Eur J Clin Pharmacol (2009) 65:705713

DOI 10.1007/s00228-009-0637-4

PHARMACOKINETICS AND DISPOSITION

Individualised dosing of amikacin in neonates:

a pharmacokinetic/pharmacodynamic analysis
Catherine M. T. Sherwin & Sofia Svahn &
Antje Van Der Linden & Roland S. Broadbent &
Natalie J. Medlicott & David M. Reith

Received: 9 January 2009 / Accepted: 11 February 2009 / Published online: 21 March 2009
# Springer-Verlag 2009

Abstract 24 to 41 weeks. The final pharmacokinetic model analysed

Purpose To examine the pharmacokinetics of amikacin and 358 amikacin concentrations. All neonates were >72 hours
its pharmacokinetic pharmacodynamic (PKPD) relationship postnatal age. Simulations were performed to develop a
in neonates. To develop an alternative dosing strategy for new dosing strategy.
amikacin in neonates. Results The final covariate model was clearance=0.23
Methods A population PKPD analysis was performed using (current weight/2)0.691 (postmenstrual age/40)3.23 and
data collected from 80 neonates with gestational ages from volume of distribution=0.957(current weight/2)0.89. Fol-
lowing the logistic regression analysis of treatment failure,
C. M. T. Sherwin (*)
new amikacin target concentrations were estimated and
Division of Clinical Pharmacology,
Cincinnati Childrens Hospital Medical Center, used in development of an alternative dosing strategy.
3333 Burnet Avenue, MLC 6018, Conclusion Simulation of a new dosing regimen yielded
Cincinnati, OH 45229-3039, USA the following recommendations: 15 mg/kg at 36-h intervals,
e-mail: catherine.sherwin@cchmc.org 14 mg/kg at 24-h intervals and 15 mg/kg at 24-h intervals
D. M. Reith for neonates 28 weeks, 2936 weeks and 37 weeks
Department of Womens and Childrens Health, postmenstrual age respectively.
Dunedin School of Medicine, University of Otago,
P.O. Box 913, Dunedin, New Zealand Keywords Amikacin . Neonates .
e-mail: david.reith@stonebow.otago.ac.nz
Population pharmacokinetics . Pharmacodynamics
S. Svahn
University of Uppsala,
Uppsala, Sweden
Introduction
e-mail: svahn.sofia@gmail.com

