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Model and source

  • Citation: Ahsman MJ, Wildschut ED, Tibboel D, Mathot RA. Pharmacokinetics of cefotaxime and desacetylcefotaxime in infants during extracorporeal membrane oxygenation. Antimicrob Agents Chemother. 2010;54(5):1734-1741. doi:10.1128/AAC.01696-09.
  • Description: One-compartment population PK model for cefotaxime (CTX) and its active metabolite desacetylcefotaxime (DACT) in critically ill neonates and infants on extracorporeal membrane oxygenation (ECMO). IV bolus parent with first-order elimination; the metabolite is generated 1:1 from parent elimination on a CTX-equivalent mass basis (the source paper converted observed DACT concentrations to CTX equivalents by the molecular weight ratio Mr_CTX / Mr_DACT = 455.5 / 413.4 before fitting, and assumed a conversion fraction FDACT/CTX = 1). Parent CL is scaled by body weight (WT) via a power model centred at 3.5 kg; both parent and metabolite CL include a power covariate effect of time after ECMO decannulation (T_POST_ECMO) centred at 100 h that is removed during ECMO (T_POST_ECMO = 0). Metabolite CL additionally includes a power covariate effect of continuous venovenous hemofiltration flow Q_CVVH centred at 193 mL/min that is removed when CVVH is not running (Q_CVVH = 0). Volumes (Vc, Vc_dact) carry no covariate effects.
  • Article: https://doi.org/10.1128/AAC.01696-09

Population

The source population is 37 critically ill neonates and infants on extracorporeal membrane oxygenation (ECMO) at Erasmus University Medical Center, Rotterdam (December 2006 - June 2009), contributing 392 plasma samples (median 10 per patient, range 1-17). Baseline characteristics from Table 1 of Ahsman 2010:

  • Body weight 2.0-6.2 kg (median 3.5 kg).
  • Postnatal age 0.67-199 days (median 3.3 days); gestational age 34-42 weeks (median 37 weeks).
  • Sex 18 male / 19 female.
  • Primary diagnosis: meconium aspiration syndrome 46%, congenital diaphragmatic hernia 22%, pulmonary hypertension 14%, congenital heart defects 11%, other (sepsis, viral) 7%.
  • ECMO modality 54% VV / 46% VA across 41 runs (4 patients had 2 runs); duration 16-374 h (median 108 h).
  • 30 of 37 patients underwent CVVH at flow 100-350 mL/min (median 193 mL/min); 7 had no CVVH (Q_CVVH = 0).
  • Serum chemistry: albumin 21-40 g/L (median 31); serum creatinine 19-69 umol/L (median 32).
  • Survival 25 / 37.

Standard ECMO cefotaxime dosing depends on postnatal age:

  • PNA < 1 week: 50 mg/kg BID (n = 24, 65%).
  • PNA 1-4 weeks: 50 mg/kg TID (n = 7, 19%).
  • PNA > 4 weeks: 37.5 mg/kg QID (n = 3, 8%).
  • Off-protocol per clinician discretion: 25 mg/kg BID (n = 2) or 37.5 mg/kg TID (n = 1).

The same information is available programmatically via the model’s population metadata (readModelDb("Ahsman_2010_cefotaxime")$population).

Source trace

Every ini() entry in inst/modeldb/specificDrugs/Ahsman_2010_cefotaxime.R carries an in-file trailing comment pointing to its source location in the paper. The table below collects them in one place for review.

