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Ho WH, Huang TH, Chen YJ, Zeng LY, Liao FF, Liou YC. Prediction of vancomycin initial dosage using artificial intelligence models applying ensemble strategy. BMC Bioinformatics 2023; 22:637. [PMID: 36949378 PMCID: PMC10035120 DOI: 10.1186/s12859-022-05117-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 12/17/2022] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Antibiotic resistance has become a global concern. Vancomycin is known as the last line of antibiotics, but its treatment index is narrow. Therefore, clinical dosing decisions must be made with the utmost care; such decisions are said to be "suitable" only when both "efficacy" and "safety" are considered. This study presents a model, namely the "ensemble strategy model," to predict the suitability of vancomycin regimens. The experimental data consisted of 2141 "suitable" and "unsuitable" patients tagged with a vancomycin regimen, including six diagnostic input attributes (sex, age, weight, serum creatinine, dosing interval, and total daily dose), and the dataset was normalized into a training dataset, a validation dataset, and a test dataset. AdaBoost.M1, Bagging, fastAdaboost, Neyman-Pearson, and Stacking were used for model training. The "ensemble strategy concept" was then used to arrive at the final decision by voting to build a model for predicting the suitability of vancomycin treatment regimens. RESULTS The results of the tenfold cross-validation showed that the average accuracy of the proposed "ensemble strategy model" was 86.51% with a standard deviation of 0.006, and it was robust. In addition, the experimental results of the test dataset revealed that the accuracy, sensitivity, and specificity of the proposed method were 87.54%, 89.25%, and 85.19%, respectively. The accuracy of the five algorithms ranged from 81 to 86%, the sensitivity from 81 to 92%, and the specificity from 77 to 88%. Thus, the experimental results suggest that the model proposed in this study has high accuracy, high sensitivity, and high specificity. CONCLUSIONS The "ensemble strategy model" can be used as a reference for the determination of vancomycin doses in clinical treatment.
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Affiliation(s)
- Wen-Hsien Ho
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, No. 100, Shin-Chuan 1st Road, Kaohsiung, 807, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, No. 100, Shin-Chuan 1st Road, Kaohsiung, 807, Taiwan
- College of Professional Studied, National Pingtung University of Science and Technology, No. 1, Shuefu Road, Pingtung, 912, Taiwan
| | - Tian-Hsiang Huang
- Department of Computer Science and Information Engineering, National Penghu University of Science and Technology, No.300, Liuhe Road, Magong, 880, Penghu, Taiwan
| | - Yenming J Chen
- Department of Information Management, National Kaohsiung University of Science and Technology, No.1, University Road, Kaohsiung, 824, Taiwan
| | - Lang-Yin Zeng
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, No. 100, Shin-Chuan 1st Road, Kaohsiung, 807, Taiwan
| | - Fen-Fen Liao
- Department of Pharmacy, Kaohsiung Medical University Hospital, No. 100, Shin-Chuan 1st Road, Kaohsiung, 807, Taiwan.
| | - Yeong-Cheng Liou
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, No. 100, Shin-Chuan 1st Road, Kaohsiung, 807, Taiwan.
- Department of Medical Research, Kaohsiung Medical University Hospital, No. 100, Shin-Chuan 1st Road, Kaohsiung, 807, Taiwan.
- Research Center of Nonlinear Analysis and Optimization, Kaohsiung Medical University, No. 100, Shin-Chuan 1st Road, Kaohsiung, 807, Taiwan.
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Kunming P, Xiaotian J, Qing X, Chenqi X, Xiaoqiang D, Qian Zhou L. Impact of pharmacist intervention in reducing vancomycin-associated acute kidney injury: A systematic review and meta-analysis. Br J Clin Pharmacol 2023; 89:526-535. [PMID: 35285970 DOI: 10.1111/bcp.15301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/16/2022] [Accepted: 03/03/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS The aim was to quantify the relationship between pharmacist intervention and vancomycin-associated acute kidney injury (AKI). METHODS Electronic databases were searched up to August 2020 for meta-analyses of cohort studies and/or randomized controlled trials. Studies that compared the incidence of AKI in patients between post- and prepharmacist intervention were investigated. The primary outcome was incidence of AKI. We also evaluated the influence of pharmacist intervention in risk factors of vancomycin-associated AKI. RESULTS The search strategy retrieved 1744 studies and 34 studies with 19 298 participants were included (22 published articles and 12 abstracts from conference proceedings). Compared with the preintervention group, the postintervention group patients had a significantly lower incidence of vancomycin-associated AKI: 7.3% for post- and 9.6% for preintervention (odds ratio [OR] 0.52, 95% confidence interval [CI]; 0.41, 0.67], P < .00001). The rate of attaining target concentration was significantly higher in the post- than preintervention group (OR 2.86, 95% CI [2.23, 3.67], P < .00001). The postintervention group significantly improved the percentage of serum creatinine laboratory tests than preintervention group (OR = 3.24, 95% CI 2.02, 5.19], P < .00001). Patients postintervention had markedly lower risk of mortality than preintervention patients (OR 0.47, 95% CI [0.31, 0.72], P = .0004). CONCLUSION Pharmacist intervention in vancomycin treatment significantly decreased the rate of vancomycin-associated AKI, while improving efficacy and reducing mortality. We speculate that this is because the pharmacist interventions optimized the rationality of vancomycin therapy, monitoring of vancomycin trough concentration and the monitoring of patients' renal function.
