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Chung E, Tjon JA, Nemec RM, Nalli N, Harvey EA, Licht C, Seto W. Pharmacokinetics of Vancomycin in Pediatric Patients Receiving Intermittent Hemodialysis or Hemodiafiltration. Kidney Int Rep 2021; 6:1003-1014. [PMID: 33912750 PMCID: PMC8071675 DOI: 10.1016/j.ekir.2021.01.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 12/27/2020] [Accepted: 01/25/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Vancomycin is a common antibiotic used to treat hemodialysis (HD) or hemodiafiltration (HDF)-related infections in pediatric patients, but optimal dosing remains unknown. This is the first observational study to characterize the pharmacokinetics and evaluate dosing of vancomycin in this population. METHODS Eligible patients received IV vancomycin 10 mg/kg per dose postdialysis followed by a series of serum vancomycin concentrations collected before, immediately after, 1 hour after, and 4 hours after dialysis. The pharmacokinetic parameters were estimated using 1- and 2-compartment models and a nonlinear least-squares algorithm. RESULTS Among 42 vancomycin courses in 16 patients, 1 compartment model had the best fit for observed data. The net drug removal was 43 ± 13% (39% for HD and 50% for HDF) from an average 3-hour HD/HDF session. The mean elimination constant was 0.28 h-1 (standard deviation [SD], 0.11 h-1) during the intradialytic period compared with 0.0049 h-1 (SD, 0.004 h-1) when off dialysis. The mean volume of distribution was 0.65 (SD, 0.19) L/kg. Duration of dialysis session and mode of dialysis (HD vs. HDF) were significant predictors of vancomycin pharmacokinetic parameters. Half-life was shorter for HDF compared with HD (2.1 vs. 3.5 hours). CONCLUSIONS Based on the simulations, an initial vancomycin dose of 10 mg/kg per dose and redosing postdialysis was optimal to achieve a vancomycin concentration range of 5 to 12 mg/L at 4 hours postdialysis and 24-hour area under the curve over minimum inhibitory concentration of ≥400 hours. Therapeutic drug monitoring is necessary to account for residual variability in vancomycin elimination in pediatric patients receiving HD/HDF.
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Affiliation(s)
- Erin Chung
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - James A. Tjon
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Rosaleen M. Nemec
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Nephrology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Nadya Nalli
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth A. Harvey
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Faculty of Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Nephrology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Winnie Seto
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluation Services, The Hospital for Sick Children, Toronto, Ontario, Canada
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Emergency medicine clinical pharmacist's impact on ordering of vancomycin loading doses. Am J Emerg Med 2020; 38:823-826. [DOI: 10.1016/j.ajem.2019.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 10/25/2022] Open
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Sun LXL, Liu KWD, Lynch S, Mistry M, Wise H, Iliescu E. Validation of a Weight Threshold-Based Vancomycin Dosing Protocol for Patients Undergoing Intermittent Hemodialysis. Can J Hosp Pharm 2019; 72:369-376. [PMID: 31692636 PMCID: PMC6799958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Patients receiving intermittent hemodialysis (IHD) are at high risk of acquiring gram-positive infections, which are often treated with IV vancomycin. Despite frequent use of vancomycin in the IHD setting, there is variability in dosing and monitoring practices among clinicians at the study institution. There is also a paucity of evidence regarding optimal vancomycin dosing to achieve target pre-IHD serum concentration. OBJECTIVES The primary objective was to compare the percentage of treatment courses with a serum vancomycin concentration between 15 and 20 mg/L, measured before the third IHD session, before and after implementation of a weight threshold-based dosing protocol. The secondary objectives were to compare the percentage of treatment courses with a pre-third IHD vancomycin concentration between 10 and 22 mg/L and the number of vancomycin measurements per treatment day, before and after protocol implementation. METHODS This quasi-experimental, single-centre study included inpatients and outpatients who underwent IHD and received at least 2 IV doses of vancomycin, with vancomycin being measured in an appropriately drawn sample before the third IHD session. Before protocol implementation, vancomycin dosing was at the clinician's discretion (usual care). After protocol implementation, each patient received a loading dose of 1000, 1500, or 2000 mg and a maintenance dose of 500, 750, or 1000 mg, depending on body weight. RESULTS The percentage of treatment courses with a pre-third IHD vancomycin concentration between 15 and 20 mg/L was greater after implementation of the protocol than with usual care, but the difference was nonsignificant (44% [8/18] versus 20% [3/15], p = 0.27). However, the percentage of treatment courses with a pre-third IHD vancomycin concentration between 10 and 22 mg/L was significantly higher after protocol implementation (94% [17/18] versus 53% [8/15], p = 0.012). There was no difference in the median number of vancomycin measurements per treatment day before and after protocol implementation (0.133 versus 0.125, p = 0.99). CONCLUSIONS At the study institution, the likelihood of achieving recommended vancomycin concentration increased (relative to previous practice) after implementation of a simplified vancomycin dosing protocol for patients undergoing IHD.