A. Van Der Linden Bacterial sepsis is common in neonates and particularly in

Department of Pathology, Dunedin School of Medicine,
Dunedin, New Zealand
e-mail: antje.vanderlinden@otagodhb.govt.nz
R. S. Broadbent
Department of Womens and Childrens Health,
Dunedin School of Medicine, University of Otago,
Dunedin, New Zealand
e-mail: roland.broadbent@otago.ac.nz
N. J. Medlicott
New Zealands National School of Pharmacy,
University of Otago,
Dunedin, New Zealand
e-mail: natalie.medlicott@otago.ac.nz
preterm neonates because of their immature immune system
[1]. Amikacin is a semi-synthetic derivative of kanamycin
which has broad in vitro and in vivo activity against most
aerobic Gram-negative bacteria and is effective against
some strains of bacteria that are resistant to other amino-
glycosides [2, 3]. Amikacin is indicated in the short-term
treatment of serious infections caused by strains of
Pseudomonas sp., E. coli, Klebsiella pneumoniae, Serratia
sp. and Staphylococcus species [4]. Specifically in the
neonatal population, amikacin is also used to treat late-
onset sepsis caused by coagulase-negative Staphylococcus
species. For Gram-negative sepsis, it is recommended that
706
the amikacin peak serum concentration should be higher
[maximum serum concentration (Cmax)/minimum inhibitory
concentration (MIC) ratio greater than 8:1] in the first to
second days of treatment [57]. However, these recom-
mendations have not been based upon studies in neonates,
for which there is a paucity of data with regard to amikacin
pharmacokinetic-pharmacodynamic (PKPD) relationships.
Several studies have demonstrated that conventional
paediatric dosing regimens are not well adapted to neonates
and result in inconsistent serum concentrations, particularly in
extremely low-birth-weight neonates [5]. Peak concentrations
are often lower than expected for optimal bactericidal effect,
and trough concentrations are often too high to be considered
safe [5, 8]. The concentrations related to toxicity in adults
have been extrapolated to neonates, but there is little
evidence indicating the specific toxic concentrations for
amikacin in neonates [9]. Given the inconsistency in the
literature and the limited evaluation of extended interval
dosing with amikacin in neonates there is a need to design a
dosing regimen adapted to extremely premature neonates.
However, before a new dosing regimen can be developed,
the pharmacokinetics (PK) of amikacin need to be further
explored, in particular, the influence of covariates.
The present study was undertaken to investigate the
pharmacokinetics and pharmacodynamics of amikacin in
neonates, and the influence of covariates upon these
parameters. This information was used to develop an
optimal dosing strategy for neonates.
Methods
Patients
A retrospective chart review was performed that included all
neonates treated with amikacin in the neonatal intensive care
unit (NICU) at Dunedin Hospital from 1 October 2003 to 31
January 2007. Amikacin was commenced for treatment of
suspected or culture-proven late-onset neonatal sepsis from
3 days post-natal age. As per the Dunedin Hospital NICU
protocol, neonates <72 h post-natal age are treated with
gentamicin and were not included in this study. Data were
collected for 82 neonates who had at least one therapeutic
amikacin concentration recorded. Two patients were excluded
from the review due to incomplete data. Three amikacin
concentrations were also excluded from the PK analysis, two
due to intravenous leakage during administration and one was
considered an outlier due to an unexplainable, exceptionally
high concentration. The study protocol was reviewed by the
Otago Ethics Committee and considered an audit.
The data obtained from the review of medical charts
included gestational age (weeks), post-natal age (days), birth
weight (kg), current weight at treatment (kg), presence of
Eur J Clin Pharmacol (2009) 65:705713
culture-proven sepsis, sex, serum creatinine (mol/L), max-
imum C-reactive protein (CRP) (mg/L) during treatment,
Apgar score at 1 min and Apgar score at 5 min. Post-menstrual
age was calculated as gestational age plus post-natal age at
birth in completed weeks.
The standard NICU protocol for suspected sepsis
required a blood culture, full blood count and CRP to be
performed. Amikacin was discontinued after 48 h unless
neonates were confirmed septic or remained clinically
unwell. Neonates with culture-proven sepsis, positive
microbial infection confirmed by cerebral spinal-fluid tap,
clinical unresolved signs or a persistent maximum CRP >
40 mg/L were classified as septic. For those neonates with
culture-proven sepsis, treatment failure (TF) was defined as
a repeated infection caused by the same bacteria within
5 days and/or a treatment switch to another antimicrobial,
usually vancomycin, due to no apparent clinical improve-
ment with amikacin treatment.
Amikacin therapy and sampling
Amikacin was administered as an intravenous infusion over
30 min using a syringe driver piggybacked to a Baxter pump
delivering a continuous IV infusion. This was followed with
1 mL normal (0.9%) saline given over 30 min. Amikacin dose
in the first week after birth was based on current weight and
gestational age. Neonates 27 and 2730 weeks gestational
age received 18 mg/kg at 48- and 36-h intervals respectively.
Neonates 31 to 33 weeks gestational age received 16 mg/kg