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Affiliation(s)
- Pan Kunming
- Department of Pharmacy, ZhongShan Hospital FuDan University, ShangHai, China
| | - Jiang Xiaotian
- Department of Nephrology, ZhongShan Hospital FuDan University, ShangHai, China
| | - Xu Qing
- Department of Pharmacy, ZhongShan Hospital FuDan University, ShangHai, China
| | - Xu Chenqi
- Department of Nephrology, ZhongShan Hospital FuDan University, ShangHai, China
| | - Ding Xiaoqiang
- Department of Nephrology, ZhongShan Hospital FuDan University, ShangHai, China
| | - Lv Qian Zhou
- Department of Pharmacy, ZhongShan Hospital FuDan University, ShangHai, China
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Elrggal ME, Haseeb A, AlGethamy M, Ahsan U, Saleem Z, Althaqafi AS, Alshuail SS, Alsiddiqi ZA, Iqbal MS, Alzahrani AF, AlQarni A, Radwan RM, Qul AKS, Mahrous AJ, Alsharif JM, Alqurashi MK, Faidah HS, Aldurdunji M. Dose optimization of vancomycin in obese patients: A systematic review. Front Pharmacol 2023; 14:965284. [PMID: 37033643 PMCID: PMC10081578 DOI: 10.3389/fphar.2023.965284] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background: Dose optimization of vancomycin plays a substantial role in drug pharmacokinetics because of the increased incidence of obesity worldwide. This systematic review was aimed to highlight the current dosing strategy of vancomycin among obese patients. Methods: This systematic review was in concordance with Preferred Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The literature search was carried out on various databases such as Scopus, PubMed/MEDLINE, ScienceDirect and EMBASE using Keywords and MeSH terms related to vancomycin dosing among obese patients. Google Scholar was also searched for additional articles. The English language articles published after January, 2000 were included in this study. The quality of the study was assessed using different assessment tools for cohort, and case reports. Results: A total of 1,029 records were identified. After screening, 18 studies were included for the final review. Of total, twelve studies are retrospective and remaining six are case-control studies. A total of eight studies were conducted in pediatrics while remaining studies were conducted in adult population. Most of the studies reported the dosing interval every 6-8 h. Differences in target trough concentration exist with respect to target ranges. The administration of loading dose (20-25 mg/kg) followed by maintenance dose (15-25 mg/kg) of vancomycin is recommended in adult patients to target therapeutic outcomes. Moreover, a dose of 40-60 mg/kg/day appears appropriate for pediatric patients. Conclusion: The initial dosing of vancomycin based on TBW could be better predictor of vancomycin trough concentration. However, the clinical significance is uncertain. Therefore, more studies are needed to evaluate the dosing strategy of vancomycin in overweight or obese patients.
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Affiliation(s)
- Mahmoud E. Elrggal
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
- *Correspondence: Abdul Haseeb,
| | - Manal AlGethamy
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Umar Ahsan
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Areej Sultan Althaqafi
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Sattam Saad Alshuail
- Department of Internal Medicine, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Zohair Ahmad Alsiddiqi
- Department of Internal Medicine, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Albaraa Faraj Alzahrani
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Abdullmoin AlQarni
- Alnoor Specialist Hospital Makkah, Department of Infectious Diseases, Makkah, Saudi Arabia
| | - Rozan Mohammad Radwan
- Pharmaceutical Care Department, Alnoor Specialist Hospital Makkah, Department of Infection Prevention and Control Program, Makkah, Saudi Arabia
| | - Ameer Khalid Saab Qul
- Pharmaceutical Care Department, Alnoor Specialist Hospital Makkah, Department of Infection Prevention and Control Program, Makkah, Saudi Arabia
| | - Ahmad Jamal Mahrous
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Jumana Majdi Alsharif
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | | | - Hani Saleh Faidah
- Department of Microbiology, Faculty of Medicine, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Mohammed Aldurdunji
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
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Yamaguchi R, Kani H, Yamamoto T, Tanaka T, Suzuki H. Development of a decision flowchart to identify the patients need high-dose vancomycin in early phase of treatment. J Pharm Health Care Sci 2022; 8:3. [PMID: 34983684 PMCID: PMC8725522 DOI: 10.1186/s40780-021-00231-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/05/2021] [Indexed: 12/29/2022] Open
Abstract
Background The standard dose of vancomycin (VCM, 2 g/day) sometimes fails to achieve therapeutic concentration in patients with normal renal function. In this study, we aimed to identify factors to predict patients who require high-dose vancomycin (> 2 g/day) to achieve a therapeutic concentration and to develop a decision flowchart to select these patients prior to VCM administration. Methods Patients who had an estimated creatinine clearance using the Cockcroft–Gault equation (eCCr) of ≥50 mL/min and received intravenous VCM were divided into 2 cohorts: an estimation set (n = 146, from April to September 2016) and a validation set (n = 126, from October 2016 to March 2017). In each set, patients requiring ≤2 g/day of VCM to maintain the therapeutic trough concentration (10–20 μg/mL) were defined as standard-dose patients, while those who needed > 2 g/day were defined as high-dose patients. Univariate and multivariate logistic regression analysis was performed to identify the predictive factors for high-dose patients and decision tree analysis was performed to develop decision flowchart to identify high-dose patients. Results Among the covariates analyzed, age and eCCr were identified as independent predictors for high-dose patients. Further, the decision tree analysis revealed that eCCr (cut off value = 81.3 mL/min) is the top predictive factor and is followed by age (cut off value = 58 years). Based on these findings, a decision flowchart was constructed, in which patients with eCCr ≥81.3 mL/min and age < 58 years were designated as high-dose patients and other patients were designated as standard-dose patients. Subsequently, we applied this decision flowchart to the validation set and obtained good predictive performance (positive and negative predictive values are 77.6 and 84.4%, respectively). Conclusion These results suggest that the decision flowchart constructed in this study provides an important contribution for avoiding underdosing of VCM in patients with eCCr of ≥50 mL/min. Supplementary Information The online version contains supplementary material available at 10.1186/s40780-021-00231-w.
