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Amann LF, Broeker A, Riedner M, Rohde H, Huang J, Nordmann P, Decousser JW, Wicha SG. Pharmacokinetic/pharmacodynamic evaluation of tigecycline dosing in a hollow fiber infection model against clinical bla-KPC producing Klebsiella Pneumoniae isolates. Diagn Microbiol Infect Dis 2024; 108:116153. [PMID: 38086168 DOI: 10.1016/j.diagmicrobio.2023.116153] [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] [Received: 02/22/2023] [Revised: 11/23/2023] [Accepted: 11/29/2023] [Indexed: 01/22/2024]
Abstract
The FDA announced a boxed warning for tigecycline due to progression of infections caused by Gram-negative bacteria and increased risk of mortality during treatment. Plasma exposure of tigecycline might not prevent bacteraemia in these cases from the focuses. Hence, we evaluated intensified dosing regimens and breakpoints that might suppress bloodstream infections, caused by progression of infection by e.g., Gram-negatives. A pharmacometric model was built from tigecycline concentrations (100-600 mg daily doses) against clinical Klebsiella pneumoniae isolates (MIC 0.125-0.5 mg/L). Regrowth occurred at clinically used doses and stasis was only achieved with 100 mg q8h for the strain with the lowest studied MIC of 0.125 mg/L. Stasis at 24 h was related to fAUC/MIC of 38.5. Our study indicates that even intensified dosing regimens might prevent bloodstream infections only for MIC values ≤0.125 mg/L for tigecycline. This indicates an overly optimistic breakpoint of 1 mg/L for Enterobacterales, which are deemed to respond to the tigecycline high dose regimen (EUCAST Guidance Document on Tigecycline Dosing 2022).
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Affiliation(s)
- Lisa F Amann
- Deptartement of Clinical Pharmacy, Institute of Pharmacy, Universität Hamburg, Hamburg, Germany
| | - Astrid Broeker
- Deptartement of Clinical Pharmacy, Institute of Pharmacy, Universität Hamburg, Hamburg, Germany
| | - Maria Riedner
- Technology Platform Mass Spectrometry, Universität Hamburg, Hamburg, Germany
| | - Holger Rohde
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Jiabin Huang
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Patrice Nordmann
- Medical and Molecular Microbiology, University of Fribourg, Fribourg, Switzerland
| | - Jean-Winoc Decousser
- Dynamic Team-EA 7380, Faculté de santé, Université Paris-Est-Créteil Val-De-Marne, France
| | - Sebastian G Wicha
- Deptartement of Clinical Pharmacy, Institute of Pharmacy, Universität Hamburg, Hamburg, Germany.
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Amann LF, Alraish R, Broeker A, Kaffarnik M, Wicha SG. Tigecycline Dosing Strategies in Critically Ill Liver-Impaired Patients. Antibiotics (Basel) 2022; 11:antibiotics11040479. [PMID: 35453230 PMCID: PMC9028393 DOI: 10.3390/antibiotics11040479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 12/04/2022] Open
Abstract
This study investigated tigecycline exposure in critically ill patients from a population pharmacokinetic perspective to support rational dosing in intensive care unit (ICU) patients with acute and chronic liver impairment. A clinical dataset of 39 patients served as the basis for the development of a population pharmacokinetic model. The typical tigecycline clearance was strongly reduced (8.6 L/h) as compared to other populations. Different models were developed based on liver and kidney function-related covariates. Monte Carlo simulations were used to guide dose adjustments with the most predictive covariates: Child–Pugh score, total bilirubin, and MELD score. The best performing covariate, guiding a dose reduction to 25 mg q12h, was Child–Pugh score C, whereas patients with Child–Pugh score A/B received the standard dose of 50 mg q12h. Of note, the obtained 24 h steady-state area under the concentration vs. time curve (AUCss) range using this dosing strategy was predicted to be equivalent to high-dose tigecycline exposure (100 mg q12h) in non-ICU patients. In addition, 26/39 study participants died, and therapy failure was most correlated with chronic liver disease and renal failure, but no correlation between drug exposure and survival was observed. However, tigecycline in special patient populations needs further investigations to enhance clinical outcome.
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Affiliation(s)
- Lisa F. Amann
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany; (L.F.A.); (A.B.)
| | - Rawan Alraish
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.A.); (M.K.)
| | - Astrid Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany; (L.F.A.); (A.B.)
| | - Magnus Kaffarnik
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.A.); (M.K.)
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany; (L.F.A.); (A.B.)