at 36-h intervals. Neonates 34 weeks gestational age
received 15 mg/kg at 24-h intervals. From 1 week of age,
neonates were given an initial dose of 15 mg/kg and were
then dosed based on gestational age as described above.
Amikacin and creatinine assays
Amikacin peak serum concentrations were measured
60 min after the start of the IV infusion, and trough
concentrations were measured at 24 h. Amikacin concen-
trations were measured using a fluorescence polarisation
immunoassay with an Abbott TDx kit (Abbott Park, IL).
Serum creatinine levels were obtained within 24 h of
amikacin levels and were assayed by the Jaffe alkaline
picrate method (Roche Diagnostics, Indianapolis, IN).
CRP was determined using a Roche Tinaquant, immu-
noturbidimetric method (Roche Diagnostics, Indianapolis,
IN). Amikacin Etests (ABBiodisk, Solna, Sweden)
were performed on the isolates of bacteria cultured from
26 septic neonates to determine amikacin MIC. Etests
were not performed on streptococci or enterococci
isolates, as these are intrinsically resistant. All analyses
were carried out at the Otago Diagnostic Laboratory at
Dunedin Hospital.
Eur J Clin Pharmacol (2009) 65:705713
Pharmacokinetic modelling
The population PK analysis of amikacin used NON-
MEM version 5, release 1.1 (non-linear mixed effect
modelling; GloboMax, Hanover, MD, USA). A mixed
effects one-compartment, first-order elimination model
was developed. The terms for variability in the model
included between-subject variability (BSV), between-
occasion variability (BOV) and residual variability. An
omega block was used in the model to account for the
high correlation between clearance and volume of
distribution. Linear and power error models were
explored and the random-effect error models included
BSV, BOV and residual variability. The final BSV and
BOV error models used an exponential error model. The
residual (unexplained) variability was evaluated using a
combined proportional (RUV-CV) and additive (RUV-
SD) error model.
Plots were generated to screen for relationships
between the estimates of the parameters from the base
model and potential covariates. The independent varia-
bles (covariates) included gestational age (weeks), post-
natal age (days), current weight, sepsis, serum creatinine,
sex, Apgar scores and post-menstrual age. A further
exploratory analysis of plots was also undertaken by
plotting post-hoc eta predictions for clearance and volume
of distribution against the biologically plausible covariates.
For inclusion of covariates, an additive and multiplicative
approach was used initially in a univariate analysis. A
forward and backward stepwise regression method was
used to determine the best covariate model. A statistically
significant improvement in the fit of the model was based
on minimisation of the objective function value (OFV) and
hypothesis-testing using the 2 distribution. The final
model was determined by investigating significant mini-
misation of the OFV and visual inspection of diagnostic
plots. After identification of probable significant cova-
riates, linear and power models were investigated. A
power model was chosen as it provided a greater reduction
in the OFV than linear models with the same number of
model parameters.
Bootstrap
The final PK model was validated by using the bootstrap
approach. The sampling strategy used a non-replacement
technique [10]. A bootstrap was performed on the final
refined covariate PK model, which was based on the whole
population. The bootstrap repeatedly fitted the data to the
final model and generated 1,000 replicates. The percentage
of runs where the covariate effects were determined to be
significant was calculated, and each model parameter was
reported as median and 95% CI.
707
Pharmacodynamic analysis
The pharmacodynamic (PD) analysis was undertaken using
a logistic regression technique for making predictions when
the dependent variable (Y) was dichotomous rather than
continuous, and the independent variables were continuous
or discrete. The outcome of Y allowed for only two possible
values. These were represented by one, a success, and
zero, a failure. The mean of the dichotomous random
variable (p) was the proportion of times Y=1 or treatment
was successful. The logistic function did not yield a value
that was either negative or greater than one, and it was
restricted to estimating the value of p to the required range.
Modelling p with the logistic function was equivalent to
fitting a linear regression model where the continuous
outcome Y was replaced by the logarithm of the odds of
success [11].
The PD analysis used treatment failure as the outcome
variable and included all the neonates with culture-proven
sepsis (n = 26). The logistic regression aimed to predict the
odds ratios for patients with TF or those likely to meet the
TF criteria based on the collected clinical data. The effect
size of the exposure variables was expressed as odds ratio
(95% CI). Relative risk was calculated to determine the risk
of treatment failure occurring dependent on the amikacin
therapeutic peak concentration and MIC.
Simulation of current and proposed dosing regimens
The final covariate PK model was used to simulate serum
concentrations during the current dosing regimen. Then an
alternative dosing regimen was explored using simulations
with the same model. A nonparametric dataset of covariate