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Affiliation(s)
- Ryo Yamaguchi
- Department of Pharmacy, The University of Tokyo Hospital, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroko Kani
- Department of Pharmacy, The University of Tokyo Hospital, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takehito Yamamoto
- Department of Pharmacy, The University of Tokyo Hospital, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. .,The Education Center for Clinical Pharmacy, Graduate School of Pharmaceutical Sciences, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Takehiro Tanaka
- Department of Pharmacy, The University of Tokyo Hospital, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroshi Suzuki
- Department of Pharmacy, The University of Tokyo Hospital, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Colin PJ, Eleveld DJ, Thomson AH. Genetic Algorithms as a Tool for Dosing Guideline Optimization: Application to Intermittent Infusion Dosing for Vancomycin in Adults. CPT Pharmacometrics Syst Pharmacol 2020; 9:294-302. [PMID: 32383808 PMCID: PMC7239335 DOI: 10.1002/psp4.12512] [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: 01/14/2020] [Accepted: 04/05/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Pieter J. Colin
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Douglas J. Eleveld
- Department of Anesthesiology University Medical Center Groningen University of Groningen Groningen The Netherlands
| | - Alison H. Thomson
- Strathclyde Institute of Pharmacy and Biomedical Sciences University of Strathclyde Glasgow UK
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Bellos I, Daskalakis G, Pergialiotis V. Relationship of vancomycin trough levels with acute kidney injury risk: an exposure–toxicity meta-analysis. J Antimicrob Chemother 2020; 75:2725-2734. [DOI: 10.1093/jac/dkaa184] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/05/2020] [Accepted: 04/13/2020] [Indexed: 02/06/2023] Open
Abstract
AbstractObjectivesNephrotoxicity represents a major complication of vancomycin administration, leading to high rates of morbidity and treatment failure. The aim of this meta-analysis was to evaluate the association between trough levels and risk of renal impairment, by defining an exposure–toxicity relationship and assessing its accuracy in predicting the development of acute kidney injury (AKI).MethodsMedline, Scopus, CENTRAL, Clinicaltrials.gov and Google Scholar databases were systematically searched from inception. Studies examining the effects of trough levels on nephrotoxicity risk in adult patients were deemed eligible.ResultsThe meta-analysis was based on 60 studies, including 13 304 patients. The development of AKI was significantly linked to both higher initial [standardized mean difference (SMD): 0.82; 95% CI: 0.65–0.98] and maximum (SMD: 1.06; 95% CI: 0.82–1.29) trough levels. Dose–response analysis indicated a curvilinear relationship between trough levels and nephrotoxicity risk (χ2 = 127.1; P value < 0.0001). A cut-off of 15 mg/L detected AKI with a sensitivity of 62.6% (95% CI: 55.6–69.2) and a specificity of 65.5% (95% CI: 58.9–71.6), while applying a 20 mg/L threshold resulted in a sensitivity of 42.9% (95% CI: 34–52.2) and a specificity of 82.5% (95% CI: 73.9–88.8).ConclusionsThe present findings suggest that the development of vancomycin-induced AKI is significantly associated with higher initial and maximum trough levels. An exposure–response relationship was defined, indicating that increasing trough levels correlate with a significant rise of nephrotoxicity risk. Future studies should verify the effectiveness of individualized pharmacokinetic tools that would enable the attainment of trough level targets and minimize the risk of renal toxicity.
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Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Daskalakis
- First Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Ueda T, Takesue Y, Nakajima K, Ichiki K, Ishikawa K, Takai Y, Yamada K, Wada Y, Tsuchida T, Otani N, Takahashi Y, Ishihara M, Shibata S, Ikeuchi H, Uchino M, Kimura T. Vancomycin loading dose is associated with increased early clinical response without attainment of initial target trough concentration at a steady state in patients with methicillin-resistant Staphylococcus aureus infections. J Clin Pharm Ther 2020; 45:682-690. [PMID: 32301537 DOI: 10.1111/jcpt.13144] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/21/2020] [Accepted: 03/22/2020] [Indexed: 12/19/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Vancomycin therapeutic guidelines suggest a loading dose of 25-30 mg/kg for seriously ill patients. However, high-quality data to guide the use of loading doses are lacking. We aimed to evaluate whether a loading dose (a) achieved a target trough concentration at steady state and (b) improved early clinical response. METHODS Patients with an estimated glomerular filtration rate ≥ 90 mL/min/1.73 m2 were included. A loading dose of 25 mg/kg vancomycin followed by 15 mg/kg twice daily was compared with traditional dosing. A Cmin sample was obtained before the fifth dose. An early clinical response 48-72 hours after the start of therapy and clinical success at end of therapy (EOT) was evaluated in patients with methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant coagulase-negative Staphylococci or Enterococcus faecium. RESULTS There was no significant difference in Cmin between the regimen with and without a loading dose (median: 10.4 and 10.2 µg/mL, P = .54). Proportions of patients achieving 10-20 and 15-20 µg/mL were 56.9% and 5.6%, respectively, in patients with a loading dose. Although there was no significant difference in success rate at EOT between groups, a loading dose was associated with increased early clinical response for all infections (adjusted odds ratio [OR]: 4.588, 95% confidence interval [CI]: 1.373-15.330) and MRSA infections (OR: 12.065, 95% CI: 1.821-79.959). Study limitations included no Cmin measurements within 24 hours and the inclusion of less critically ill patients. WHAT IS NEW AND CONCLUSION A loading dose of 25 mg/kg followed by 15 mg/kg twice daily did not achieve the optimal Cmin at steady state in patients with normal renal function. However, more early clinical responses were obtained with a loading dose compared with traditional dosing, possibly because of a prompt albeit temporary achievement of a more effective concentration.
