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Kanazawa N, Shigemi A, Amadatsu N, Arimura K, Shimono S, Oda K, Chuang VTG, Matsumoto K, Kawamura H, Terazono H. A cohort study of the risk factors and the target AUC to avoid vancomycin-associated acute kidney injury in pediatric patients. J Infect Chemother 2024; 30:323-328. [PMID: 37940038 DOI: 10.1016/j.jiac.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/20/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES In recent years, Vancomycin (VCM) dosing design using area under the concentration-time curve (AUC) has been recommended as a measure of efficacy and safety, but there are fewer reports on pediatric patients than on adults. In this study, we evaluated the threshold of AUC for AKI occurrence in pediatric patients and investigated the factors that contribute to the occurrence of AKI. METHODS Pediatric patients aged 1-15 years on VCM treatment who underwent TDM at Kagoshima University Hospital from April 2016 to March 2022 were included in the computation of AUC using pediatric population pharmacokinetic parameters. RESULTS The ROC curve showed that the AUC threshold for the risk of developing AKI was 583.0 μg・h/mL, and the AUC-ROC curve was 0.873 (sensitivity 0.930, specificity 0.750). Univariate analysis showed that factors associated with AKI incidence were the duration of VCM administration, ICU admission, and AUCSS. Concomitant medications identified as risk factors for AKI incidence were tazobactam/piperacillin, liposomal amphotericin B, calcineurin inhibitors, contrast agents, and H2-receptor blockers. The multivariate analysis showed that AUC ≧ 583.0 μg・h/mL (odds ratio 20.14, 95% CI 3.52-115.22, p < 0.001) and H2-receptor blockers (odds ratio 8.70, 95% confidence interval = 1.38-54.87, p = 0.02) were independent factors for AKI incidence. CONCLUSIONS We showed that in pediatric patients receiving VCM, the risk of AKI increases as AUC increases. The findings imply that concurrent use of VCM and H2-receptor blockers may increase the risk of AKI.
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Affiliation(s)
- Naoko Kanazawa
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Akari Shigemi
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan; Department of Infection Control and Prevention, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Nao Amadatsu
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Kotaro Arimura
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Shohei Shimono
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1, Honjo, Chuo-ku, Kumamoto-shi, Kumamoto, 860-8556, Japan
| | - Victor Tuan Giam Chuang
- Discipline of Pharmacy, Curtin Medical School, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Hideki Kawamura
- Department of Infection Control and Prevention, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Hideyuki Terazono
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan.
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Haag H, Lau A. Correlation of Calculated Vancomycin Trough Concentrations and Exposure: A Monte Carlo Simulation. Ann Pharmacother 2023; 57:1410-1414. [PMID: 36999486 DOI: 10.1177/10600280231160571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Current recommendations are to dose vancomycin to target 24-hour area under the curve (AUC) of 400-600 mg·h/L to optimize efficacy and safety. Limited data support AUC monitoring, and some centers continue to use trough concentrations. A target of 10-20 mg/L has been proposed to reduce nephrotoxicity risk. OBJECTIVE To use previously published pharmacokinetic equations in a Monte Carlo simulation relating AUC exposure to trough concentrations when targeting an AUC between 400 and 600 mg·h/L. METHODS Previously published pharmacokinetic data were used as input parameters for a Monte Carlo simulation using previously published formulae to correlate AUC to simulated trough concentrations. Pharmacokinetic parameters were assumed to occur in a normal distribution pattern. We excluded irrelevant simulated cases. Maintenance doses of 15 mg/kg were rounded to the nearest 250 mg. Calculated trough concentrations for AUCs of both 400 and 600 mg·h/L were evaluated in each simulation. RESULTS A total of 10 000 Monte Carlo simulations were performed. Targeting an AUC of 400 mg·h/L resulted in a mean trough concentration of 10.3 ± 0.8 mg/L. Targeting an AUC of 600 mg·h/L resulted in a mean trough concentration of 15.4 ± 1.2 mg/L. CONCLUSION AND RELEVANCE We demonstrate that a lower trough concentration range may be supported by an AUC of 400-600 mg·h/L, which may reduce risk and rates of nephrotoxicity without compromising previously established efficacious target trough concentrations.