distributions was used to represent 1,000 virtual patients
using MATLAB (student version 7.1, The Mathworks,
2005). The covariates of interest were post-menstrual age
(weeks) and current weight (kg), and these ranged from
24.7 to 44.1 and 0.45 to 4.43 respectively, based on a
dataset that comprised 719 individual neonates. The
simulation modelled an intravenous infusion of amikacin
given over 30 min for two doses. The new dosing regimen
was proposed to achieve treatment success as defined by
Cmax in the range 2435 mg/L and area under the
concentration-time curve over 24 h (AUC24) in the range
130590 mgh/L. An extended interval dosing regimen was
developed in line with current literature recommendations
for dosing aminoglycosides in neonates [8, 12, 13].
Results
Eighty neonatal patients were included in the final study
for which there were 358 amikacin peak and trough
708
concentrations. In this population, there were 46 (57.5%)
extremely premature neonates, with a gestational age of
<28 weeks, and 44 (55%) of these neonates were
extremely low-birth-weight infants (<1,000 g) (Table 1).
There were 98 treatment episodes including 35 (35.7%)
confirmed septic episodes from 26 (32.5%) neonates. Four
neonates each received treatment for two separate episodes
of culture-proven sepsis, and one patient had three treatment
episodes for confirmed sepsis. All episodes of culture-proven
sepsis were from blood cultures, with no confirmed episodes
diagnosed from urine or cerebral spinal-fluid tap cultures.
The clinical diagnoses included pneumonia (3), bacterial
meningitis (2), congenital sepsis (3) and suspected necrotis-
ing enterocolitis (3). Seven neonates in the study population
died, five within 1 week of birth, with four of those from
overwhelming septicaemia. Twenty-one (21.4%) septic
episodes in 12 individual patients met the predefined criteria
for treatment failure.
The majority of neonatal sepsis was caused by Staphy-
lococcus epidermidis (14), non-specified Staphylococcus
sp. (10) and Staphylococcus aureus (3). Remaining sepsis
events were attributed to Staphylococcus hominis (2),
Staphylococcus capitis (1), Staphylococcus warneri (1), E.
coli (2), Enterococcus faecalis (1) and Enterococcus
faecium (1). Five of the cultures contained mixed growth
with bacterial species and/or fungal species being isolated.
Forty-five amikacin E-tests were performed. Staphylococ-
cus epidermidis amikacin MIC ranged from 1.5 to 12 mg/L
and for non-specified Staphylococcus sp., MIC ranged
from 0.75 to 3 mg/L. Only 26 isolates were confirmed as
causative septic agents, 14 of which were from episodes of
treatment failure.
Pharmacokinetic model
The base PK model estimated amikacin clearance as
0.069 L/h (0.486 SE %, 0.0590.078 95% CI) and volume
of distribution as 0.63 L (3.42 SE %, 0.560.69 95% CI),
Table 1 Demographic summary of the amikacin study population, presented as median (range)
Characteristics of patients (n, %) Septic (n=31, 38.75%)
Gestational age (weeks) 27 (2434)
Post-natal age (days) 9 (364)
Post-menstrual age (weeks) 28.8 (24.741.1)
Birth weight (kg) 0.93 (0.582.1)
Current weight (kg) 0.97 (0.633.51)
Male sex (n, %) 23 (74%)
Apgar score at 1 min 7 (19)
Apgar score at 5 min 9 (210)
Serum creatinine (mol/L) 58 (42111)
C-reactive protein maximum (mg/L) 30 (0.5239)
Eur J Clin Pharmacol (2009) 65:705713
with BSV estimated at 24.4% (5.83 SE %) for CL and
4.52% (2.61 SE %) for V. For residual variability, the
coefficient of variability (RUV-CV) was estimated at 13.7
(2.46 CV %) and standard deviation (RUV-SD) was 2.34
1.18 mg/L. The model was allowed to determine the
allometric scale most appropriate for the current weight,
resulting in a power function of 0.691 being used. Current
weight had the most significant effect on the model. The
final covariate model was chosen as it produced the most
significant minimisation of OFV ( 330.4) and reduced the
BSV and residual variability. Visual inspection of diagnos-
tic plots was also used to confirm selection of the final
covariate model (Fig. 1). The final covariate PK model is
shown in equation 1.
CL q1
CWT=2 q3
PMA=40 q4 L=h
1
V q 2
CWT=2 q5 L
where CL refers to clearance, V to volume of distribution,
CWT to current weight and PMA to post-menstrual age.
The final PK covariate model estimates and results from
the bootstrap model are outlined in Table 2. The final model
accounted for some of the heterogeneity within the data
as the predicted concentration vs. weighted residual plot
illustrated (Fig. 2).
Pharmacodynamic model
There were 35 confirmed septic episodes from 26 neonates.
Univariate analysis of the variables showed there was no
influence from amikacin AUC, sex, post-natal age, amikacin
peak or amikacin MIC upon treatment failure when included
in the logistic regression model as independent variables.
Other than amikacin peak/MIC ratio, there were no inde-
pendent predictors of treatment failure (Table 3). In those
with culture-proven sepsis, the relative risk (95% CI) for
treatment failure was 2.86 (1.575.19) for amikacin peak/
MIC <6 and 2.25 (0.955.34) for amikacin peak/MIC <8.
Non-septic (n=49, 61.25%) All (n=80, 100%)
28 (2441) 28 (2441)
9 (331) 9 (364)
30.0 (24.744.0) 29.43 (24.744.0)
1.02 (0.44.4) 0.97 (0.444.4)
1.20 (0.454.43) 1.03 (0.454.43)
23 (46%) 46 (57%)
7 (19) 7 (19)
10 (510) 9 (210)
59 (20111) 58.5 (20111)
1 (0.576) 2 (0.5239)
Eur J Clin Pharmacol (2009) 65:705713 709