- Correspondence: ; Tel.: +49-40-42838-3487
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Dadkhah A, Alihodzic D, Broeker A, Kröger N, Langebrake C, Wicha SG. Evaluation of the Robustness of Therapeutic Drug Monitoring Coupled with Bayesian Forecasting of Busulfan with Regard to Inaccurate Documentation. Pharm Res 2021; 38:1721-1729. [PMID: 34664209 PMCID: PMC8602150 DOI: 10.1007/s11095-021-03115-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/20/2021] [Indexed: 12/13/2022]
Abstract
Background Inaccurate documentation of sampling and infusion times is a potential source of error in personalizing busulfan doses using therapeutic drug monitoring (TDM). Planned times rather than the actual times for sampling and infusion time are often documented. Therefore, this study aimed to evaluate the robustness of a limited sampling TDM of busulfan with regard to inaccurate documentation. Methods A pharmacometric analysis was conducted in NONMEM® 7.4.3 and “R” by performing stochastic simulation and estimation with four, two and one sample(s) per patient on the basis of a one-compartment- (1CMT) and two-compartment (2CMT) population pharmacokinetic model. The dosing regimens consisted of i.v. busulfan (0.8 mg/kg) every 6 h (Q6H) or 3.2 mg/kg every 24 h (Q24H) with a 2 h- and 3 h infusion time, respectively. The relative prediction error (rPE) and relative root-mean-square error (rRmse) were calculated in order to determine the accuracy and precision of the individual AUC estimation. Results A noticeable impact on the estimated AUC based on a 1CMT-model was only observed if uncertain documentation reached ± 30 min (1.60% for Q24H and 2.19% for Q6H). Calculated rPEs and rRmse for Q6H indicate a slightly lower level of accuracy and precision when compared to Q24H. Spread of rPE’s and rRmse for the 2CMT-model were wider and higher compared to estimations based on a 1CMT-model. Conclusions The estimated AUC was not affected substantially by inaccurate documentation of sampling and infusion time. The calculated rPEs and rRmses of estimated AUC indicate robustness and reliability for TDM of busulfan, even in presence of erroneous records. Supplementary Information The online version contains supplementary material available at 10.1007/s11095-021-03115-8.
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Affiliation(s)
- Adrin Dadkhah
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany. .,Dept. of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany.
| | - Dzenefa Alihodzic
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Astrid Broeker
- Dept. of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Langebrake
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian G Wicha
- Dept. of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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Welte R, Beyer R, Hotter J, Broeker A, Wicha SG, Gasperetti T, Ranke P, Zaruba MM, Lorenz I, Eschertzhuber S, Ströhle M, Bellmann-Weiler R, Joannidis M, Bellmann R. Pharmacokinetics of trimethoprim/sulfametrole in critically ill patients on continuous renal replacement therapy. J Antimicrob Chemother 2021; 75:1237-1241. [PMID: 31990343 DOI: 10.1093/jac/dkz556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We investigated the effect of continuous renal replacement therapy (CRRT) on the pharmacokinetics of trimethoprim and sulfametrole. PATIENTS AND METHODS We enrolled critically ill adults undergoing CRRT and critically ill adults with normal or slightly impaired renal function (plasma creatinine concentration <1.5 mg/dL, control group). All patients received trimethoprim/sulfametrole at standard doses. Pharmacokinetics were determined after the first dose and at steady-state. In addition, a population pharmacokinetic model using plasma data was built. We also assessed the renal clearance (CLR) and the extracorporeal clearance in patients undergoing CRRT. RESULTS Twelve patients were enrolled in the CRRT group and 12 patients in the control group. There was no statistically significant difference in trimethoprim pharmacokinetics between the two groups. In patients on CRRT, total plasma clearance (CLtot) and V of sulfametrole were significantly higher than in the control group. However, sulfametrole exposure was not significantly altered during CRRT. The population pharmacokinetic analysis indicated that neither CRRT intensity nor residual diuresis were significant covariates on trimethoprim or sulfametrole CL. Median CL by continuous venovenous haemofiltration accounted for about one-third of CLtot of trimethoprim and for about one-half of CLtot of sulfametrole. In patients on CRRT, CLR of trimethoprim and sulfametrole were <5% of CLtot. CONCLUSIONS During CRRT, standard doses of trimethoprim/sulfametrole appear to be adequate.