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Affiliation(s)
- Takashi Ueda
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshio Takesue
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazuhiko Nakajima
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kaoru Ichiki
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kaori Ishikawa
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshiko Takai
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kumiko Yamada
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yasunao Wada
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Toshie Tsuchida
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Naruhito Otani
- Department of Public Health, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshiko Takahashi
- Department of Pharmacy, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Mika Ishihara
- Department of Pharmacy, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Sumiyo Shibata
- Department of Pharmacy, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Motoi Uchino
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takeshi Kimura
- Department of Pharmacy, Hyogo College of Medicine Hospital, Nishinomiya, Japan
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He N, Su S, Yan Y, Liu W, Zhai S. The Benefit of Individualized Vancomycin Dosing Via Pharmacokinetic Tools: A Systematic Review and Meta-analysis. Ann Pharmacother 2019; 54:331-343. [PMID: 31694384 DOI: 10.1177/1060028019887363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Various pharmacokinetic (PK) equations and software have been developed to individualize vancomycin dosing. However, the benefit of using any PK information to guide vancomycin dosing has not been fully elucidated. Objective: To appraise available evidence on the effectiveness and safety of individualized vancomycin dosing via PK tools. Methods: PubMed, EMBASE, the Cochrane Library, and 2 Chinese literature databases were searched through August 1, 2019. Randomized controlled trials (RCTs) and cohort studies that reported the PK and clinical outcomes of individualized vancomycin dosing versus empirical dosing were included. Pooled risk ratios (RRs) and mean differences were calculated for dichotomous and continuous outcomes, respectively. Results: A total of 21 studies involving 4346 patients were finally included, of which 3 were RCTs and 18 were cohort studies. Meta-analysis revealed that PK-guided vancomycin dosing significantly increased the attainment of target trough concentration (RR = 1.59; 95% CI = 1.49-1.70) and decreased the incidence of nephrotoxicity (RR = 0.57; 95% CI = 0.46-0.71). Additionally, the available evidence showed that target area under the curve/minimum inhibitory concentration attainment rate and time to target concentration could improve. However, the evidence on clinical outcomes was scarce, and no significant differences were detected in clinical response rate, microbiological eradication rate, mortality, and length of hospital stay between PK-guided vancomycin dosing and empirical dosing strategies. Conclusion and Relevance: Individualized vancomycin dosing via PK tools significantly increases the attainment of target trough concentration and decreases the incidence of nephrotoxicity. Evidence on clinical effectiveness was limited and showed no significant benefit. Further well-designed studies are warranted to assess its clinical effectiveness and inform routine care.
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Affiliation(s)
- Na He
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Shan Su
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Yingying Yan
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Wenxi Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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Zhou Y, Gao F, Chen C, Ma L, Yang T, Liu X, Liu Y, Wang X, Zhao X, Que C, Li S, Lv J, Cui Y, Yang L. Development of a Population Pharmacokinetic Model of Vancomycin and its Application in Chinese Geriatric Patients with Pulmonary Infections. Eur J Drug Metab Pharmacokinet 2018; 44:361-370. [PMID: 30506225 PMCID: PMC6520475 DOI: 10.1007/s13318-018-0534-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The optimal use of vancomycin in the elderly requires information about the drug’s pharmacokinetics and the influence of various factors on the drug’s disposition. However, because of sampling restrictions, it is often difficult to perform traditional pharmacokinetic studies in elderly patients. Objective This study was conducted to estimate the population pharmacokinetics of vancomycin in Chinese geriatric patients (age ≥ 65 years) with pulmonary infections and to explore the clinical application of this information for vancomycin dose individualization. Methods The steady-state trough concentrations were retrospectively collected from January 2011 to December 2016 and were analyzed using the nonlinear mixed-effect model software. The final model was evaluated using the bootstrap method, goodness-of-fit plots and the normalized prediction distribution error method. Main Outcome Measure Model parameters and prediction error. Results A total of 125 steady-state trough concentrations from 70 patients were retrospectively collected. A one-compartment model was established. The final model was depicted as clearance (CL) [L/h] = 2.45 × (CLCR/56.28) × 0.542; volume of distribution (Vd) [L] = 154. The creatinine clearance (CLCR) was identified as the most significant covariate in the final model. The typical values of CL and Vd in the final model were 2.45 L/h and 154 L, respectively. Model validation outcomes showed that the final model was stable and had satisfactory prediction performance. Conclusion A population pharmacokinetic model was established to estimate the pharmacokinetics characteristics of Chinese geriatric patients with pulmonary infections, and this model can be used to develop an initial vancomycin dosing regimen for geriatric patients.