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Affiliation(s)
- Hans Haag
- Vancouver General Hospital, Vancouver, BC, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Anthony Lau
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
- Emergency Medicine, Vancouver General Hospital, Vancouver, BC, Canada
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Alsultan A, Al Munjem MF, Atiq KM, Aljehani ZK, Al Muqati H, Almohaizeie A, Ballal DA, Refaei TM, Al Jeraisy M, Assiri A, Abouelkheir M. Population pharmacokinetics of vancomycin in very low birth weight neonates. Front Pediatr 2023; 11:1093171. [PMID: 37063687 PMCID: PMC10101232 DOI: 10.3389/fped.2023.1093171] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/03/2023] [Indexed: 04/18/2023] Open
Abstract
Introduction Vancomycin dosing in very low birth weight (VLBW) neonates is challenging. Compared with the general neonatal population, VLBW neonates are less likely to achieve the vancomycin therapeutic targets. Current dosing recommendations are based on studies of the general neonatal population, as only a very limited number of studies have evaluated vancomycin pharmacokinetics in VLBW neonates. The main aim of this study was to develop a vancomycin population pharmacokinetic model to optimize vancomycin dosing in VLBW neonates. Methods This multicenter study was conducted at six major hospitals in Saudi Arabia. The study included VLBW neonates who received vancomycin and had at least one vancomycin serum trough concentration measurement at a steady state. We developed a pharmacokinetic model and performed Monte Carlo simulations to develop an optimized dosing regimen for VLBW infants. We evaluated two different targets: AUC0-24 of 400-600 or 400-800 µg. h/mL. We also estimated the probability of trough concentrations >15 and 20 µg/mL. Results In total, we included 236 neonates, 162 in the training dataset, and 74 in the validation dataset. A one-compartment model was used, and the distribution volume was significantly associated only with weight, whereas clearance was significantly associated with weight, postmenstrual age (PMA), and serum creatinine (Scr). Discussion We developed dosing regimens for VLBW neonates, considering the probability of achieving vancomycin therapeutic targets, as well as different toxicity thresholds. The dosing regimens were classified according to PMA and Scr. These dosing regimens can be used to optimize the initial dose of vancomycin in VLBW neonates.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Correspondence: Abdullah Alsultan Manal Abouelkheir
| | | | | | - Zekra Kamel Aljehani
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Hessa Al Muqati
- Pharmacy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdullah Almohaizeie
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Dalia Ahmed Ballal
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Tahani Makki Refaei
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Majed Al Jeraisy
- Pharmacy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulmohsen Assiri
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Manal Abouelkheir
- Department of Clinical Pharmacy, Faculty of Pharmacy, Misr International University, Cairo, Egypt
- Correspondence: Abdullah Alsultan Manal Abouelkheir
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4
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Aljutayli A, Thirion DJ, Nekka F. Critical assessment of the revised guidelines for vancomycin therapeutic drug monitoring. Biomed Pharmacother 2022; 155:113777. [DOI: 10.1016/j.biopha.2022.113777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/02/2022] Open
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Al-Eyadhy A, Al-Jelaify MR. Suboptimal vancomycin levels in critically ill children with sickle cell disease and acute chest syndrome. J Infect Chemother 2022; 28:1304-1309. [DOI: 10.1016/j.jiac.2022.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/24/2022] [Accepted: 05/29/2022] [Indexed: 10/18/2022]
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Zhou B, Xiong W, Bai K, Dang H, Li J, Xu F, Fu YQ, Liu C. Clinical Application Value of Pharmacokinetic Parameters of Vancomycin in Children Treated in the Pediatric Intensive Care Unit. Front Pediatr 2022; 10:867712. [PMID: 35844752 PMCID: PMC9279905 DOI: 10.3389/fped.2022.867712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To explore the efficacy and safety of vancomycin as measured by pharmacokinetic/pharmacodynamic parameters in children with severe infection in the Pediatric Intensive Care Unit (PICU) and to determine the appropriate threshold for avoiding nephrotoxicity. METHODS The medical records of hospitalized children with severe infection treated with vancomycin in the PICU of a tertiary pediatric hospital from September 2018 to January 2021 were retrospectively collected. Univariate analysis was used to assess the correlation between vancomycin pharmacokinetic/pharmacodynamic parameters and therapeutic efficacy or vancomycin-related nephrotoxicity. Binary logistic regression was used to analyze the risk factors for vancomycin-related nephrotoxicity. The vancomycin area under the concentration-time curve over 24 h (AUC0-24) threshold was determined by receiver operating characteristic (ROC) curve analysis. RESULTS One hundred and 10 patients were included in this study. Seventy-six patients (69.1%) exhibited clinically effective response, while the rest exhibited clinically ineffective response. There were no significant differences in APACHE II score, steady-state trough concentration, peak concentration or AUC0-24 of vancomycin between the effective and ineffective groups. Among the 110 patients, vancomycin-related nephrotoxicity occurred in 15 patients (13.6%). Multivariate analysis showed that vancomycin treatment duration, trough concentration, and AUC0-24 were risk factors for vancomycin-related nephrotoxicity. The ROC curve indicated that AUC0-24 < 537.18 mg.h/L was a suitable cutoff point for predicting vancomycin-related nephrotoxicity. CONCLUSION No significant correlations were found between the trough concentration or AUC0-24 of vancomycin and therapeutic efficacy when the daily dose of vancomycin was approximately 40 mg/kg d, while the trough concentration and AUC0-24 were both closely related to vancomycin-related nephrotoxicity. The combination of AUC0-24 and trough concentration for therapeutic drug monitoring may reduce the risk of nephrotoxicity.