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Affiliation(s)
- Lu Xuan Lisa Sun
- , PharmD, RPh, ACPR, is a Clinical Pharmacist with Kingston Health Sciences Centre, Kingston, Ontario
| | - Kang-Wei David Liu
- , BScPhm, PharmD, RPh, MPH, BCPS, was, at the time of this study, a Clinical Pharmacist (General Medicine) with Kingston Health Sciences Centre, Kingston, Ontario. He is now the Director of Pharmacy at Norfolk General Hospital, Simcoe, Ontario, and West Haldimand General Hospital, Hagersville, Ontario
| | - Stephanie Lynch
- , BSc(Pharm), RPh, ACPR, PharmD, BCACP, is a Clinical Pharmacist (Nephrology) with Kingston Health Sciences Centre, Kingston, Ontario
| | - Mielen Mistry
- , BScPhm, RPh, ACPR, is a Clinical Pharmacist (General Medicine) with Kingston Health Sciences Centre, Kingston, Ontario
| | - Heather Wise
- , BSc(Pharm), RPh, ACPR, is a Clinical Pharmacist (Critical Care/Infectious Diseases) with Kingston Health Sciences Centre, Kingston, Ontario
| | - Eduard Iliescu
- , MD, BSc, MSc, FRCPC, FACP, FASN, is the Medical Director Hemodialysis, Kingston Health Sciences Centre and Satellites, Kingston, Ontario. He is also Regional Medical Lead for the South East Local Health Integration Network and the Ontario Renal Network
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El Nekidy WS, El‐Masri MM, Ghazi IM, Soong D. Factors predicting vancomycin therapy outcomes in hemodialysis outpatients and the role of the nephrology stewardship pharmacist. Hemodial Int 2019; 23:449-457. [DOI: 10.1111/hdi.12775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/28/2019] [Accepted: 06/30/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Islam M. Ghazi
- Philadelphia College of Pharmacy at University of the Sciences Philadelphia Pennsylvania USA
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Goti V, Chaturvedula A, Fossler MJ, Mok S, Jacob JT. Hospitalized Patients With and Without Hemodialysis Have Markedly Different Vancomycin Pharmacokinetics: A Population Pharmacokinetic Model-Based Analysis. Ther Drug Monit 2018; 40:212-221. [PMID: 29470227 DOI: 10.1097/ftd.0000000000000490] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Despite being in clinical use for about 6 decades, vancomycin dosing remains perplexing and complex. METHODS A population pharmacokinetic modeling and simulation approach was used to evaluate the efficiency of the current nomogram-based dosing of vancomycin. Serum vancomycin concentrations were obtained as a part of routine therapeutic drug monitoring from two 500-bed academic medical centers. A population pharmacokinetic model was first built using these therapeutic drug monitoring data. Population pharmacokinetic modeling was conducted using NONMEM (7.2 and 7.3). The forward addition-backward elimination approach was used to test the covariate effects. Appropriate numerical and visual criteria were used as model diagnostics for checking model appropriateness and model qualification. The current nomogram efficiency was evaluated by determining the percentage of subjects in the therapeutic range (10-20 mg/L). RESULTS A 2-compartment model with between-subject variability on clearance (CL), central volume of distribution (Vc), and peripheral volume of distribution best fit the data. Blood urea nitrogen, age, creatinine clearance, and hemodialysis status were significant covariates on clearance. Hemodialysis status was a significant covariate on Vc and peripheral volume of distribution. In the final model, creatinine clearance was retained as a covariate on CL whereas hemodialysis status was retained as covariate on both CL and Vc. Using Monte Carlo simulations, the current nomogram was optimized by the addition of a loading dose and reducing the maintenance doses. The current nomogram is suboptimal. Optimization of the nomogram resulted in >40% subjects consistently being in the therapeutic range at troughs collected after the first 6 doses. CONCLUSIONS CL and Vc differ markedly between patients undergoing hemodialysis and those not undergoing hemodialysis. Dosing nomogram based on these covariate relationships may potentially help in accurate dosing of vancomycin.