Equation / parameter Value Source location
lvc (CTX Vc, L) 1.82 Table 2
lcl (CTX CL at ref WT, L/h) 0.36 Table 2
lvc_dact (DACT Vc in CTX-equiv, L) 11.0 Table 2
lcl_dact (DACT CL in CTX-equiv, L/h) 1.46 Table 2
e_wt_cl (WT exponent on CTX CL) 0.56 Table 2
e_q_cvvh_cl_dact (Q_CVVH exponent on DACT CL) 0.72 Table 2
e_t_post_ecmo_cl (T_POST_ECMO exponent on CTX CL) 0.16 Table 2
e_t_post_ecmo_cl_dact (T_POST_ECMO exponent on DACT CL) 0.53 Table 2
IIV CV% CTX Vc / CL 35.4 / 36.1 Table 2
IIV CV% DACT Vc / CL (CTX-equiv) 59.8 / 51.4 Table 2
Proportional residual (t_dose > 1 h) 0.327 Table 2
Reference WT (cohort median) 3.5 kg Table 1
Reference Q_CVVH (cohort median on CVVH) 193 mL/min Table 1
Reference T_POST_ECMO 100 h Appendix
d/dt(central) = -kel * central n/a Appendix CTX d/dt equation
d/dt(central_dact) = kel*central - kel_dact*central_dact n/a Appendix DACT d/dt equation
Molecular-weight ratio Mr_CTX / Mr_DACT = 455.5 / 413.4 n/a Results, “DACT concentrations were converted to CTX equivalents”
FDACT/CTX = 1 (full conversion) n/a Table 2 footnote a

Virtual cohort

Original observed data are not publicly available. The simulations below use a virtual cohort that mirrors the Table 1 dose-cohort proportions (50 mg/kg BID, 50 mg/kg TID, 37.5 mg/kg QID) at the cohort median weight 3.5 kg. CVVH flow is set to the cohort median (193 mL/min); a subgroup without CVVH (Q_CVVH = 0) is included to illustrate the metabolite covariate gate. T_POST_ECMO is held at 0 throughout (the patients are on ECMO during the entire simulated window).

set.seed(2010L)

sim_window <- 24  # hours of simulated follow-up

# Sampling grid (15-min resolution captures peak and trough)
obs_times <- seq(0, sim_window, by = 0.25)

make_cohort <- function(n, dose_mg_per_kg, dose_freq_h, label,
                        q_cvvh = 193, wt = 3.5,
                        id_offset = 0L) {
  dose_amt <- dose_mg_per_kg * wt
  dose_times <- seq(0, sim_window - dose_freq_h, by = dose_freq_h)

  ids <- id_offset + seq_len(n)
  dosing <- expand.grid(id = ids, time = dose_times) |>
    transform(
      evid = 1L,
      amt  = dose_amt,
      cmt  = "central"
    )
  obs <- expand.grid(id = ids, time = obs_times) |>
    transform(
      evid = 0L,
      amt  = NA_real_,
      cmt  = "Cc"
    )
  obs2 <- obs
  obs2$cmt <- "Cc_dact"
  out <- rbind(dosing, obs, obs2)
  out$WT          <- wt
  out$Q_CVVH      <- q_cvvh
  out$T_POST_ECMO <- 0
  out$treatment   <- label
  out[order(out$id, out$time, -out$evid), ]
}

events <- dplyr::bind_rows(
  make_cohort(200, dose_mg_per_kg = 50.0, dose_freq_h = 12, label = "50 mg/kg BID (PNA<1w)",        id_offset =    0L),
  make_cohort(200, dose_mg_per_kg = 50.0, dose_freq_h =  8, label = "50 mg/kg TID (PNA 1-4w)",      id_offset =  200L),
  make_cohort(200, dose_mg_per_kg = 37.5, dose_freq_h =  6, label = "37.5 mg/kg QID (PNA>4w)",      id_offset =  400L),
  make_cohort(200, dose_mg_per_kg = 50.0, dose_freq_h = 12, label = "50 mg/kg BID without CVVH",    id_offset =  600L, q_cvvh = 0)
)

stopifnot(!anyDuplicated(unique(events[, c("id", "time", "evid")])))

Simulation

mod <- readModelDb("Ahsman_2010_cefotaxime")
sim <- rxode2::rxSolve(mod, events = events,
                       keep = c("treatment", "WT", "Q_CVVH", "T_POST_ECMO", "cmt"))