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Affiliation(s)
- René Welte
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Rudolph Beyer
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Hotter
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Astrid Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Tiziana Gasperetti
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Paul Ranke
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Marc-Michael Zaruba
- Department of Internal Medicine III, Medical University of Innsbruck, Innsbruck, Austria
| | - Ingo Lorenz
- Department of General and Surgical Intensive Care Medicine, Centre of Operative Medicine, Medical University of Innsbruck and Innsbruck General Hospital, Innsbruck, Austria
| | - Stephan Eschertzhuber
- Transplant ICU, Department of Anaesthesia and Critical Care, Centre of Operative Medicine, Innsbruck General Hospital and Medical University of Innsbruck, Innsbruck, Austria
| | - Mathias Ströhle
- Department of General and Surgical Intensive Care Medicine, Centre of Operative Medicine, Medical University of Innsbruck and Innsbruck General Hospital, Innsbruck, Austria
| | - Rosa Bellmann-Weiler
- Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Romuald Bellmann
- Clinical Pharmacokinetics Unit, Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
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Iqbal K, Broeker A, Nowak H, Rahmel T, Nussbaumer-Pröll A, Österreicher Z, Zeitlinger M, Wicha S. A pharmacometric approach to define target site-specific breakpoints for bacterial killing and resistance suppression integrating microdialysis, time–kill curves and heteroresistance data: a case study with moxifloxacin. Clin Microbiol Infect 2020; 26:1255.e1-1255.e8. [DOI: 10.1016/j.cmi.2020.02.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/18/2020] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
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Amann LF, Vicente ER, Rathke M, Broeker A, Riedner M, Wicha SG. Stability studies with tigecycline in bacterial growth medium and impact of stabilizing agents. Eur J Clin Microbiol Infect Dis 2020; 40:215-218. [PMID: 32720091 PMCID: PMC7782409 DOI: 10.1007/s10096-020-03970-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/28/2020] [Indexed: 10/26/2022]
Abstract
PURPOSE This study aimed to examine the degradation of tigecycline in Mueller Hinton broth (ca-MHB), as knowledge about bacterial susceptibility is key for therapeutic decisions. METHODS Antioxidative stabilizers were evaluated on tigecycline stability in a quantitative chromatography assay and tigecycline induced kill against Staphylococcus aureus (ATCC29213) was determined in time kill studies. RESULTS Ascorbic acid caused rapid degradation of tigecycline and resulted in loss of antibacterial activity. Tigecycline was stabilized in aged broth by 2% pyruvate and bacterial growth, and tigecycline killing was similar to fresh broth without supplementation, but independent of age. CONCLUSION Our results underline the importance of using freshly prepared ca-MHB or the need for stabilizers for tigecycline susceptibility testing while using aged ca-MHB.
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Affiliation(s)
- Lisa F Amann
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, DE-20146, Hamburg, Germany
| | - Emilia Ruda Vicente
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, DE-20146, Hamburg, Germany
| | - Mareike Rathke
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, DE-20146, Hamburg, Germany
| | - Astrid Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, DE-20146, Hamburg, Germany
| | - Maria Riedner
- Department of Chemistry, University of Hamburg, Martin-Luther-King-Platz 6, 20146, Hamburg, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, DE-20146, Hamburg, Germany.
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7
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Broeker A, Vossen MG, Thalhammer F, Wallis SC, Lipman J, Roberts JA, Wicha SG. An Integrated Dialysis Pharmacometric (IDP) Model to Evaluate the Pharmacokinetics in Patients Undergoing Renal Replacement Therapy. Pharm Res 2020; 37:96. [PMID: 32409892 PMCID: PMC7225193 DOI: 10.1007/s11095-020-02832-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/22/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE Clearance via renal replacement therapy (RRT) can significantly alter the pharmacokinetic profile of drugs. The aim of this study was (i) to improve the use of clinical trial data and (ii) to provide a model that allows quantification of all aspects of drug elimination via RRT including adsorption to dialysis membranes and/or degradation of the drug in the dialysate. METHODS An integrated dialysis pharmacometric (IDP) model was developed to simultaneously incorporate all available RRT information. The sensitivity, accuracy and precision of the IDP model was compared to conventional approaches in clinical trial simulations and applied to clinical datasets of teicoplanin and doripenem. RESULTS The IDP model was more accurate, precise and sensitive than conventional plasma-concentration-based approaches when estimating the clearanceRRT (relative bias <1%). In contrast to conventional approaches, adsorption and degradation were quantifiable using the IDP model (relative bias: -1.1% and - 1.9%, respectively). Applied to clinical data, clearanceRRT, drug degradation (effluent-half-lifedoripenem: 13.5 h-1) and adsorption (polysulphone adsorption capacityteicoplanin: 31.2 mg) were assessed. CONCLUSION The IDP model allows accurate, precise and sensitive characterization of clearanceRRT, adsorption and degradation. Successful quantification of all aspects of clearanceRRT in clinical data demonstrated the benefit of the IDP model as compared to conventional approaches.