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Affiliation(s)
- Vineet Goti
- Department of Pharmaceutical Sciences, Mercer University, Atlanta, Georgia
| | - Ayyappa Chaturvedula
- Department of Pharmaceutical Sciences, Mercer University, Atlanta, Georgia.,Department of Pharmacotherapy, University of North Texas Health Science Center, Fort Worth, Texas
| | - Michael J Fossler
- Department of Pharmaceutical Sciences, Mercer University, Atlanta, Georgia.,Clinical Operations & Quantitative Sciences, Trevena Inc, King of Prussia, Pennsylvania
| | - Steve Mok
- Department of Pharmacy, Emory Healthcare
| | - Jesse T Jacob
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Rambaran KA, Alzghari SK, Seifert CF. Evaluation of Factors which Influence Mortality in Gram-positive Bacteremia in Hemodialysis Patients. Cureus 2018; 10:e2917. [PMID: 30186722 PMCID: PMC6122677 DOI: 10.7759/cureus.2917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Vascular access infection is one of the major contributors to hemodialysis (HD) patient morbidity and mortality. There is a paucity of consensus guidelines on vancomycin use in the HD population. The primary objective of this study was to determine if vancomycin serum concentrations were associated with positive outcomes in HD patients with Gram-positive bacteremia. A retrospective cohort study conducted at a 443-bed tertiary teaching county hospital from January 1, 2010 to January 1, 2016 was performed. Patients aged 18-89, with chronic renal failure on hemodialysis who presented with positive blood cultures with Gram-positive bacteria and received intravenous vancomycin for at least 24 hours were evaluated. A multivariate analysis was utilized comparing factors related to outcomes including Simplified Acute Physiology Score II (SAPS II), loading dose, 30-day mortality and vancomycin serum concentrations. A total of 139 patients were obtained, 90 of whom had documented pre-dialysis serum vancomycin concentrations. A multivariate analysis showed that a lower SAPS II score [OR 1.220 (95% CI: 1.086-1.370, p < 0.0001)], a higher loading dose/kg [OR 0.7911 (0.6302-0.9929, p = 0.0239)], and pre-dialysis concentrations between 15 and 20 mcg/mL [0.05437 (95% CI: 0.0033-0.8891, p = 0.0099)] were associated with decreased mortality (overall multivariate model, p < 0.0001). When patient acuity and loading dosing are taken into account, pre-dialysis vancomycin serum concentrations between 15 and 20 mcg/mL were associated with decreased mortality in Gram-positive bacteremic intermittent HD patients. Further prospective studies are needed to assess whether targeting a pre-dialysis serum vancomycin concentration of 15-20 mcg/mL can improve mortality.