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Affiliation(s)
- Ying Zhou
- College of Pharmacy, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing, China.,Department of Pharmacy, Peking University First Hospital, No.6 Dahongluochang Street, Xicheng District, Beijing, China
| | - Feifei Gao
- College of Pharmacy, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing, China.,Department of Pharmacy, Peking University First Hospital, No.6 Dahongluochang Street, Xicheng District, Beijing, China
| | - Chaoyang Chen
- College of Pharmacy, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing, China
| | - Lingyun Ma
- College of Pharmacy, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing, China
| | - Ting Yang
- College of Pharmacy, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing, China
| | - Xiao Liu
- College of Pharmacy, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing, China
| | - Yaou Liu
- College of Pharmacy, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing, China
| | - Xiaoqing Wang
- College of Pharmacy, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing, China.,Department of Pharmacy, Peking University First Hospital, No.6 Dahongluochang Street, Xicheng District, Beijing, China
| | - Xia Zhao
- College of Pharmacy, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing, China
| | - Chengli Que
- Department of Respiratory Medicine, Peking University First Hospital, No.1 Dahongluochang Street, Xicheng District, Beijing, China
| | - Shuangling Li
- Intensive-Care Unit, Peking University First Hospital, No.1 Dahongluochang Street, Xicheng District, Beijing, China
| | - JiCheng Lv
- Department of Nephrology, Peking University First Hospital, No.1 Dahongluochang Street, Xicheng District, Beijing, China
| | - Yimin Cui
- College of Pharmacy, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing, China. .,Department of Pharmacy, Peking University First Hospital, No.6 Dahongluochang Street, Xicheng District, Beijing, China.
| | - Li Yang
- Department of Nephrology, Peking University First Hospital, No.1 Dahongluochang Street, Xicheng District, Beijing, China.
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10
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Bowers RD, Cooper AA, Wente CL, Wilson DT, Johnson SW, Drew RH. Evaluation of a vancomycin dosing nomogram in obese patients weighing at least 100 kilograms. Pharm Pract (Granada) 2018; 16:1204. [PMID: 30416622 PMCID: PMC6207350 DOI: 10.18549/pharmpract.2018.03.1204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 07/04/2018] [Indexed: 11/14/2022] Open
Abstract
Background There remains variability in both practice and evidence related to optimal initial empiric dosing strategies for vancomycin. Objective Our primary objective was to describe the percentage of obese patients receiving vancomycin doses consistent with nomogram recommendations achieving targeted initial steady-state serum vancomycin concentrations. Secondary objectives were to describe the primary endpoint in subgroups based on patient weight and estimated creatinine clearance, to describe the rate of supratherapeutic vancomycin accumulation following an initial therapeutic trough concentration, and to describe the rate of vancomycin-related adverse events. Methods This single-center, IRB-approved, retrospective cohort included adult patients ≥ 100 kilograms total body weight with a body mass index (BMI) >30 kilograms/m2 who received a stable nomogram-based vancomycin regimen and had at least one steady-state vancomycin trough concentration. Data collected included vancomycin regimens and concentrations, vancomycin indication, serum creatinine, and vancomycin-related adverse events. Patients were divided into two cohorts by goal trough concentration: 10-15 mcg/mL and 15-20 mcg/mL. Results Of 325 patients screened, 85 were included. Goal steady-state concentrations were reached in 42/85 (49.4%) of total patients. Conclusions Achievement of initial steady-state vancomycin serum concentrations in the present study (approximately 50%) was consistent with the use of published vancomycin dosing nomograms.
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Affiliation(s)
- Riley D Bowers
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Cape Fear Valley Medical Center. Fayetteville, NC (United States).
| | - April A Cooper
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Duke Regional Hospital. Durham, NC (United States).
| | - Catherine L Wente
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Duke Regional Hospital. Durham, NC (United States).
| | - Dustin T Wilson
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Duke University Hospital. Durham, NC (United States).
| | - Steven W Johnson
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Novant Health - Forsyth Medical Center. Winston-Salem, NC (United States).
| | - Richard H Drew
- Department of Pharmacy Practice, College of Pharmacy & Health Sciences, Campbell University. Buies Creek, NC; & Duke University School of Medicine. Durham, NC (United States).
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11
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Validation of a Nomogram for Achieving Target Trough Concentration of Vancomycin: Accuracy in Patients With Augmented Renal Function. Ther Drug Monit 2018; 40:693-698. [PMID: 30157096 DOI: 10.1097/ftd.0000000000000562] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adjustment of initial vancomycin (VCM) dosage has been recommended on the basis of the renal function nomogram in therapeutic drug monitoring guidelines in Japan. However, this nomogram has not been clinically validated, and few studies have focused on its usefulness in patients with risk of augmented renal function. Therefore, this study aimed to evaluate the validity of the VCM nomogram and the association between patient conditions related to augmented renal function and its accuracy. METHODS In this retrospective study, we screened data of 398 patients who received VCM and had estimated glomerular filtration rates ≥30 mL·min·1.73 m. Patients who met nomogram dosing criteria were categorized into a nomogram group, and the associations of age, renal function, and individual conditions such as febrile neutropenia, solid tumor, blood cancer, and brain injury with subtherapeutic concentrations (<10.0 mcg/mL) of VCM were evaluated. RESULTS In total, 177 patients were categorized into the nomogram group, and 83 (47%), 81 (46%), and 13 patients (7%) had VCM trough concentrations of 10-20, <10, and >20 mcg/mL, respectively. Age <50 years was only significantly associated with subtherapeutic trough concentrations. Specific conditions of patients such as febrile neutropenia, solid tumor, and blood cancer were associated with elevated VCM clearance; however, there was no decline in trough VCM concentrations regardless of the presence of the specific conditions. CONCLUSIONS The Japanese VCM dosing nomogram was effective in minimizing the number of instances of supratherapeutic VCM serum concentrations; however, it lacked accuracy in achieving target trough concentrations. The accuracy of the nomogram could be enhanced by categorizing patients according to age. Nevertheless, this study provides novel evidence of the usefulness of this nomogram in avoiding subtherapeutic concentrations of VCM in patients with risk factors for augmented renal clearance.