5 5

3 3

1 1
WRES

WRES
-1 -1

-3 -3

-5 -5

25 28 31 34 37 40 43 0 8 16 24 32 40 48 56 64 72 80 88
PMA (weeks) PNA (days)
a) WRES vs. PMA base model b) WRES vs. PNA base model

5 5

3 3

1 1

WRES
WRES

-1 -1

-3 -3

-5 -5

25 28 31 34 37 40 43 0 8 16 24 32 40 48 56 64 72 80 88
PMA (weeks) PNA (days)
c) WRES vs. PMA final model d) WRES vs. PNA final model
Fig. 1 Diagnostic plots comparing the base and final models. WRES Weighted residual, PMA post-menstrual age, PNA post-natal age

Simulations of dosing regimens trough concentration below 5 mg/L. The present study
revised the target concentrations using the results of the PD
The existing amikacin dosing regimen recommended target analysis. The optimum target for Cmax was adjusted from a
concentrations for peaks between 20 and 30 mg/L with a peak of 2030 mg/L to 2435 mg/L (which was considered,

Table 2 NONMEM estimates of population pharmacokinetic parameters

Parameter Final model Bootstrap (n=1,000)

Estimates 95% CI Median 95% CI

Clearance (L/h) 0.23 0.173 to 0.287 0.23 0.173 to 0.306

CWT (3) 0.691 0.307 to 1.08 0.687 0.073 to 0.972
PMA (4) 3.23 1.82 to 4.64 3.23 1.805 to 4.955
Volume of distribution (L) 0.957 0.883 to 1.03 0.965 0.8725 to 1.03
CWT (5) 0.89 0.783 to 0.997 0.9 0.76 to 0.98
BSV-CL (%) 4.6 0.457 to 9.66 4.5 0.209 to 9.675
BSV-V (%) 0.446 0.181 to 1.07 0.477 0.03 to 1.015
RUV-CV (%) 3.8 1.88 to 5.72 4.0 1.68 to 6.44
RUV-SD (%) 2.42 0.44 to 4.4 2.09 0.56 to 3.88

