title: Developmental pharmacokinetics of gentamicin in preterm and term neonates: population modelling of a prospective study.
abstract: OBJECTIVE
  Preterm and term newborn infants show wide interindividual variability (IIV) in pharmacokinetic parameters of gentamicin. More extensive knowledge and use of predictive covariates could lead to faster attainment of therapeutic concentrations and a reduced need for concentration monitoring. This study was performed to characterize the population pharmacokinetics of gentamicin in preterm and term neonates and to identify and quantify relationships between patient characteristics and IIV. A secondary aim was to evaluate cystatin C as a marker for gentamicin clearance in this patient population.
  
  
  METHODS
  Data were collected in a prospective study performed in the Neonatal Intensive Care Unit at the University Children's Hospital, Uppsala, Sweden. Population pharmacokinetic modelling was performed using nonlinear mixed-effects modelling (NONMEM) software. Bodyweight was included as the primary covariate according to an allometric power model. Other evaluated covariates were age (postmenstrual age, gestational age [GA], postnatal age [PNA]), markers for renal function (serum creatinine, serum cystatin C) and concomitant medication with cefuroxime, vancomycin or indometacin. Covariate-parameter relationships were explored using a stepwise covariate model building procedure. The predictive performance of the developed model was evaluated using an independent external dataset for a similar patient population.
  
  
  RESULTS
  Sixty-one newborn infants (GA range 23.3-42.1 weeks, PNA range 0-45 days) were enrolled in the study. In total, 894 serum gentamicin samples were included in the analysis. The concentration-time profile was described using a three-compartment model. Gentamicin clearance increased with the GA and PNA (included in a nonlinear fashion). The GA was also identified as having a significant influence on the central volume of distribution, with a preterm neonate having a larger central volume of distribution per kilogram of bodyweight than a term neonate. Cystatin C and creatinine were not correlated with gentamicin clearance in this study population. The external dataset was well predicted by the developed model.
  
  
  CONCLUSIONS
  Bodyweight and age (GA and PNA) were found to be major factors contributing to IIV in gentamicin clearance in neonates. Based on these data, cystatin C and serum creatinine were not correlated with gentamicin clearance and therefore not likely to be predictive markers of renal function in this patient population. Based on predictions from the developed model, preterm neonates do not reach targeted peak and trough gentamicin concentrations after a standard dosage regimen of 4 mg/kg given once daily, suggesting a need for higher loading doses and prolonged dosing intervals in this patient population.
authors.affiliation: Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden.
authors.forename: Elisabet I
authors.initials: EI
authors.lastname: Nielsen
authors.forename: Marie
authors.initials: M
authors.lastname: Sandström
authors.forename: Per Hartvig
authors.initials: PH
authors.lastname: Honoré
authors.forename: Uwe
authors.initials: U
authors.lastname: Ewald
authors.forename: Lena E
authors.initials: LE
authors.lastname: Friberg
mesh_terms: D000367:Age Factors; D015415:Biomarkers / Q000032:analysis*; D001835:Body Weight; D002444:Cefuroxime / Q000008:administration & dosage; D003404:Creatinine / Q000097:blood; D055316:Cystatin C / Q000097:blood*; D004347:Drug Interactions; D005260:Female; D005839:Gentamicins / Q000008:administration & dosage / Q000493:pharmacokinetics*; D005865:Gestational Age; D006801:Humans; D007213:Indomethacin / Q000008:administration & dosage; D007223:Infant; D007231:Infant, Newborn / Q000097:blood*; D007234:Infant, Premature / Q000097:blood*; D008297:Male; D017711:Nonlinear Dynamics; D014640:Vancomycin / Q000008:administration & dosage
chemical_list: D015415:Biomarkers; D055316:Cystatin C; D005839:Gentamicins; D014640:Vancomycin; D003404:Creatinine; D002444:Cefuroxime; D007213:Indomethacin