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12
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Lima TDM, Seba KS, Gonçalves JCS, Cardoso FLL, Estrela RDCE. A Rapid and Simple HPLC Method for Therapeutic Monitoring of Vancomycin. J Chromatogr Sci 2018; 56:115-121. [PMID: 29069326 DOI: 10.1093/chromsci/bmx089] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Indexed: 01/05/2023]
Abstract
Therapeutic monitoring of the antibiotic vancomycin is important to achieve specific plasma concentration and prevent toxic effects. Several assays have been described for vancomycin determination in clinical practice, but high-performance liquid chromatography is still considered the gold standard for the quantification of vancomycin. In this study, we developed a new and rapid high-performance liquid chromatography method requiring 50 μL of plasma for the quantification of vancomycin. Acetonitrile was used for processing plasma by protein precipitation (1:2.5). Isocratic chromatographic analysis was carried out on a C18 silica-based (2.7 μm) column with the mobile phase containing 20 mM ammonium acetate/formic acid buffer (pH 4.0):methanol 88:12 (v/v). A diode array detector was used for UV detection at 240 nm. This method was validated according to the Brazilian Health Surveillance Agency legislation and International Conference on Harmonization guidelines. The measurement range was 1-100 μg/mL, analysis time was 8 min, and intermediate precision was <12%, supporting the present method as a fast, simple, and effective alternative for therapeutic monitoring of vancomycin.
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Affiliation(s)
- Tácio de Mendonça Lima
- Faculty of Pharmaceutical Sciences, University of São Paulo, Av. Professor Lineu Prestes, 580 - Cidade Universitária São Paulo- SP, CEP 05508-000, Brazil
| | - Karine Souza Seba
- National School of Public Health, Oswaldo Cruz Foundation, R. Leopoldo Bulhões, 1480 - Bonsucesso, Rio de Janeiro - RJ, CEP 21041-210, Brazil
| | - José Carlos Saraiva Gonçalves
- Faculty of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373 - Cidade Universitária, Rio de Janeiro - RJ, CEP 21941-170, Brazil
| | - Fernando Luiz Lopes Cardoso
- Hospital Infection Control Team, University Hospital Clementino Fraga Filho, R. Prof. Rodolpho Paulo Rocco, 255 - Cidade Universitária, Rio de Janeiro - RJ, CEP 21941-913, Brazil
| | - Rita de Cássia Elias Estrela
- Faculty of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373 - Cidade Universitária, Rio de Janeiro - RJ, CEP 21941-170, Brazil.,Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Av. Brasil, 4365 - Manguinhos, Rio de Janeiro - RJ, CEP 21040-360, Brazil, Brazil
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13
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Yoon S, Park KR, Lee S, Song SH, Park WB, Jang IJ, Yu KS. Assessment of Appropriateness of an Initial Dosing Regimen of Vancomycin and Development of a New Dosing Nomogram. Basic Clin Pharmacol Toxicol 2017; 122:233-238. [PMID: 28834212 DOI: 10.1111/bcpt.12873] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/01/2017] [Indexed: 11/28/2022]
Abstract
Vancomycin is a glycopeptide antibiotic used to treat Gram-positive infections including methicillin-resistant Staphylococcus aureus (MRSA). The objectives of this study were to evaluate the appropriateness of the initial dosing regimen of vancomycin, identify factors to be considered in regimen selection and develop a new dosing nomogram. Therapeutic drug monitoring (TDM) data of vancomycin obtained from Seoul National University Hospital from 2011 to 2013 were included in this analysis. The vancomycin trough concentrations at steady-state were estimated using Abbott's PKS software program and then categorized into three levels: subtherapeutic, therapeutic and toxic. The newly developed nomograms were evaluated by analysing the percentage of patients with target vancomycin trough concentration using the data of 2,570 patients of the first TDM cases. Therapeutic level was achieved only in approximately one-fifth of the cases, while 56.0% and 23.8% of the TDMs were considered subtherapeutic and toxic, respectively. As body-weight and creatinine clearance (CrCL) increased, the proportion of patients with a subtherapeutic level increased. Using the newly developed nomogram increased the proportion of patients who achieved therapeutic levels from 23.1% to 45.0% or 13.8% to 36.2% (target, 10-15 and 15-20 mg/L, respectively). These results suggest that the vancomycin concentrations fail to reach the therapeutic level or exceed the safe upper margin of the therapeutic level depending on age, body-weight and CrCL. Considering these factors, the new nomograms provide a strategy to achieve target concentrations of vancomycin more rapidly than existing regimens.