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Affiliation(s)
- Astrid Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany
| | - Matthias G Vossen
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Thalhammer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Steven C Wallis
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany.
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8
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Alihodzic D, Broeker A, Baehr M, Kluge S, Langebrake C, Wicha SG. Impact of Inaccurate Documentation of Sampling and Infusion Time in Model-Informed Precision Dosing. Front Pharmacol 2020; 11:172. [PMID: 32194411 PMCID: PMC7063976 DOI: 10.3389/fphar.2020.00172] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/07/2020] [Indexed: 12/31/2022] Open
Abstract
Background Routine clinical TDM data is often used to develop population pharmacokinetic (PK) models, which are applied in turn for model-informed precision dosing. The impact of uncertainty in documented sampling and infusion times in population PK modeling and model-informed precision dosing have not yet been systematically evaluated. The aim of this study was to investigate uncertain documentation of (i) sampling times and (ii) infusion rate exemplified with two anti-infectives. Methods A stochastic simulation and estimation study was performed in NONMEM® using previously published population PK models of meropenem and caspofungin. Uncertainties, i.e. deviation between accurate and planned sampling and infusion times (standard deviation (SD) ± 5 min to ± 30 min) were added randomly in R before carrying out the simulation step. The estimation step was then performed with the accurate or planned times (replacing real time points by scheduled study values). Relative bias (rBias) and root mean squared error (rRMSE) were calculated to determine accuracy and precision of the primary and secondary PK parameters on the population and individual level. The accurate and the misspecified (using planned sampling times) model were used for Bayesian forecasting of meropenem to assess the impact on PK/PD target calculations relevant to dosing decisions. Results On the population level, the estimates of the proportional residual error (prop.-err.) and the interindividual variability (IIV) on the central volume of distribution (V1) were most affected by erroneous records in the sampling and infusion time (e.g. rBias of prop.-err.: 75.5% vs. 183% (meropenem) and 10.1% vs. 109% (caspofungin) for ± 5 vs. ± 30 min, respectively). On the individual level, the rBias of the planned scenario for the typical values V1, Q and V2 increased with increasing uncertainty in time, while CL, AUC and elimination half-life were least affected. Meropenem as a short half-life drug (~1 h) was more affected than caspofungin (~ 9-11 h). The misspecified model provided biased PK/PD target information (e.g. falsely overestimated time above MIC (T > MIC) when true T > MIC was <0.4 and thus patients at risk of undertreatment), while the accurate model gave precise estimates of the indices across all simulated patients. Conclusions Even 5-minute-uncertainties caused bias and significant imprecision of primary population and individual PK parameters. Thus, our results underline the importance of accurate documentation of time.
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Affiliation(s)
- Dzenefa Alihodzic
- Department of Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Astrid Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Michael Baehr
- Department of Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Langebrake
- Department of Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Georg Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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Broeker A, Nardecchia M, Klinker KP, Derendorf H, Day RO, Marriott DJ, Carland JE, Stocker SL, Wicha SG. Towards precision dosing of vancomycin: a systematic evaluation of pharmacometric models for Bayesian forecasting. Clin Microbiol Infect 2019; 25:1286.e1-1286.e7. [PMID: 30872102 DOI: 10.1016/j.cmi.2019.02.029] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [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] [Received: 10/18/2018] [Revised: 02/21/2019] [Accepted: 02/23/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Vancomycin is a vital treatment option for patients suffering from critical infections, and therapeutic drug monitoring is recommended. Bayesian forecasting is reported to improve trough concentration monitoring for dose adjustment. However, the predictive performance of pharmacokinetic models that are utilized for Bayesian forecasting has not been systematically evaluated. METHOD Thirty-one published population pharmacokinetic models for vancomycin were encoded in NONMEM®7.4. Data from 292 hospitalized patients were used to evaluate the predictive performance (forecasting bias and precision, visual predictive checks) of the models to forecast vancomycin concentrations and area under the curve (AUC) by (a) a priori prediction, i.e., solely by patient characteristics, and (b) also including measured vancomycin concentrations from previous dosing occasions using Bayesian forecasting. RESULTS A priori prediction varied substantially-relative bias (rBias): -122.7-67.96%, relative root mean squared error (rRMSE) 44.3-136.8%, respectively-and was best for models which included body weight and creatinine clearance as covariates. The model by Goti et al. displayed the best predictive performance with an rBias of -4.41% and an rRMSE of 44.3%, as well as the most accurate visual predictive checks and AUC predictions. Models with less accurate predictive performance provided distorted AUC predictions which may lead to inappropriate dosing decisions. CONCLUSION There is a diverse landscape of population pharmacokinetic models for vancomycin with varied predictive performance in Bayesian forecasting. Our study revealed the Goti model as suitable for improving precision dosing in hospitalized patients. Therefore, it should be used to drive vancomycin dosing decisions, and studies to link this finding to clinical outcomes are warranted.