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Affiliation(s)
- Bo Zhou
- Department of Pharmacy, Children's Hospital of Chongqing Medical University, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Wenyi Xiong
- Department of Pediatrics, Chengdu Seventh People's Hospital, Chengdu Tumor Hospital, Chengdu, China
| | - Ke Bai
- National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Hongxing Dang
- National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Li
- National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Xu
- National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yue-Qiang Fu
- National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Chengjun Liu
- National Clinical Research Center for Child Health and Disorders, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, Chongqing, China
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7
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Jorgensen SCJ, Spellberg B, Shorr AF, Wright WF. Should Therapeutic Drug Monitoring Based on the Vancomycin Area Under the Concentration-Time Curve Be Standard for Serious Methicillin-Resistant Staphylococcus aureus Infections?-No. Clin Infect Dis 2021; 72:1502-1506. [PMID: 33740050 DOI: 10.1093/cid/ciaa1743] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Indexed: 12/16/2022] Open
Abstract
In this counterpoint we critically appraise the evidence supporting therapeutic drug monitoring based on the vancomycin 24-hour area under the concentration-time curve (AUC24) for serious methicillin-resistant Staphylococcus aureus infections. We reveal methodologically weaknesses and inconsistencies in the data and suggest that, in the absence of clear and convincing evidence of benefit compared with modestly reducing trough targets, alternative strategies are more likely to result in superior safety and efficacy. These include focusing on fundamental antibiotic stewardship to limit vancomycin exposure overall, achieving earlier and more complete source control, and establishing alternative therapeutic options to vancomycin. Implementation of AUC24-based therapeutic drug monitoring will take resources away from these more promising, alternative solutions.
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Affiliation(s)
| | - Brad Spellberg
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Andrew F Shorr
- Division of Pulmonary and Critical Care, Department of Medicine, Washington Hospital Center, Washington, DC, USA
| | - William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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8
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Wright WF, Jorgensen SCJ, Spellberg B. Heaping the Pelion of Vancomycin on the Ossa of Methicillin-resistant Staphylococcus aureus: Back to Basics in Clinical Care and Guidelines. Clin Infect Dis 2021; 72:e682-e684. [PMID: 32901250 PMCID: PMC8130018 DOI: 10.1093/cid/ciaa1360] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Brad Spellberg
- Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
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9
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Stewart JJ, Jorgensen SCJ, Dresser L, Lau TTY, Gin A, Thirion DJG, Nishi C, Dalton B. A Canadian perspective on the revised 2020 ASHP-IDSA-PIDS-SIDP guidelines for vancomycin AUC-based therapeutic drug monitoring for serious MRSA infections. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:3-9. [PMID: 36340210 PMCID: PMC9612435 DOI: 10.3138/jammi-2020-0028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/06/2020] [Indexed: 04/13/2023]
Abstract
BACKGROUND A revised consensus guideline on therapeutic drug monitoring (TDM) of vancomycin for serious methicillin-resistant Staphylococcus aureus (MRSA) infections was recently published with endorsement of numerous American pharmacy and medical societies. Changing practice from trough TDM to area-under-the-curve-(AUC)-guided dosing was suggested. METHODS Recent literature was critically appraised to determine whether AUC TDM is appropriate for Canadian hospital practice. RESULTS Previous 2009 vancomycin consensus guidelines recommended trough levels of 15-20 mg/L for serious MRSA infections, based on relatively poor evidence for efficacy or safety. In the past decade, aggressive trough targets have led to unnecessary toxicity. Adoption of a TDM strategy using an alternative parameter (AUC) has been suggested, although the evidence for any outcome benefits is low quality. In addition, implementation would require greater resources at health care institutions in the forms of more frequent serum levels or acquisition of costly Bayesian software programs. Most studies on this subject have been observational and retrospective; therefore, relationships between TDM parameters and outcomes have not been convincingly and consistently demonstrated to be causal in nature. Despite claims to the contrary, based on few in silico experiments, available clinical data suggest correlation of trough levels and AUC is high. TDM with lower target trough levels is a simpler solution to reduce risk of toxicity. CONCLUSIONS There are serious concerns with adoption of AUC TDM of vancomycin into routine practice in Canada. Trough-based monitoring with modest reduction in target levels remains the most evidence-informed practice at this time.