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Affiliation(s)
- Seonghae Yoon
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Kyoung Ryun Park
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - SeungHwan Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Sang-Hoon Song
- Department of Laboratory Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - In-Jin Jang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
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Tongsai S, Koomanachai P. The safety and efficacy of high versus low vancomycin trough levels in the treatment of patients with infections caused by methicillin-resistant Staphylococcus aureus: a meta-analysis. BMC Res Notes 2016; 9:455. [PMID: 27686168 PMCID: PMC5041442 DOI: 10.1186/s13104-016-2252-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/22/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Recent guidelines have recommended vancomycin trough levels of 15-20 mg/L for treatment of serious infections caused by methicillin-resistant Staphylococcus aureus (MRSA). However, high trough levels may increase risk of nephrotoxicity and mortality, and high vancomycin trough levels have not been well studied. This study was designed to combine safety and efficacy results from independent studies and to compare between high and low vancomycin trough levels in the treatment of MRSA-infected patients using meta-analysis. METHODS From 19 eligible studies, 9 studies were included in meta-analysis to compare clinical success between high and low vancomycin trough levels, while 10 and 11 studies met criteria for comparing trough levels and nephrotoxicity and trough levels and mortality, respectively. The PubMed/Medline, Web of Science, and Scopus databases, and hand searching were used to identify eligible studies dated up to March 2016. Of 2344 subjects with MRSA infection, 1036 were assigned to trough levels ≥15 mg/L and 1308 to trough levels <15 mg/L. RESULTS High vancomycin trough levels were found to be associated with risk of nephrotoxicity (odds ratio [OR] 2.14, 95 % confidence interval [CI] 1.42-3.23 and adjusted OR 3.33, 95 % CI 1.91-5.79). There was no evidence of difference between high and low vancomycin trough levels for mortality (OR; 1.09; 95 % CI 0.75-1.60) or clinical success (OR 1.07; 95 % CI 0.68-1.68). CONCLUSION In this study, high vancomycin trough levels were identified as an independent factor associated with risk of nephrotoxicity in MRSA-infected patients. Association between vancomycin trough levels and both adverse effects and clinical outcomes requires further study.
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Affiliation(s)
- Sasima Tongsai
- Clinical Epidemiology Unit, Office for Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wang Lang Road, Siriraj, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Pornpan Koomanachai
- Division of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wang Lang Road, Siriraj, Bangkoknoi, Bangkok, 10700, Thailand
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15
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Vancomycin dosing nomograms targeting high serum trough levels in different populations: pros and cons. Eur J Clin Pharmacol 2016; 72:777-88. [PMID: 27117446 DOI: 10.1007/s00228-016-2063-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 04/12/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE Utilization of higher doses of vancomycin to achieve the trough concentrations of 15-20 mg/L for complicated infections has been recommended by the Infectious Diseases Society of America clinical practice guideline in recent years. Concerning this recommendation, several nomograms have been constructed targeting this optimal trough level range in different populations of patients. In this review, we have collected available nomograms targeting high trough serum levels of vancomycin, particularly comparing their advantages and limitations. METHOD The data were collected by searching Scopus, PubMed, Google scholar, Medline, and Cochrane database systematic reviews. The key words used as search terms were "vancomycin", "high trough level", "dosing nomogram", "dosing strategy", "neonates", "critically ill", "pediatrics", and "hemodialysis". We have included 17 related human studies published up to the date of this publication. RESULTS & CONCLUSION Most of the available nomograms have determined the doses according to body weight and renal function. Their initial predicting success rate were 44-76 % for non-critically ill patients, 42-84 % for critically ill patients, 54 % for one nomogram specially designed for hemodialysis patients, and 71 % for the only nomogram developed for neonates. Based on validation studies, in most of cases, using a vancomycin dosing nomogram significantly improved and accelerated achievement of target trough concentrations. However, it should be noted that there are limited data about patients' clinical and microbiological outcomes and they are only validated in narrow groups of patients. Thus, their widespread application could not be encouraged for all patients before performing adequately powered, prospective randomized studies.
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16
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O'Brien KA, Mok S. Evaluation of the Safety of a Vancomycin Nomogram Used to Achieve Target Trough Concentrations. Hosp Pharm 2015; 50:900-910. [PMID: 27729678 DOI: 10.1310/hpj5010-900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Dosing vancomycin to achieve target concentrations of 15 to 20 mg/L has been recommended for select infections. To date, few vancomycin nomograms designed to target these higher concentrations have been published, and only one has been published in North America. Based on the success of this nomogram in developing empiric vancomycin regimens that achieve higher target trough concentrations with low rates of nephrotoxicity, a vancomycin nomogram targeting concentrations of 15 to 20 mg/L was developed and implemented at Emory University Hospital and Emory University Hospital Midtown. OBJECTIVE To evaluate the impact of a vancomycin-dosing nomogram on the incidence of vancomycin- associated nephrotoxicity and the time to achieve targeted trough concentrations. METHODS A retrospective chart review of 200 patients who received vancomycin dosed to achieve target trough serum concentrations of 15 to 20 mg/L was performed. RESULTS After implementation of the vancomycin nomogram, no statistically significant difference in incidence of vancomycin-associated nephrotoxicity was found (14% vs 16%; P = .197). Fewer patients had an initial vancomycin trough concentration within target range (29.1% vs 21.7%; P < .001). Adherence to the nomogram was poor, with only 41% of patients being dosed per the nomogram's recommendations. CONCLUSION Based on our results, implementation of a vancomycin dosing nomogram had no impact on the incidence of nephrotoxicity, and significantly fewer patients had an initial vancomycin trough within the target range of 15 to 20 mg/L. The clinical utility of a vancomycin dosing nomogram is still to be determined.
