Population pharmacokinetics of ceftazidime in critically ill children: impact of cystic fibrosis.

BACKGROUND: Pharmacokinetics data on ceftazidime are sparse for the paediatric population, particularly for children with cystic fibrosis (CF) or severe infections. OBJECTIVES: To characterize the population pharmacokinetics of ceftazidime in critically ill children, identify covariates that affect drug disposition and evaluate the current dosing regimens. METHODS: The study was registered with Clinicaltrials.gov (NCT01344512). Children receiving ceftazidime were selected in 13 French hospitals. Plasma concentrations were determined by UPLC-MS/MS. Population pharmacokinetic analyses were performed using NONMEN software. RESULTS: One hundred and eight patients, aged 28 days to 12 years, with CF (n = 32), haematology and/or oncology disorders (n = 47) or severe infection (n = 29) were included. Ceftazidime was administered by continuous or intermittent infusions; 271 samples were available for analysis. A two-compartment model with first-order elimination and allometric scaling was developed and covariate analysis showed that ceftazidime pharmacokinetics were also significantly affected by CLCR and CF. Ceftazidime clearance was 82% higher in CF than in non-CF patients. Monte Carlo simulations showed that the percentage of target attainment (PTA) for the target of T>MIC = 65% was (i) lower in CF than in non-CF children with intermittent infusions and (ii) higher with continuous than intermittent infusion in all children. CONCLUSIONS: The population pharmacokinetics model for ceftazidime in children was influenced by body weight, CLCR and CF. A higher PTA was obtained with continuous versus intermittent infusions. Further studies should explore the benefits of continuous versus intermittent infusion of ceftazidime, including current versus increased doses in CF children.

Variability of ciprofloxacin pharmacokinetics in children: impact on dose range in sickle cell patients.

Objectives: To determine the ciprofloxacin population pharmacokinetics in paediatric patients and the impact of underlying disease and evaluate the appropriateness of current dosage regimens. Patients and methods: Plasma concentrations of ciprofloxacin from children treated with ciprofloxacin were measured by HPLC. The pharmacokinetic population analysis was performed using NONMEM v7.2 (Icon Development Solutions, USA). Results: Two datasets were combined and 128 plasma concentrations in 60 patients aged 5.6 years (range 0.3-18.9), treated with a median daily dose of 30.0 mg/kg (range 6.5-52.0) presenting with sickle cell disease (SCD; n = 20, 33%), haemopathy (n = 15, 25%), cystic fibrosis (CF; n = 3, 5%) and other diseases (n  =  22, 37%) were analysed. Data were best described by a two-compartment model with first-order elimination. Ciprofloxacin clearance (mean ±â€Šâ€ŠSD) was 0.81 ±â€Š0.30 L/h/kg, increased allometrically with weight, decreased with increasing creatinine concentration, was 89% higher in SCD compared with non-SCD patients and increased by 0.95 L/h/kg per year of age. The volume of distribution was 6.9 L/kg and depended only on the weight. Monte Carlo simulations were performed separately in SCD and non-SCD patients to target an AUC/MIC ratio >125 at steady-state, required for antibacterial efficacy, and recommendations of dosing regimens were proposed. Conclusions: In addition to known covariates, ciprofloxacin clearance is greater in SCD children compared with non-SCD patients. The dosing of this agent needs to be adapted to this subgroup of patients.

[Consent in children: Practical situations (part 2)]. / Recherche en pédiatrie (2) : le consentement en pratique.

Ethical and regulatory documents frame informed consent in pediatric research; their application is obligatory but may be complex. In this specific context, pediatric investigators have a central ethical role to play to ensure the strict respect of regulatory and ethical requirements adapted to the French legal, social, and cultural context as well as good clinical practices. This article attempts to shed light on the considerations that can allow researchers to come to terms with industrial and institutional demands while responding to the needs of patients, particularly in the domain of pediatric research.

[Legal aspects of consent in children (Part 1)]. / Recherche en pédiatrie (1) : dispositions juridiques relatives au consentement.

