVES The trough concentration of vancomycin and the area under the concentration-time curve (AUC)/minimum inhibitory concentration (MIC) ratio are crucial in determining vancomycin efficacy against methicillin-resistant Staphylococcus aureus. However, the use of similar pharmacokinetic principles in determining antibiotic efficacy against other gram-positive cocci is lacking. We performed a pharmacokinetic/pharmacodynamic analysis (association of target trough concentration values and AUC/MIC with therapeutic outcome) of vancomycin in patients with Enterococcus faecium bacteraemia. METHODS Between January 2014 and December 2021 we performed a retrospective cohort study of patients with E. faecium bacteraemia treated with vancomycin. Patients who received renal replacement therapy or had chronic kidney disease were excluded. Clinical failure, the primary outcome, was defined as a composite of 30-day all-cause mortality, vancomycin-susceptible infection requiring change of treatment, and/or recurrence. AUC24 was estimated using a Bayesian estimation approach based on an individual vancomycin trough concentration. The MIC for vancomycin was determined using a standardised agar dilution method. Additionally, classification was used to identify the vancomycin AUC24/MIC ratio associated with clinical failure. RESULTS Of the 151 patients identified, 69 were enrolled. All MICs of vancomycin for E. faecium were ≤1.0 µg/mL. The AUC24 and AUC24/MIC ratio were not significantly different between the clinical failure group and the clinical success group (432±123 µg/mL/hour vs 488±92 µg/mL/hour; p=0.075). However, 7 of 12 patients (58.3%) in the clinical failure group and 49 of 57 patients (86.0%) in the clinical success group had a vancomycin AUC24/MIC ratio ≥389 (p=0.041). No significant association between trough concentration or AUC24 ≥600 µg/mL×hour and acute kidney injury was observed (p=0.365 and p=0.487, respectively). CONCLUSION The AUC24/MIC ratio is associated with the clinical outcome of vancomycin administration in E. faecium bacteraemia. In Japan, where vancomycin-resistant enterococcal infection is rare, empirical therapy with a target AUC24 ≥389 should be recommended.
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Affiliation(s)
- Naohiro Tochikura
- Department of Pharmacy, Nihon University Itabashi Hospital, Itabashi-ku, Tokyo, Japan
| | - Chiaki Matsumoto
- Department of Pharmacy, Nihon University Itabashi Hospital, Itabashi-ku, Tokyo, Japan
| | - So Iwabuchi
- Department of Pharmacy, Nihon University Itabashi Hospital, Itabashi-ku, Tokyo, Japan
| | - Hiroya Aso
- Department of Pharmacy, Nihon University Itabashi Hospital, Itabashi-ku, Tokyo, Japan
| | - Sakae Fukushima
- Department of Pharmacy, Nihon University Itabashi Hospital, Itabashi-ku, Tokyo, Japan
| | - Susumu Ootsuka
- Department of Pharmacy, Nihon University Itabashi Hospital, Itabashi-ku, Tokyo, Japan
| | - Nobuhiro Ooba
- Department of Clinical Pharmacy, Nihon University School of Pharmacy, Funabashi, Chiba, Japan
| | - Masaki Ishihara
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Hideto Nakajima
- Division of Neurology, Department of Medicine, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Hiroshi Umemura
- Division of Laboratory Medicine, Department of Pathology and Microbiology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Tomohiro Nakayama
- Division of Laboratory Medicine, Department of Pathology and Microbiology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
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Nix DE, Davis LE, Matthias KR. Response to Rybak et al. Am J Health Syst Pharm 2022; 79:1308-1311. [PMID: 35511826 DOI: 10.1093/ajhp/zxac126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
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Affiliation(s)
- David E Nix
- Department of Pharmacy Practice & Science University of Arizona Tucson, AZ, USA
| | - Lisa E Davis
- Department of Pharmacy Practice & Science University of Arizona Tucson, AZ, USA
| | - Kathryn R Matthias
- Department of Pharmacy Practice & Science University of Arizona Tucson, AZ, USA
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