Population Pharmacokinetics of Temocillin in Acute Enterobacterial Pyelonephritis in Children

Overview

Temocillin, a 6-alpha-methoxypenicillin derivative of ticarcillin, is a narrow-spectrum antibiotic, primarily restricted to Enterobacterales. Therefore, its prescription for the treatment of febrile urinary tract infections requiring hospitalization in pediatrics appears interesting. However, and despite marketing authorization in pediatrics for the treatment of complicated urinary tract infections (including acute pyelonephritis), the pharmacokinetic parameters of this antibiotic have not been specifically evaluated in pediatrics, and the optimal dose is not known in this population. Through this study, we propose to determine the pharmacokinetic parameters of temocillin in children aged 0-15 years with a febrile urinary tract infection due to Gram-negative rod (GNR), without sepsis but requiring hospitalization. The results will help to establish dose recommendations for temocillin in the pediatric population, based on age and renal function.

Clinical Context of Temocillin Use: Temocillin is an old antibiotic, a 6-alpha-methoxypenicillin derivative of ticarcillin, which has been rediscovered in recent years due to its narrow spectrum of activity and its ability to resist hydrolysis by most beta-lactamases, including ESBL. Temocillin is bactericidal, is not impacted by the inoculum effect, and has a low selection of resistant mutants. Due to its narrow spectrum (essentially limited to Enterobacterales), it appears to have a reduced overall impact on the fecal microbiota. Studies have retrospectively reported clinical and microbiological efficacy of temocillin in urinary tract infections caused by ESBL-producing Enterobacterales in children and adults. More generally, Enterobacterales have a high susceptibility to temocillin, with susceptibility rates exceeding 90-95% in several epidemiological studies in both children and adults. This is higher than that of third-generation cephalosporins, which still remain the first-line treatment in recent french guidelines (GPIP, SPILF), As a result, temocillin has been approved for the treatment of acute pyelonephritis (febrile urinary tract infections), including in the pediatric population. In France, it is primarily used for the treatment of ESBL-associated febrile urinary tract infections. Since september 2024, Robert Debré University Hospital uses temocillin has an empiricial antibiotic therapy for hospitalized cases of febrile urinary tract infections, without any sign of sepsis, at the recommended high dose of 50 mg/kg/day in 2 intravenous injections of 30 min spaced 12 hours apart. Pharmacokinetic Data of Temocillin: Temocillin is a bactericidal antibiotic for parenteral use, belonging to the beta-lactam family. Temocillin binds strongly to plasma proteins (approximately 80% binding) and has a prolonged elimination half-life of approximately 5 hours. Its elimination is primarily renal. As with other beta-lactams, the best pharmacokinetic/pharmacodynamic (PK/PD) criterion correlated with the efficacy of temocillin appears to be the cumulative percentage of time over 24 hours during which temocillin's free concentration exceeds the minimum inhibitory concentration (fT\>MIC) at steady state. A target fT\>MIC 40% of is associated with antibacterial effect and in vivo survival. In adults, Monte Carlo pharmacokinetic simulations have demonstrated that an IV regimen of 2 grams every 12 hours allows a %ft\>MIC of 40% to be achieved in 95% of treated patients and for MICs up to 8 mg/L. In children up to 15 years of age, the standard recommended dosage is 25 mg/kg/day in 2 IV injections (max. 4g/day) but a higher dosage of 50 mg/kg/day in 2 IV injections (max. 4g/day) is indicated for the treatment of severe infections (including acute pyelonephritis requiring hospitalization). However, these proposed regimens recommendations do not originate from paediatric PK/PD studies but are derived from adult studies. To date, no study has evaluated the pharmacokinetic parameters of temocillin specifically in children (\<15 years), and the optimal dosage regimen maximizing the probability of reaching the target PK/PD criterion (fT\>MIC of 40%) in the treatment of febrile urinary tract infections due to GNR is currently unknown.