In pediatric research, the patient is legally a minor and therefore protected by law. Research can only be conducted after parental consent and patient assent have been obtained. In this context, this review discusses the historical events and documents related to all ethical precautions and obligations. It also underlines that physicians shall respect all legal measures, but that individual involvement must comply with ethical standards while taking into account issues particular to pediatric research related to parental consent and child assent to clinical trials.

Nocturnal activity of 11ß-hydroxy steroid dehydrogenase type 1 is increased in type 1 diabetic children.

AIM: The objective of this study was to investigate low-grade inflammation in children with type 1 diabetes (T1D) and its association with cortisol levels as well as its bioavailability through 11ß-hydroxy steroid dehydrogenase type 1 (11ß-HSD1) activity. METHODS: Children with T1D (n=45) and their non-diabetic siblings (n=28) participated in the study. Interleukin-6 (IL-6) and high-sensitivity C-reactive protein (CRPhs) were measured between 1400 and 1800h. Glucocorticoid metabolites were measured in the first morning urine on clinic day and 11ß-HSD1 activity was estimated by tetrahydrocortisol/tetrahydrocortisone (THF/THE) ratio. RESULTS: Diabetic patients presented with an increased THF/THE ratio compared with controls (median: 0.68 [range: 0.45-1.18] vs 0.45 [0.27-0.98], respectively; P<10(-3)). There was no difference between diabetic patients and controls for IL-6 (0.6ng/mL [0.6-6.8] vs 0.6 [0.6-2.2], respectively; P=0.43) and CRPhs (0.4mg/L [0-7.4] vs 0.3 [0-8.2]; P=0.26, respectively). When adjusted for age, gender and BMI, the THF/THE ratio was significantly associated with CRPhs (ß=0.32, P=0.02) in diabetic patients, but not in controls. CONCLUSION: Low-grade inflammation assessed by plasma CRPhs and IL-6 concentrations was not detectable in our cohort of T1D children. Nocturnal 11ß-HSD1 activity was increased and associated with plasma CRPhs concentration in diabetic patients. These results may be explained by either a direct or inflammation-mediated effect of the relative hepatic lack of insulin due to subcutaneous insulin therapy.

Physical and chemical stability of marine lipid-based liposomes under acid conditions.

Liposomes made from a marine lipid extract containing a high polyunsaturated fatty lipid ratio were submitted to large pH variations, ranging from 1 to 8. Shape transformations were followed by video microscopy using giant liposomes and micromanipulation experiments. Acidification induced a decrease of the vesicle size simultaneous to the appearance of invaginations. These pH-dependent structural rearrangements were interpreted in terms of osmotic shocks and chemical modifications of the membranes. Liposomes produced by direct filtration were studied using turbidity measurements and optical microscopy observations. A low pH led to an instantaneous vesicle aggregation and to complex supramolecular and/or morphological changes as a function of time. The subsequent buffer neutralization of the liposome suspensions induced a partial reversion of the aggregation phenomenon while the structural membrane rearrangements were persisting. Furthermore, weak chemical degradations (oxidation and hydrolysis) were evidenced when the vesicles were incubated at low pH up to a 24-h incubation time. Thus, although acidification revealed liposome size and shape changes, the bilayer structure was maintained indicating that marine lipid-based liposomes could be used as oral administration vectors.

In vitro behavior of marine lipid-based liposomes. Influence of pH, temperature, bile salts, and phospholipase A2.