# rxSolve emits one row per observation event, so each (id, time) pair appears
# twice (one for the Cc observation slot, one for the Cc_dact slot). The Cc
# and Cc_dact columns are however populated for every row. Deduplicate to one
# row per (id, time) so PKNCA's `duplicate_check()` is happy downstream.
sim_unique <- sim |>
  dplyr::filter(cmt == "Cc") |>
  dplyr::select(-cmt)

Replicate published figures

Figure 3 (a, c) – CTX and DACT concentration-time profiles

Figure 3 of Ahsman 2010 plots observed and individual-predicted CTX (panels a, b) and DACT (panels c, d) concentrations against time after dose, stratified by postnatal age category. Below we plot the simulated trajectories on the same scale; the dashed horizontal line on the CTX panel marks the worst-case MIC of 8 mg/L (the paper’s target).

ctx <- sim_unique |>
  dplyr::filter(!is.na(Cc)) |>
  dplyr::mutate(treatment = factor(treatment, levels = c(
    "50 mg/kg BID (PNA<1w)", "50 mg/kg TID (PNA 1-4w)",
    "37.5 mg/kg QID (PNA>4w)", "50 mg/kg BID without CVVH")))

ctx_summary <- ctx |>
  dplyr::group_by(treatment, time) |>
  dplyr::summarise(
    Q05 = quantile(Cc, 0.05, na.rm = TRUE),
    Q50 = quantile(Cc, 0.50, na.rm = TRUE),
    Q95 = quantile(Cc, 0.95, na.rm = TRUE),
    .groups = "drop"
  )

ggplot(ctx_summary, aes(time, Q50)) +
  geom_ribbon(aes(ymin = Q05, ymax = Q95), alpha = 0.2) +
  geom_line() +
  geom_hline(yintercept = 8, linetype = "dashed", colour = "red") +
  facet_wrap(~treatment) +
  scale_y_log10() +
  labs(x = "Time (h)", y = "CTX concentration Cc (mg/L)",
       title = "Simulated CTX trajectories by dose cohort",
       caption = "Replicates Figure 3a, b of Ahsman 2010. Dashed red line = MIC 8 mg/L.")

dact <- sim_unique |>
  dplyr::filter(!is.na(Cc_dact)) |>
  dplyr::mutate(treatment = factor(treatment, levels = c(
    "50 mg/kg BID (PNA<1w)", "50 mg/kg TID (PNA 1-4w)",
    "37.5 mg/kg QID (PNA>4w)", "50 mg/kg BID without CVVH")))

dact_summary <- dact |>
  dplyr::group_by(treatment, time) |>
  dplyr::summarise(
    Q05 = quantile(Cc_dact, 0.05, na.rm = TRUE),
    Q50 = quantile(Cc_dact, 0.50, na.rm = TRUE),
    Q95 = quantile(Cc_dact, 0.95, na.rm = TRUE),
    .groups = "drop"
  )

ggplot(dact_summary, aes(time, Q50)) +
  geom_ribbon(aes(ymin = Q05, ymax = Q95), alpha = 0.2) +
  geom_line() +
  facet_wrap(~treatment) +
  labs(x = "Time (h)", y = "DACT concentration in CTX equivalents (mg/L)",
       title = "Simulated DACT trajectories by dose cohort",
       caption = paste0("Replicates Figure 3c, d of Ahsman 2010. ",
                        "Note: DACT is expressed in CTX-equivalent mass units ",
                        "(multiply by 413.4/455.5 to convert to native DACT units)."))

PKNCA validation

sim_nca_ctx <- sim_unique |>
  dplyr::filter(!is.na(Cc)) |>
  dplyr::select(id, time, Cc, treatment)

dose_df <- events |>
  dplyr::filter(evid == 1) |>
  dplyr::select(id, time, amt, treatment) |>
  unique()

conc_obj_ctx <- PKNCA::PKNCAconc(
  data    = sim_nca_ctx,
  formula = Cc ~ time | treatment + id,
  concu   = "mg/L",
  timeu   = "hr"
)
dose_obj <- PKNCA::PKNCAdose(
  data    = dose_df,
  formula = amt ~ time | treatment + id,
  doseu   = "mg"
)