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Affiliation(s)
| | | | - Charles F Seifert
- Pharmacy Practice, Texas Tech University Health Sciences Center School of Pharmacy, Lubbock, USA
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Association of bacterial genotypes and epidemiological features with treatment failure in hemodialysis patients with methicillin-resistant Staphylococcus aureus bacteremia. PLoS One 2018; 13:e0198486. [PMID: 29864149 PMCID: PMC5986133 DOI: 10.1371/journal.pone.0198486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/18/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Methicillin-resistant Staphylococcus aureus (MRSA) infections in the hemodialysis (HD) population are epidemiologically classified as healthcare-associated infections. The data about the clinical impact and bacterial characteristics of hospital-onset (HO)- and community-onset (CO)-MRSA in HD patients are scarce. The current study analyzed the difference in the clinical and molecular characteristics of HO-MRSA and CO-MRSA. METHODS We performed a retrospective review and molecular analysis of clinical isolates from 106 HD patients with MRSA bacteremia from 2009 to 2014. CA genotypes were defined as isolates carrying the SCCmec type IV or V, and HA genotypes were defined as isolates harboring SCCmec type I, II, or III. RESULTS CO-MRSA infections occurred in 76 patients, and 30 patients had HO-MRSA infections. There was no significant difference in the treatment failure rates between patients with CO-MRSA infections and those with HO-MRSA infections. CA genotypes were associated with less treatment failure (odds ratio [OR]: 0.18; 95% confidence interval [95% CI], 0.07-0.49; p = 0.001). For isolates with a vancomycin minimum inhibitory concentration (MIC) < 1.5 mg/L, the multivariate analysis revealed that HA genotypes and cuffed tunneled catheter use were associated with treatment failure. For isolates with a vancomycin MIC ≥1.5 mg/L, the only risk factor for treatment failure was a higher Pitt score (OR: 1.76; 95% CI, 1.02-3.05; p = 0.043). CONCLUSION CA genotypes, but not the epidemiological classification of CO-MRSA, impacted the clinical outcome of MRSA bacteremia in the HD population.
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The ratio of pre-dialysis vancomycin trough serum concentration to minimum inhibitory concentration is associated with treatment outcomes in methicillin-resistant Staphylococcus aureus bacteremia. PLoS One 2018; 13:e0193585. [PMID: 29505620 PMCID: PMC5837094 DOI: 10.1371/journal.pone.0193585] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 02/14/2018] [Indexed: 11/25/2022] Open
Abstract
Background Vancomycin is a standard treatment for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and its efficacy is closely linked to the recommended serum trough concentration of 15–20 mg/L. However, it is unknown how the pre-dialysis trough serum concentration (Cpre-HD) correlates with MRSA eradication in renal failure patients undergoing intermittent hemodialysis (HD). Objective To evaluate the relationship between Cpre-HD and the treatment outcomes in this population. Materials and methods A retrospective study was conducted to enroll renal failure patients undergoing HD who had received vancomycin treatment for MRSA bacteremia during January 2013 to June 2016. Treatment failure was defined as persistent bacteremia after ≥ 7 days of vancomycin therapy or recurrent MRSA infection within 30 days. Patient characteristics, vancomycin dosing regimen, Cpre-HD, vancomycin minimum inhibitory concentration (MIC), and subsequent culture data were reviewed. The receiver operating characteristic (ROC) curve was used to find the optimal cut-off point of Cpre-HD. Results 42 patients were enrolled and 64% had treatment failure. Although there were no significant differences in demographics or Cpre-HD between the two groups, Cpre-HD/MIC was significantly higher in the success group than that in the failure group (22.80±10.90 vs. 14.94±6.11, p = 0.019). The area under the ROC curve was 0.74, while the sensitivity, specificity, positive predictive value, and negative predictive value were 67%, 78%, 62.5%, and 81%, respectively, at the optimal Cpre-HD/MIC of ≧ 18.6. Conclusions Cpre-HD/MIC was associated with vancomycin treatment outcome in MRSA bacteremia, and targeting to achieve a Cpre-HD/MIC of ≧ 18.6 may improve treatment outcomes in renal failure patients who are on intermittent HD.