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Affiliation(s)
- A Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Germany
| | - M Nardecchia
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Germany
| | - K P Klinker
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - H Derendorf
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - R O Day
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia; Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
| | - D J Marriott
- Department of Clinical Microbiology & Infectious Diseases, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - J E Carland
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia; Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
| | - S L Stocker
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia; Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
| | - S G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Germany.
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Broeker A, Wicha SG, Dorn C, Kratzer A, Schleibinger M, Kees F, Heininger A, Kees MG, Häberle H. Tigecycline in critically ill patients on continuous renal replacement therapy: a population pharmacokinetic study. Crit Care 2018; 22:341. [PMID: 30558639 PMCID: PMC6296114 DOI: 10.1186/s13054-018-2278-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 11/26/2018] [Indexed: 01/03/2023]
Abstract
Background Tigecycline is a vital antibiotic treatment option for infections caused by multiresistant bacteria in the intensive care unit (ICU). Acute kidney injury (AKI) is a common complication in the ICU requiring continuous renal replacement therapy (CRRT), but pharmacokinetic data for tigecycline in patients receiving CRRT are lacking. Methods Eleven patients mainly with intra-abdominal infections receiving either continuous veno-venous hemodialysis (CVVHD, n = 8) or hemodiafiltration (CVVHDF, n = 3) were enrolled, and plasma as well as effluent samples were collected according to a rich sampling schedule. Total and free tigecycline was determined by ultrafiltration and high-performance liquid chromatography (HPLC)-UV. Population pharmacokinetic modeling using NONMEM® 7.4 was used to determine the pharmacokinetic parameters as well as the clearance of CVVHD and CVVHDF. Pharmacokinetic/pharmacodynamic target attainment analyses were performed to explore the potential need for dose adjustments of tigecycline in CRRT. Results A two-compartment population pharmacokinetic (PK) model was suitable to simultaneously describe the plasma PK and effluent measurements of tigecycline. Tigecycline dialysability was high, as indicated by the high mean saturation coefficients of 0.79 and 0.90 for CVVHD and CVVHDF, respectively, and in range of the concentration-dependent unbound fraction of tigecycline (45–94%). However, the contribution of CRRT to tigecycline clearance (CL) was only moderate (CLCVVHD: 1.69 L/h, CLCVVHDF: 2.71 L/h) in comparison with CLbody (physiological part of the total clearance) of 18.3 L/h. Bilirubin was identified as a covariate on CLbody in our collective, reducing the observed interindividual variability on CLbody from 58.6% to 43.6%. The probability of target attainment under CRRT for abdominal infections was ≥ 0.88 for minimal inhibitory concentration (MIC) values ≤ 0.5 mg/L and similar to patients without AKI. Conclusions Despite high dialysability, dialysis clearance displayed only a minor contribution to tigecycline elimination, being in the range of renal elimination in patients without AKI. No dose adjustment of tigecycline seems necessary in CRRT. Trial registration EudraCT, 2012–005617-39. Registered on 7 August 2013. Electronic supplementary material The online version of this article (10.1186/s13054-018-2278-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany
| | - S G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany.
| | - C Dorn
- Institute of Pharmacy, University of Regensburg, Universitätstr. 31, 93053, Regensburg, Germany
| | - A Kratzer
- Hospital Pharmacy, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - M Schleibinger
- Department of Orthopaedics and Trauma, Hospital Ingolstadt, Krumenauerstraße 25, 85049, Ingolstadt, Germany
| | - F Kees
- Department of Pharmacology and Toxicology, University of Regensburg, Universitätsstr. 31, 93053, Regensburg, Germany
| | - A Heininger
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Division Hospital and Environmental Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - M G Kees
- Department of Anesthesiology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - H Häberle
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
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