CWT Current weight, PMA post-menstrual age, 95% CI confidence interval calculated from parameter standard errors, V volume of distribution,
CL clearance, BSV-CL between-subject variability related to clearance, BSV-V between-subject variability related to volume of distribution, RUV-
CV coefficient of variation of residual error (proportional error), RUV-SD coefficient of variation of residual error (additive error)
710 Eur J Clin Pharmacol (2009) 65:705713

56 because of the potential for toxicity, to be an acceptable

upper limit) [4, 6]. The upper and lower bounds for AUC24
Predicted concentrations (mg/L)

49
were 130 and 590 mgh/L, which were taken from the range
42 obtained by the univariate logistic regression for treatment
35
failure. The bounds for weight were 0.46.0 kg, and post-
menstrual age was adjusted to fit the required categories.
28
Table 4 outlines an example of percentage of success
21 achieved with simulated amikacin dosing for neonates with
a post-menstrual age 2327 weeks. A dosing regimen with
14
a dose range of 1415 mg/kg and dosing interval of 24
7 36 h based on post-menstrual age resulted in a high rate of
0 success for both AUC24 and Cmax on days 1 and 2 (Table 5).
0 7 14 21 28 35 42 49 56 Using this regimen, a serum amikacin concentration test
Observed concentrations (mg/L) could be performed at 24 h post-dose in order to detect
a) DV vs. PRED final model potential toxicity, for example using a criteria of trough
concentration <2 mg/L. If necessary, the dosing interval
could then be increased in the presence of unacceptably
5
high amikacin levels at 24 h post-dose.
3

Discussion
WRES

The principal findings of the present study were that the

-1
main determinants of amikacin clearance were current
weight and post-menstrual age, the main determinant of
-3
volume of distribution was current weight and the main
predictor of TF was peak/MIC ratio <8. Although the PK
-5
findings are similar to those previously reported, the present
0 9 18 27 36 45 54 study offers an extension of the PK modelling with
Predicted concentrations (mg/L) application of PD data in the simulation of a new dosing
regimen.
b) WRES vs. PRED final model
Overall, few population PK studies have been conducted
to describe the PK of amikacin in neonates [1416].
Published data on the use of amikacin are even more
5 limited for neonates with birth weights below 1.5 kg and
gestational age <30 weeks [17]. The BSV and residual
3
variability reported in the present study are lower than those
WRES

1 reported in previous studies [18]. The present study

included more extremely premature neonates (gestational
-1 age <28 weeks, 57.5%) and extremely low-birth-weight
infants (<1000 g, 55%) than previously published studies
-3
investigating amikacin PK in neonates. Consideration was
-5
given to investigating the potential effect of shrinkage on
the empirical Bayes estimates [19], but this was not
considered to explain the lower observed variability
0.0 3.2 6.4 9.6 12.8 16.0 19.2 22.4 25.6 28.8 32.0
determined in the final model of this study.
Time (hours) post dose
There is a wide BSV in relation to the PK of amikacin
c) WRES vs. time (hours) final model [5], and this makes it difficult to achieve a safe and
Fig. 2 Pharmacokinetic model: diagnostic plots for final covariate
effective dosing regimen particularly for extremely preterm
model. DV Dependent variable, PRED predicted concentration, WRES neonates [20, 21]. Differences in body composition and the
weighted residual renal immaturity associated with neonates contribute to the
variability of the PK parameters, particularly clearance [20].
Other variables that have been reported to influence
Eur J Clin Pharmacol (2009) 65:705713 711

Table 3 Univariate logistic

regression for treatment failure Exposure variable Number Median (range) or n (%) OR (95% CI)

MIC 25 3 (012) 1.30 (0.851.98)