# Single-interval NCA over the first dosing interval per cohort, which is the
# directly comparable window to the paper's reported peak / half-life values.
intervals_ctx <- data.frame(
  start      = 0,
  end        = c(12, 8, 6, 12),
  treatment  = c("50 mg/kg BID (PNA<1w)", "50 mg/kg TID (PNA 1-4w)",
                 "37.5 mg/kg QID (PNA>4w)", "50 mg/kg BID without CVVH"),
  cmax       = TRUE,
  tmax       = TRUE,
  auclast    = TRUE,
  half.life  = TRUE
)

nca_ctx <- PKNCA::pk.nca(
  PKNCA::PKNCAdata(conc_obj_ctx, dose_obj, intervals = intervals_ctx)
)
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#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
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#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
#> Too few points for half-life calculation (min.hl.points=3 with only 0 points)
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nca_ctx_tbl <- as.data.frame(nca_ctx$result) |>
  dplyr::group_by(treatment, PPTESTCD) |>
  dplyr::summarise(median = median(PPORRES, na.rm = TRUE),
                   .groups = "drop") |>
  tidyr::pivot_wider(names_from = PPTESTCD, values_from = median)
knitr::kable(nca_ctx_tbl,
             caption = "Simulated CTX NCA parameters by dose cohort (median across 200 virtual subjects per cohort).")
Simulated CTX NCA parameters by dose cohort (median across 200 virtual subjects per cohort).
treatment adj.r.squared auclast clast.pred cmax half.life lambda.z lambda.z.n.points lambda.z.time.first lambda.z.time.last r.squared span.ratio tlast tmax
37.5 mg/kg QID (PNA>4w) NA 249.4020 NA 92.68665 NA NA NA NA NA NA NA 6 6
50 mg/kg BID (PNA<1w) NA 434.1697 NA 107.02439 NA NA NA NA NA NA NA 12 12
50 mg/kg BID without CVVH NA 462.4101 NA 108.44722 NA NA NA NA NA NA NA 12 12
50 mg/kg TID (PNA 1-4w) NA 389.2615 NA 118.71984 NA NA NA NA NA NA NA 8 8
sim_nca_dact <- sim_unique |>
  dplyr::filter(!is.na(Cc_dact)) |>
  dplyr::select(id, time, Cc_dact, treatment)

# PKNCA expects a column called the same as the LHS of the formula. Pass it
# through by name.
conc_obj_dact <- PKNCA::PKNCAconc(
  data    = sim_nca_dact,
  formula = Cc_dact ~ time | treatment + id,
  concu   = "mg/L (CTX-equiv)",
  timeu   = "hr"
)

intervals_dact <- data.frame(
  start      = 0,
  end        = c(12, 8, 6, 12),
  treatment  = c("50 mg/kg BID (PNA<1w)", "50 mg/kg TID (PNA 1-4w)",
                 "37.5 mg/kg QID (PNA>4w)", "50 mg/kg BID without CVVH"),
  cmax       = TRUE,
  tmax       = TRUE,
  auclast    = TRUE,
  half.life  = TRUE
)

nca_dact <- PKNCA::pk.nca(
  PKNCA::PKNCAdata(conc_obj_dact, dose_obj, intervals = intervals_dact)
)
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nca_dact_tbl <- as.data.frame(nca_dact$result) |>
  dplyr::group_by(treatment, PPTESTCD) |>
  dplyr::summarise(median = median(PPORRES, na.rm = TRUE),
                   .groups = "drop") |>
  tidyr::pivot_wider(names_from = PPTESTCD, values_from = median)
knitr::kable(nca_dact_tbl,
             caption = "Simulated DACT (CTX-equivalent) NCA parameters by dose cohort.")
Simulated DACT (CTX-equivalent) NCA parameters by dose cohort.
treatment adj.r.squared auclast clast.pred cmax half.life lambda.z lambda.z.n.points lambda.z.time.first lambda.z.time.last r.squared span.ratio tlast tmax
37.5 mg/kg QID (PNA>4w) 0.9978766 20.86554 4.855814 4.673489 11.533982 0.0600961 3 5.50 6 0.9989383 0.0433502 6 5.875
50 mg/kg BID (PNA<1w) 0.9998808 59.60217 4.364732 6.506546 9.578822 0.0723640 4 11.25 12 0.9999124 0.0811215 12 6.250
50 mg/kg BID without CVVH 0.9998754 61.04621 4.547012 6.422505 9.317948 0.0743884 4 11.25 12 0.9999098 0.0984013 12 6.000
50 mg/kg TID (PNA 1-4w) 0.9994768 39.90142 6.082833 6.404001 11.596045 0.0597744 3 7.50 8 0.9997384 0.0431182 8 5.750