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Affiliation(s)
- Jackson J Stewart
- Pharmacy Department, Alberta Health Services, Edmonton, Alberta, Canada
| | | | - Linda Dresser
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacy, Sinai Health System, Toronto, Ontario, Canada
| | - Tim TY Lau
- Pharmaceutical Sciences, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alfred Gin
- Winnipeg Regional Health Authority Regional Pharmacy Program, Winnipeg, Manitoba, Canada
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Daniel JG Thirion
- Pharmacy Department, McGill University Health Centre, Montreal, Quebec, Canada
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
| | - Cesilia Nishi
- Pharmaceutical Sciences, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Bruce Dalton
- Pharmacy Department, Alberta Health Services, Edmonton, Alberta, Canada
- Correspondence: Dr Bruce Dalton, Alberta Health Services—Pharmacy Services, 1403 29th St NW, Calgary, Alberta T2N3Z5 Canada. Telephone: 403-919-2416. E-mail:
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10
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Jorgensen SCJ, Dersch-Mills D, Timberlake K, Stewart JJ, Gin A, Dresser LD, Dalton BR. AUCs and 123s: a critical appraisal of vancomycin therapeutic drug monitoring in paediatrics. J Antimicrob Chemother 2021; 76:2237-2251. [PMID: 33675656 DOI: 10.1093/jac/dkab048] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The revised vancomycin guidelines recommend implementing AUC24-based therapeutic drug monitoring (TDM) using Bayesian methods in both adults and paediatrics. The motivation for this change was accumulating evidence showing aggressive dosing to achieve high troughs, as recommended in the first guidelines for adults and extrapolated to paediatrics, is associated with increased nephrotoxicity without improving clinical outcomes. AUC24-based TDM requires substantial resources that may need to be diverted from other valuable interventions. It can therefore be justified only after certain assumptions are shown to be true: (i) there is a clear relationship between vancomycin efficacy and/or toxicity and the proposed therapeutic range; and (ii) maintaining exposure within the target range with AUC24-based TDM improves clinical outcomes and/or decreases toxicity. In this review, we critically appraise the scientific basis for these assumptions. We find studies evaluating the relationship between vancomycin AUC24/MIC and efficacy in adults and children do not offer strong support for the recommended lower limit of the proposed therapeutic range (i.e. AUC24/MIC ≥400). Nephrotoxicity in children increases in a stepwise manner along the vancomycin exposure continuum but it is unclear if one parameter (AUC24 versus trough) is a superior predictor. Overall, evidence in children suggests good-to-excellent correlation between AUC24 and trough. Most importantly, there is no convincing evidence that the method of vancomycin TDM has a causal role in improving efficacy or reducing toxicity. These findings question the need to transition to resource-intensive AUC24-based TDM over retaining trough-based TDM with lower targets to minimize nephrotoxicity in paediatrics.
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Affiliation(s)
| | | | - Kathryn Timberlake
- Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jackson J Stewart
- Pharmacy Services, University of Alberta Hospital, Edmonton, AB, Canada
| | - Alfred Gin
- Department of Pharmacy, Winnipeg Regional Health Authority, Winnipeg, MB, Canada.,Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Linda D Dresser
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Antimicrobial Stewardship Program, University Health Network, Toronto, ON, Canada
| | - Bruce R Dalton
- Pharmacy Services, Alberta Health Services, Calgary, AB, Canada
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11
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Prediction of Area Under the Curve of Vancomycin in Infants: A Comparison of Two Methods. Indian J Pediatr 2020; 87:331-332. [PMID: 32215783 DOI: 10.1007/s12098-020-03269-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
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