Amikacin peak concentration 31 27.7 (17.136.8) 0.88 (0.741.04)
Current weight (kg) 35 1.0 (0.633.51) 1.35 (0.404.50)
C-reactive protein maximum (mg/L) 35 57 (0.5239) 1.01 (0.961.07)
AUC (mgh/L) 35 267.49 (133.39589.62) 1.01 (1.001.01)
OR Odds ratio, AUC area under Male sex 35 21 male (60) 0.42 (0.101.80)
the concentration-time curve,, Post-menstrual age (weeks) 35 29.57 (2541.14) 0.97 (0.781.21)
Cmax maximum peak concentra-
tion, MIC minimum inhibitory Amikacin peak concentration and MIC 22 10.8 (2.371.6) 1.02 (0.961.08)
concentration Cmax and MIC 24 9.2 (1.9162.9) 1.01 (0.981.05)
a
Values are relative risk instead Amikacin peak/MIC <6 22 2 (9%) 2.86 (1.575.19)a
of odds ratio (as predicts success Amikacin peak/MIC <8 22 4 (18%) 2.25 (0.955.34)a
perfectly)

variability include renal function, gestational age, post-natal
age, haematocrit, fever and lean body weight [3].
The present study showed post-menstrual age to have the
greatest significant effect on clearance. Post-menstrual age
is suggested to be a predictor of amikacin clearance because
it predicts the time course of development of glomerular
filtration rate (GFR) [22]. GFR matures during infancy and
approaches an adult rate (6 L/h per 70 kg) by 6 months
post-natal age [23]. Post-natal age and gestational age were
investigated as separate covariates in the PK model during
development but did not provide the best minimisation to
the OFV. The study did not include neonates <72 h post-
natal age as they were not treated with amikacin. As the
present study only included neonates of more than 72 h of
age, the rapid changes associated with renal function in
neonates <72 h were not applicable to the model.
The effects of gestational age and post-natal age when
included as covariates in models are reported to provide
disproportionate effects, and use of them as separate
covariates may not be informative for renal clearance in

Table 4 Example of percentage of success achieved with simulated amikacin dosing for PMA 2327 weeks

Run PMA (weeks) Dose (mg/kg) Interval (h) AUC24 success AUC24 success Cmax success Cmax success
% day 1 % day 2 % day 1 % day 2

1 2327 19 48 99 99 24 9
2 2327 18 48 99 99 80 53
3 2327 17 48 99 99 94 81
4 2327 16 48 99 99 99 96
5 2327 15 48 97 98 98 99
6 2327 14 48 94 95 84 97
7 2327 13 48 91 92 47 75
8 2327 19 36 99 99 48 10
9 2327 18 36 99 99 76 30
10 2327 17 36 99 99 93 61
11 2327 16 36 99 99 98 85
12 2327 15 36 99 99 98 96a
13 2327 14 36 99 99 83 98
14 2327 13 36 99 99 50 90
15 2327 17 24 99 91 93 17
16 2327 16 24 99 95 99 44
17 2327 15 24 99 97 97 72
18 2327 14 24 99 99 88 93
19 2327 13 24 99 99 52 97

