The Importance of Individualized Vancomycin Dosing to Ensure Optimal Exposure Early in Therapy

Early Notice Pointer, an IoT-like Platform for Point-of-Care Feet and Body Balance Screening

Improper foot biomechanics associated with uneven bodyweight distribution contribute to impaired balance and fall risks. There is a need to complete the panel of commercially available devices for the self-measurement of BMI, fat, muscle, bone, weight, and hydration with one that measures weight-shifting at home as a pre-specialist assessment system. This paper reports the development of the Early Notice Pointer (ENP), a user-friendly screening device based on weighing scale technology. The ENP is designed to be used at home to provide a graphic indication and customised and evidence-based foot and posture triage. The device electronically detects and maps the bodyweight and distinct load distributions on the main areas of the feet: forefoot and rearfoot. The developed platform also presents features that assess the user's balance, and the results are displayed as a simple numerical report and map. The technology supports data display on mobile phones and accommodates multiple measurements for monitoring. Therefore, the evaluation could be done at non-specialist and professional levels. The system has been tested to validate its accuracy, precision, and consistency. A parallel study to describe the frequency of arch types and metatarsal pressure in young adults (1034 healthy subjects) was conducted to explain the importance of self-monitoring at home for better prevention of foot arch- and posture-related conditions. The results showed the potential of the newly created platform as a screening device ready to be wirelessly connected with mobile phones and the internet for remote and personalised identification and monitoring of foot- and body balance-related conditions. The real-time interpretation of the reported physiological parameters opens new avenues toward IoT-like on-body monitoring of human physiological signals through easy-to-use devices on flexible substrates for specific versatility.

Genetic Algorithms as a Tool for Dosing Guideline Optimization: Application to Intermittent Infusion Dosing for Vancomycin in Adults

This paper demonstrates the use of a genetic algorithm (GA) for the optimization of a dosing guideline. GAs are well‐suited to derive combinations of doses and dosing intervals that go into a dosing guideline when the number of possible combinations rule out the calculation of all possible outcomes. GAs also allow for different constraints to be imposed on the optimization process to safeguard the clinical feasibility of the dosing guideline. In this work, we demonstrate the use of a GA for the optimization of intermittent vancomycin administration in adult patients. Constraints were placed on the dose strengths, the length of the dosing intervals, and the maximum infusion rate. In addition, flexibility with respect to the timing of the first maintenance dose was included in the optimization process. The GA‐based optimal solution is compared with the Scottish Antimicrobial Prescribing Group vancomycin guideline.

The Impact of Concomitant Empiric Cefepime on Patient Outcomes of Methicillin-Resistant Staphylococcus aureus Bloodstream Infections Treated With Vancomycin

Background

Data suggest that vancomycin + β-lactam combinations improve clearance of methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs). However, it is unclear which specific β-lactams confer benefit. This analysis evaluates the impact of concomitant empiric cefepime on outcomes of MRSA BSIs treated with vancomycin.

Methods

Retrospective cohort study of adults with MRSA BSI from 2006 to 2017. Vancomycin + cefepime therapy was defined as ≥24 hours of cefepime during the first 72 hours of vancomycin. The primary outcome was microbiologic failure, defined as BSI duration ≥7 days and/or 60-day recurrence. Multivariable logistic regression was used to evaluate the association between vancomycin + cefepime therapy and binary outcomes. Cause-specific and subdistribution hazard models were used to evaluate the association between vancomycin + cefepime and BSI clearance.

Results

Three hundred fifty-eight patients were included, 129 vancomycin and 229 vancomycin + cefepime. Vancomycin + cefepime therapy was independently associated with reduced microbiologic failure (adjusted odds ratio [aOR], 0.488; 95% confidence interval [CI], 0.271–0.741). This was driven by a reduction in the incidence of BSI durations ≥7 days (vancomycin + cefepime aOR, 0.354; 95% CI, 0.202–0.621). Vancomycin + cefepime had no association with 30-day mortality (aOR, 0.952; 95% CI, 0.435–2.425). Vancomycin + cefepime was associated with faster BSI clearance in both cause-specific (HR, 1.408; 95% CI, 1.125–1.762) and subdistribution hazard models (HR, 1.264; 95% CI, 1.040–1.536).

Conclusions

Concomitant empiric cefepime improved MRSA BSI clearance and may be useful as the β-lactam component of synergistic vancomycin + β-lactam regimens when empiric or directed gram-negative coverage is desired.