Population pharmacokinetics of piperacillin in critically ill children including those undergoing continuous kidney replacement therapy

Clin Microbiol Infect. 2022 Sep;28(9):1287.e9-1287.e15. doi: 10.1016/j.cmi.2022.03.031. Epub 2022 Apr 4.


Objectives: Despite that piperacillin-tazobactam combination is commonly used in critically ill children, increasing evidence suggests that the current dosing schedules are not optimal for these patients. The aim of this work is to develop a population pharmacokinetic model for piperacillin to evaluate the efficacy of standard dosing in children with and without continuous kidney replacement therapy (CKRT) and to propose alternative dosing schemes maximizing target attainment.

Methods: Four hundred twenty-nine piperacillin concentrations measured in different matrices, obtained from 32 critically ill children (19 without CKRT, 13 with CKRT) receiving 100 mg/kg of piperacillin/tazobactam every 8 hours (increased to 12 hours after the fourth dose) were modelled simultaneously using the population approach with NONMEM 7.4. The percentage of patients with 90% fT > MIC and target attainment (percentage of dosing interval above MIC) were estimated for different intermittent and continuous infusions in the studied population.

Results: Piperacillin pharmacokinetic was best described with a two-compartment model. Renal, nonrenal, and hemofilter clearances were found to be influenced by the glomerular filtration rate, height (renal clearance), weight (nonrenal clearance), and filter surface (hemofilter clearance). Only seven (37%) children without CKRT and seven (54%) with CKRT achieved 90% fT > MIC with the current dosing schedule. Of the alternative regimens evaluated, a 24-hour continuous infusion of 200 mg/kg (CKRT) and 300 mg/kg (no CKRT) provided 100% fT > MIC (percent of time free drug remains above the minimum inhibitory concentration) (≤16 mg/L) and target attainments ≥90% across all evaluated MICs.

Discussion: In children with and without CKRT, standard dosing failed to provide an adequate systemic exposure, while prolonged and continuous infusions showed an improved efficacy.

Keywords: Acute kidney injury; Continuous renal replacement therapy; Critically ill children; Dose individualization; Piperacillin; Population pharmacokinetics; Tazobactam.

MeSH terms

  • Anti-Bacterial Agents / pharmacology
  • Child
  • Critical Illness* / therapy
  • Humans
  • Microbial Sensitivity Tests
  • Piperacillin* / therapeutic use
  • Piperacillin, Tazobactam Drug Combination
  • Renal Replacement Therapy


  • Anti-Bacterial Agents
  • Piperacillin, Tazobactam Drug Combination
  • Piperacillin