AUC24 Area under the concentration-time curve for 24 h, Cmax maximum peak concentration
a
Highest percentage success without the expense of prolonging dosing interval
712
Table 5 Proposed dosing regimen based on achieving optimal AUC24 and Cmax
PMA (weeks) Dose (mg/kg) Interval (h) AUC24 success %
day 1
28 15 36 99
2932 14 24 99
3336 14 24 97
37 15 24 78
Note: Dosing may be modified by measuring serum amikacin concentration at 24 h post-dose. Dosing regimen does not apply to neonates of
<72 h post-natal age
PMA Post-menstrual age, AUC24 area under the concentration-time curve for 24 h, Cmax maximum peak concentration
neonates >72 h age. This is stated to be particularly evident
beyond the initial neonatal period, and therefore it may be
more appropriate to use post-menstrual age [21, 24]. The
PK base model in the present study estimated clearance of
0.069 L/h (1.15 mL/min) in neonates with a gestational age
of 2441 weeks. Published PK models have previously
reported amikacin clearance as 0.75 and 0.87 mL kg1 min1
in neonates of less than 31 weeks gestation [8, 25]. In
neonates less than 72 h old, with the majority comedicated
with non-steroidal anti-inflammatory drugs, amikacin clear-
ance has been reported as reduced, at 0.60 mL kg1 min1
for gestational age 2830 weeks and 0.44 mL kg1 min1
for gestational age <28 weeks [23, 25].
The primary determinant of amikacin volume of distri-
bution in the present study was current weight. Previous
studies found the covariates influencing V in neonates to be
sepsis, body water and post-natal age [14, 26]. Patients with
severe sepsis may have substantial changes in the extra-
cellular fluid volume which may alter the volume of
distribution of many drugs [27]. Based on their relative
higher water content, preterm neonates already have a higher
volume of distribution for hydrophilic drugs. Therefore, a
relatively higher dose per kilogram of amikacin is deemed
necessary in more-preterm neonates to achieve a sufficient
concentration at the site of infection [20].
Although previous studies report substantial changes in
volume of distribution during the first weeks of life, the
present study included only neonates more than 72 h of age
and hence might not have detected these changes [5, 8, 21,
25, 28]. An increase in volume of distribution associated
with gestational age is suggested to be related to an increase
in lean body mass particularly around 36 weeks gestational
age rather than an increase in fat body mass. In neonates,
anatomical and functional immaturity of the kidney limits
glomerular and tubular functional capacity. Renal matura-
tion has been shown to be related to gestational age [29].
Changes in GFR in neonates are related to nephrogenesis,
which is not complete until around 34 weeks gestational
age [30]. Incomplete nephrogenesis means that premature
Eur J Clin Pharmacol (2009) 65:705713
AUC24 success % Cmax success % Cmax success %
day 2 day 1 day 2
99 98 97
99 96 97
97 99 98
76 95 93
neonates cannot respond to haemodynamic adjustments as
effectively as full-term neonates [31]. This suggests that
amikacin dosage regimens should be individualised espe-
cially in the 34- to 38-week gestational age group [5] by
adjusting the dose according to body weight and the dosing
interval according to both body weight and post-menstrual age.
Results from the present study indicated the prime
determinant of treatment failure was a peak/MIC <8. The
ability to achieve a therapeutic maximum serum concentra-
tion (Cmax) can be critical to patient survival because of a
significant decrease in the rate of mortality due to infection
in critically ill patients [3, 21, 3234]. Hence, extended-
interval dosing regimens are recommended as they are
expected to result in higher Cmax and greater efficacy [5, 8,
13, 20, 21, 23, 33]. However, there is also a risk that
extending the dosage interval beyond 24 h might provide
an opportunity for bacterial re-growth.
There were various limitations associated with the
present study and this was reflected in the results of the
PK model, PD models, the simulations and the proposed
dosing regimens for amikacin in this neonatal population.
There were a limited number of neonates used for the PK
and PD analyses. However, numbers will always be limited
in any prospective observational study that identifies
adverse outcomes (e.g. treatment failure) because once a
problem is identified clinicians will take immediate
corrective action. In addition, the dataset consisted of 55%
extremely low-birth-weight infants (< 1,000 g) and 57.5%
extremely premature neonates (gestational age <28 week),
providing a possible bias in the PK model. The number of
older neonates was limited as the population dataset
contained only 10 (12.5%) neonates with gestational age
34 weeks.
Acknowledgements The authors would like to acknowledge Pro-
fessor Stephen Duffull, School of Pharmacy, University of Otago,
Dunedin, New Zealand, for his assistance with the PK modelling and
the simulations. Catherine Sherwin is supported by a Freemasons
Postgraduate Fellowship in Paediatrics and Child Health from the
Freemasons of New Zealand.
Eur J Clin Pharmacol (2009) 65:705713
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