Pneumonia Clinical Trial
Official title:
Population Pharmacokinetic (PK) Study of Zinforo (Ceftaroline) in Critical Care Patients With Early-onset Pneumonia and Normal or Augmented Renal Clearance
Pneumonia is the most frequent infection in critically ill patients and remains a significant
challenge to intensivists world-wide due to persisting high mortality and morbidity.
Compelling evidence suggests that appropriate antibiotic therapy remains the most important
intervention to improve patients' outcome, including the administration of a suitable
molecule at an optimized dosage regimen. A vast array of pathophysiological changes can occur
in critically ill patients that can complicate antibiotic dosing. Knowledge of the
pharmacokinetic and pharmacodynamic properties of the antibiotics used for the management of
critically ill patients is essential for selecting the antibiotic dosing regimens, which will
optimize patient outcomes. Changes in volume of distribution (Vd) and clearance (CL) of
antibiotics have been noted in these patients, which may affect the antibiotic concentration
at the target site. It follows that the pharmacodynamic parameters that determine antibiotic
efficacy, which can vary between antibiotic classes, may also be affected. Optimization of
these parameters is necessary to maximize the rate of response through patient recovery and
minimized antibiotic resistance.
In a multicenter observational study in critically ill patients with normal plasma renal
indices at admission, about 65% of patients manifested augmented creatinine clearance on at
least one occasion in the first seven study days. Augmented creatinine clearance may
significantly impact drug pharmacokinetics for a variety of renally eliminated
pharmaceuticals (such as low-molecular weight heparins, aminoglycosides, glycopeptides, and
β-lactams), leading to subtherapeutic concentrations and potentially adverse clinical
outcomes. Currently little data exist that describe the consequences of augmented creatinine
clearance on antibiotics PK.
Ceftaroline (600 mg bid) is a cephalosporin with expanded gram-positive activity, including
MRSA and penicillin-resistant streptococcus, which was approved by the US Food and Drug
Administration (FDA) on October 29, 2010 for the treatment of acute bacterial SSSIs and
community-acquired bacterial pneumonia. Ceftaroline showed also good activity against some of
the common gram-negative respiratory pathogens (eg, Haemophilus influenzae, Moraxella
catarrhalis, Neisseria meningitidis, and Pasteurella multocida). However, it does not display
clinically relevant activity against Pseudomonas aeruginosa, Stenotrophomonas maltophilia, or
Acinetobacter baumannii. Ceftaroline also lacks activity against gram-negative organisms with
extended-spectrum β-lactamases. Importantly, because ceftaroline appears to induce AmpC
β-lactamases despite MIC values in susceptible range, ittheoretically should be avoided in
gram-negative bacteria known to harbor inducible AmpC β-lactamases (eg, Serratia, Proteus,
Citrobacter, Morganella, Enterobacter, Providencia, and P. aeruginosa). In patients,
ceftaroline is given as a prodrug, ceftaroline fosamil. After intravenous administration, the
prodrug is rapidly transformed by plasma phosphatase enzymes to its bioactive metabolite. The
pharmacokinetics of ceftaroline has been evaluated in single and multiple dose studies in
healthy volunteers, in subjects with various degrees of renal impairment and in healthy
elderly subjects. The volume of distribution is equal to 20.3 L, which corresponds to
extracellular fluid volume. The protein binding is low (20%). The main route of elimination
is via renal excretion, with a clearance estimated to160 mL/min close to the creatinine
clearance. The elimination half-live is 2.6 h in adults with normal renal function.
Unfortunately, no PK study has been performed in infected critically ill patients with
augmented creatinine clearance. The best PK-PD index predicting drug efficacy is %Time>CMI. A
bacteriostatic effect is achieved when free drug concentrations exceed the MIC for 30 to 40%
of the dose administration interval (30 to 40%T>MIC). Near maximum organism kill is achieved
at 50 to 60%T>MIC (30%T>MIC for Staphylococcus aureus).
This project aims to characterize ceftaroline PK in patients with early-onset pneumonia and
augmented creatinine clearance. The choice of ceftaroline is justified by its spectrum
suitable for micro-organisms commonly encountered in early onset pneumonia, including
methicillin-resistant Staphylococcus aureus. Secondary main objective is to predict the
probably of reaching PK-PD targets using Monte Carlo simulations under various scenario in
order to identify optimal ceftaroline administration schemes in critical care patients with
various degrees of renal impairment.
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