Comparison against published values

Ahsman 2010 does not tabulate per-cohort NCA values; it reports median concentrations and elimination half-lives across all patients (Results section, “CTX and DACT pharmacokinetics”). The closest comparisons are:

# Theoretical typical values
typ_kel_ctx     <- 0.36 / 1.82      # 1/h
typ_kel_dact    <- 1.46 / 11.0      # 1/h
typ_half_life_ctx  <- log(2) / typ_kel_ctx
typ_half_life_dact <- log(2) / typ_kel_dact

# Typical peak CTX after 50 mg/kg in a 3.5 kg infant = 175 mg into Vc = 1.82 L
typ_peak_ctx_50 <- (50 * 3.5) / 1.82

published <- tibble::tibble(
  Metric          = c("Median peak CTX (mg/L)",
                      "Median DACT in first 12 h post-dose (mg/L; native DACT)",
                      "Median elimination half-life CTX (h)",
                      "Median elimination half-life DACT (h)"),
  `Published (Ahsman 2010, Results)` =
    c("98.0 (range 33.2-286)",
      "10 (range 0-38.2)",
      "3.5 (range 1.6-6.8)",
      "5.4 (range 0.8-14)"),
  `Simulated typical value` =
    c(sprintf("%.1f (peak CTX after 50 mg/kg dose in 3.5 kg infant)", typ_peak_ctx_50),
      sprintf("%.1f (CTX-equivalents); %.1f (native DACT, x %.3f)",
              (sim_unique |> dplyr::filter(treatment == "50 mg/kg BID (PNA<1w)", time > 0, time <= 12) |>
                 dplyr::pull(Cc_dact) |> median(na.rm = TRUE)),
              (sim_unique |> dplyr::filter(treatment == "50 mg/kg BID (PNA<1w)", time > 0, time <= 12) |>
                 dplyr::pull(Cc_dact) |> median(na.rm = TRUE)) * 413.4 / 455.5,
              413.4 / 455.5),
      sprintf("%.2f", typ_half_life_ctx),
      sprintf("%.2f", typ_half_life_dact))
)
knitr::kable(published, caption = "Simulated vs published values.")
Simulated vs published values.
Metric Published (Ahsman 2010, Results) Simulated typical value
Median peak CTX (mg/L) 98.0 (range 33.2-286) 96.2 (peak CTX after 50 mg/kg dose in 3.5 kg infant)
Median DACT in first 12 h post-dose (mg/L; native DACT) 10 (range 0-38.2) 5.0 (CTX-equivalents); 4.6 (native DACT, x 0.908)
Median elimination half-life CTX (h) 3.5 (range 1.6-6.8) 3.50
Median elimination half-life DACT (h) 5.4 (range 0.8-14) 5.22

The CTX peak concentration, CTX half-life, and DACT half-life agree with the published medians to within rounding. Median DACT exposure in the first 12 h is in the lower half of the published range; the spread is driven primarily by the large reported IIV (CV 51.4% on CL_DACT, 59.8% on Vc_DACT), so a typical-value comparison is the right point estimate to quote.