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El Nekidy WS, El-Masri MM, Umstead GS, Dehoorne-Smith M. Predicting Maintenance Doses of Vancomycin for Hospitalized Patients Undergoing Hemodialysis. Can J Hosp Pharm 2016; 69:341-347. [PMID: 27826151 DOI: 10.4212/cjhp.v69i5.1588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Methicillin-resistant Staphylococcus aureus is a leading cause of death in patients undergoing hemodialysis. However, controversy exists about the optimal dose of vancomycin that will yield the recommended pre-hemodialysis serum concentration of 15-20 mg/L. OBJECTIVE To develop a data-driven model to optimize the accuracy of maintenance dosing of vancomycin for patients undergoing hemodialysis. METHODS A prospective observational cohort study was performed with 164 observations obtained from a convenience sample of 63 patients undergoing hemodialysis. All vancomycin doses were given on the floor after completion of a hemodialysis session. Multivariate linear generalized estimating equation analysis was used to examine independent predictors of pre-hemodialysis serum vancomycin concentration. RESULTS Pre-hemodialysis serum vancomycin concentration was independently associated with maintenance dose (B = 0.658, p < 0.001), baseline pre-hemodialysis serum concentration of the drug (B = 0.492, p < 0.001), and interdialytic interval (B = -2.133, p < 0.001). According to the best of 4 models that were developed, the maintenance dose of vancomycin required to achieve a pre-hemodialysis serum concentration of 15-20 mg/L, if the baseline serum concentration of the drug was also 15-20 mg/L, was 5.9 mg/kg with interdialytic interval of 48 h and 7.1 mg/kg with interdialytic interval of 72 h. However, if the baseline pre-hemodialysis serum concentration was 10-14.99 mg/L, the required dose increased to 9.2 mg/kg with an interdialytic interval of 48 h and 10.0 mg/kg with an interdialytic interval of 72 h. CONCLUSIONS The maintenance dose of vancomycin varied according to baseline pre-hemodialysis serum concentration of the drug and interdialytic interval. The current practice of targeting a pre-hemodialysis concentration of 15-20 mg/L may be difficult to achieve for the majority of patients undergoing hemodialysis.
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Affiliation(s)
- Wasim S El Nekidy
- PharmD, BCPS, BCACP, was, at the time of this study, a Resident at St John Hospital and Medical Center in Detroit, Michigan. At the time of submission, he was a Clinical Pharmacy Specialist with the Departments of Pharmacy and Nephrology, Windsor Regional Hospital, Windsor, Ontario, and he is now a Senior Pharmacotherapy Specialist - Nephrology with the Department of Pharmacy, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Maher M El-Masri
- PhD, RN, is Professor and Research Leadership Chair, Faculty of Nursing, University of Windsor, Windsor, Ontario
| | - Greg S Umstead
- PharmD, is a Clinical Pharmacy Specialist, St John Hospital and Medical Center, Detroit, Michigan
| | - Michelle Dehoorne-Smith
- PharmD, is Manager of Patient Care Services, St John Hospital and Medical Center, Detroit, Michigan
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Maxson R, Pate J, Starr J. Evaluation of weight-based vancomycin dosing for hospitalized hemodialysis patients. Ren Fail 2016; 38:1677-1682. [DOI: 10.1080/0886022x.2016.1229992] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Rebecca Maxson
- Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Birmingham, AL, USA
| | - Julia Pate
- Department of Pharmacy, Centennial Medical Center, Nashville, TN, USA
| | - Jessica Starr
- Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Birmingham, AL, USA
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Abstract
The increasing number of infections produced by beta-lactam-resistant Gram-positive bacteria and the morbidity secondary to these infections make it necessary to optimize the use of vancomycin. In 2009, the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Disease Pharmacists published specific guidelines about vancomycin dosage and monitoring. However, these guidelines have not been updated in the past 6 years. This review analyzes the new available information about vancomycin published in recent years regarding pharmacokinetics and pharmacodynamics, serum concentration monitoring, and optimal vancomycin dosing in special situations (obese people, burn patients, renal replacement therapy, among others). Vancomycin efficacy is linked to a correct dosage which should aim to reach an area under the curve (AUC)/MIC ratio of ≥400; serum trough levels of 15 to 20 mg/liter are considered a surrogate marker of an AUC/MIC ratio of ≥400 for a MIC of ≤1 mg/liter. For Staphylococcus aureus strains presenting with a MIC >1 mg/liter, an alternative agent should be considered. Vancomycin doses must be adjusted according to body weight and the plasma trough levels of the drug. Nephrotoxicity has been associated with target vancomycin trough levels above 15 mg/liter. Continuous infusion is an option, especially for patients at high risk of renal impairment or unstable vancomycin clearance. In such cases, vancomycin plasma steady-state level and creatinine monitoring are strongly indicated.
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