To deliver polyunsaturated fatty acids (PUFA) by the oral route, liposomes based on a natural mixture of marine lipids were prepared by filtration and characterized in media that mimic gastrointestinal fluids. First the influence of large pH variations from 1.5-2.5 (stomach) to 7.4 (intestine) at the physiological temperature (37 degrees C) was investigated. Acidification of liposome suspensions induced instantaneous vesicle aggregation, which was partially reversible when the external medium was further neutralized. Simultaneously, complex morphological bilayer rearrangements occurred, leading to the formation of small aggregates. These pH- and temperature-dependent structural changes were interpreted in terms of osmotic shock and lipid chemical alterations, i.e., oxidation and hydrolysis, especially in the first hours of storage. Besides, oxidative stability was closely related to the state of liposome aggregation and the supramolecular organization (vesicles or mixed micelles). The effects of bile salts and phospholipase A2 (PLA2) on the liposome structures were also studied. Membrane solubilization by bile salts was favored by preliminary liposome incubation in acid conditions. PLA2 showed a better activity on liposome structures than on the corresponding mixed lipid-bile salt micelles. As a whole, in spite of slight morphological modifications, vesicle structures were preserved after an acid stress and no lipid oxidation products were detected during the first 5 h of incubation. Thus, marine lipids constituted an attractive material for the development of liposomes as potential oral PUFA supplements.

Incorporation of alpha-tocopherol in marine lipid-based liposomes: in vitro and in vivo studies.

Liposomes made from a natural marine lipid extract and containing a high polyunsaturated n-3 fatty lipid ratio were envisaged as oral route vectors and a potential alpha-tocopherol supplement. The behavior of vesicles obtained by simple filtration and of giant vesicles prepared by electroformation was investigated in gastrointestinal-like conditions. The influence of alpha-tocopherol incorporation into liposomes was studied on both physical and chemical membrane stability. Propanal, as an oxidation product of n-3 polyunsaturated fatty acids, was quantified by static headspace gas chromatography when alpha-tocopherol incorporation into liposome ratios ranged from 0.01 to 12 mol%. Best oxidative stability was obtained for liposomes that contained 5 mol% alpha-tocopherol. Compared to the other formulas, propanal formation was reduced, and time of the oxidation induction phase was longer. Moreover, alpha-tocopherol induced both liposome structural modifications, evidenced by turbidity, and phospholipid chemical hydrolysis, quantified as the amount of lysophospholipids. This physicochemical liposome instability was even more pronounced in acid storage conditions, i.e., alpha-tocopherol incorporation into liposome membranes accelerated the structural rearrangements and increased the rate of phospholipid hydrolysis. In particular, giant vesicles incubated at pH 1.5 underwent complex irreversible shape transformations including invaginations. In parallel, the absorption rate of alpha-tocopherol was measured in lymph-cannulated rats when alpha-tocopherol was administrated, as liposome suspension or added to sardine oil, through a gastrostomy tube. Alpha-tocopherol recovery in lymph was increased by almost threefold, following liposome administration. This may be related to phospholipids that should favor alpha-tocopherol solubilization and to liposome instability in the case of a high amount of alpha-tocopherol in the membranes. A need to correlate results obtained from in vitro liposome behavior with in vivo lipid absorption was demonstrated by this study.

Induction of new physicochemical and functional properties by the glycosylation of whey proteins.

Nucleophilic primary amino groups of whey proteins (beta-lactoglobulin and alpha-lactalbumin) were modified with reducing sugars in mild heat conditions. After 49 hr of heating (60 degrees C) at pH 6.5, 20-30% of beta-lactoglobulin amino groups were substituted with aldohexoses (galactose, mannose, glucose) and lactose, whereas up to 70% and 90% of beta-lactoglobulin amino groups were modified with ribose and glyceraldehyde, respectively. Gel electrophoresis and reversed-phase HPLC coupled with electrospray ionization mass spectrometry of glycosylated proteins indicated that the substitution was random. Consequently, highly heterogeneous families of glycosylated proteins were generated. Proteins substituted with hexoses and lactose exhibited higher solubility and improved emulsifying properties as compared with nonglycosylated proteins, in the whole pH range studied. In contrast, proteins glycosylated with ribose and glyceraldehyde showed lower solubility close to their isoelectric points. Beta-lactoglobulin modified with ribose and glyceraldehyde displayed substantial differences in denaturation behavior as compared with native protein. When compared with beta-lactoglobulin, glycosylation of alpha-lactalbumin was quicker. There was no difference in glycosylation yields nor rates of alpha-lactalbumin in presence and absence of calcium.