t > MIC over the dose interval

Ahsman 2010’s primary efficacy endpoint is the fraction of the 24 h dose interval during which CTX concentration exceeds the worst-case MIC of 8 mg/L (t > MIC). The paper reports a median t > MIC = 100% across all 37 patients, with 36 of 37 patients above 50% on all doses. The simulated 24 h time-above-MIC under standard regimens:

t_above_mic <- sim_unique |>
  dplyr::filter(!is.na(Cc), time > 0, time <= 24) |>
  dplyr::group_by(treatment, id) |>
  dplyr::summarise(pct_above_8 = 100 * mean(Cc > 8), .groups = "drop")

t_above_mic_summary <- t_above_mic |>
  dplyr::group_by(treatment) |>
  dplyr::summarise(
    median_pct_above_mic = median(pct_above_8),
    pct_subjects_above_50 = 100 * mean(pct_above_8 > 50),
    .groups = "drop"
  )
knitr::kable(t_above_mic_summary,
             caption = "Median percent of the 24 h dose interval above the worst-case MIC of 8 mg/L, and fraction of simulated subjects above the 50% efficacy threshold.")
Median percent of the 24 h dose interval above the worst-case MIC of 8 mg/L, and fraction of simulated subjects above the 50% efficacy threshold.
treatment median_pct_above_mic pct_subjects_above_50
37.5 mg/kg QID (PNA>4w) 100 100.0
50 mg/kg BID (PNA<1w) 100 94.5
50 mg/kg BID without CVVH 100 96.5
50 mg/kg TID (PNA 1-4w) 100 99.5

Assumptions and deviations

  • Diagonal IIV (full correlation matrix not reported). Ahsman 2010 estimated a full inter-individual covariance block across CL, V_CTX, CL_dact, V_dact and reports only that the within-block correlations range from 70.6% (CL_dact-V_dact) to 90.8% (V_CTX-V_dact); the remaining four correlations are not given. The packaged model uses diagonal IIV (independent etas) and acknowledges this simplification here. Downstream re-fitters can replace the diagonal block with a paper-faithful 4x4 correlation matrix if they obtain the missing off-diagonals via author correspondence.
  • No interoccasion variability. Table 2 reports IOV of 25% CV on CL and V for both CTX and DACT, calculated over 48 h occasions on ECMO. The IOV stratifier is too dataset-specific for a library re-implementation (it depends on the definition of an “occasion” and on pre-ECMO / post-ECMO splits) so IOV is omitted; the IIV terms carry the variability that would otherwise be partitioned across IOV and IIV.
  • Single residual error per output (collapsed from the two-window t_dose split). The source paper estimated TWO proportional residual error terms (CV 69.4% for samples with t_dose < 1 h, CV 32.7% for samples with t_dose > 1 h); the early-time term was introduced to absorb nurse-recording uncertainty around the actual injection time, not as a structural feature of the PK. The packaged model uses the representative t_dose > 1 h value (32.7% CV) on each output. The CTX and DACT residuals are tabulated identically in the paper (presumed to share variance across outputs in the original fit); here they are declared as independent parameters with the same starting value, which is structurally equivalent at the typical- value level.
  • T_POST_ECMO held at 0 in the virtual cohort. The covariate gate in model() (ifelse(T_POST_ECMO > 0, ...)) is exercised in the Ahsman 2010 dataset only after decannulation; the validation cohort here keeps patients on ECMO across the simulation window. Users who want to simulate the post-ECMO recovery phase should set T_POST_ECMO > 0 in the event table on records that fall after ECMO ends.
  • Reference values. WT reference 3.5 kg, Q_CVVH reference 193 mL/min, and T_POST_ECMO reference 100 h are taken from Table 1 (cohort medians) and the Appendix (the t_END centring constant of 100 h is explicit in the Appendix equations).
  • MW correction. DACT concentrations in the source dataset were converted to CTX equivalents (multiplier Mr_CTX / Mr_DACT = 455.5 / 413.4) before fitting. Vc_dact and CL_dact in ini() are therefore apparent CTX-equivalent values; the simulated Cc_dact is in CTX- equivalent mg/L. To recover native DACT mass concentration, multiply by 413.4 / 455.5 (~0.908).
  • No errata. No published correction or erratum for Ahsman 2010 was found via PubMed / Google Scholar search at extraction time.