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Affiliation(s)
- Kristen A O'Brien
- Clinical Assistant Professor, Mercer University College of Pharmacy , Atlanta, Georgia
| | - Steve Mok
- Clinical Pharmacy Specialist, Emory University Hospital Midtown , Atlanta, Georgia
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17
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Lin WW, Wu W, Jiao Z, Lin RF, Jiang CZ, Huang PF, Liu YW, Wang CL. Population pharmacokinetics of vancomycin in adult Chinese patients with post-craniotomy meningitis and its application in individualised dosage regimens. Eur J Clin Pharmacol 2015; 72:29-37. [PMID: 26423622 DOI: 10.1007/s00228-015-1952-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/16/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE Vancomycin (VCM) is a first-line antibacterial drug used to treat post-craniotomy meningitis (PCM). VCM pharmacokinetic parameters are altered in PCM patients, compared to those in other patients. Although VCM population pharmacokinetics (PPK) has been reported, changes in VCM PPK in adult Chinese PCM patients remain unknown. We developed a VCM PPK model in adult Chinese PCM patients and proposed a new strategy for individualising VCM administration using this model. METHODS Data was obtained from a prospective study of 100 adult PCM patients in the Neurosurgery Department of the First Affiliated Hospital of Fujian Medical University. The trough concentrations at steady state were determined by enzyme multiplied immunoassay. Nonlinear mixed-effect model software was employed to develop the PPK model. The final model was evaluated using the bootstrap method and normalised prediction error distribution and through the testing of 20 independent adult PCM patients. RESULTS VCM clearance in PCM patients was higher than that observed in other patients. Creatinine clearance affected VCM clearance, whereas no co-administered drugs influenced VCM pharmacokinetics. Trough concentrations were accurately predicted by the final model, while the prediction errors were less than ±32 %. Moreover, a new strategy for individualising VCM regimens using the PPK model was proposed and validated. CONCLUSIONS A PPK model was developed to estimate the individual clearance in inpatients receiving intravenously infused VCM and could be used to develop individualised dosing of adult Chinese PCM patients.
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Affiliation(s)
- Wei-Wei Lin
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, 20 Cha Zhong M. Rd, Taijiang, Fuzhou, 350005, People's Republic of China
| | - Wei Wu
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, 20 Cha Zhong M. Rd, Taijiang, Fuzhou, 350005, People's Republic of China
| | - Zheng Jiao
- Department of Pharmacy, Huashan Hospital, Fudan University, 12 Wu Lu Mu Qi M. Rd, Shanghai, 20040, People's Republic of China.
| | - Rong-Fang Lin
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, 20 Cha Zhong M. Rd, Taijiang, Fuzhou, 350005, People's Republic of China
| | - Chang-Zhen Jiang
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, 20 Cha Zhong M. Rd, Taijiang, Fuzhou, 350005, People's Republic of China
| | - Pin-Fang Huang
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, 20 Cha Zhong M. Rd, Taijiang, Fuzhou, 350005, People's Republic of China
| | - Yi-Wei Liu
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, 20 Cha Zhong M. Rd, Taijiang, Fuzhou, 350005, People's Republic of China
| | - Chang-Lian Wang
- Department of Pharmacy, The First Affiliated Hospital, Fujian Medical University, 20 Cha Zhong M. Rd, Taijiang, Fuzhou, 350005, People's Republic of China.
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18
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Dong MH, Wang JW, Wu Y, Chen BY, Yu M, Wen AD. Evaluation of body weight-based vancomycin therapy and the incidence of nephrotoxicity: a retrospective study in the northwest of China. Int J Infect Dis 2015; 37:125-8. [DOI: 10.1016/j.ijid.2015.06.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/26/2015] [Accepted: 06/30/2015] [Indexed: 10/23/2022] Open
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Cardile AP, Tan C, Lustik MB, Stratton AN, Madar CS, Elegino J, Hsue G. Optimization of time to initial vancomycin target trough improves clinical outcomes. SPRINGERPLUS 2015. [PMID: 26203410 PMCID: PMC4506278 DOI: 10.1186/s40064-015-1146-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Outcomes data for the efficacy of interventions designed to decrease the time to initial target vancomycin troughs are sparse. OBJECTIVE A vancomycin therapeutic drug monitoring (TDM) program was initiated to reduce the time to initial target troughs and to examine the impact on clinical outcomes. METHODS Single-center, pre- and post-intervention observational study in a 250 bed teaching facility. Adult inpatients treated with physician-guided, vancomycin therapy (historical control, CTRL) were compared to high trough, pharmacist-guided vancomycin therapy (TDM). Nephrotoxicity analyses were conducted to the ensure safety of the TDM. Clinical outcome analysis was limited to patients with normal renal function and culture-confirmed gram positive infections and a pre-defined MRSA subset. RESULTS 340 patients met initial inclusion criteria for the nephrotoxicity analysis (TDM, n = 173; CTRL, n = 167). Acute kidney injury occurrence was similar between the CTRL (n = 20) and TDM (n = 23) groups (p = 0.7). Further exclusions yielded 145 patients with gram positive infections for clinical outcomes evaluation (TDM, n = 66; CTRL, n = 75). The time to initial target trough was shorter in the TDM group (3 vs. 5 days, p < 0.001). Patients in the TDM group discharged from the hospital more rapidly, 7 vs. 14 days (Hazards Ratio (HR), 1.41; 95% Confidence Interval [CI] 1.08-1.83; p = 0.01), reached clinical stability faster, 4 vs. 8 days (HR, 1.51; 95% CI 1.08-2.11; p = 0.02), and had shorter courses of vancomycin, 4 vs. 7 days (HR, 1.5; 95% CI 1.15-1.95; p = 0.003). In the MRSA infection subset (TDM, n = 36; CTRL, n = 35), patients in the TDM group discharged from the hospital more rapidly, 7 vs. 16 days (HR, 1.89; 95% CI 1.08-3.3; p = 0.03), reached clinical stability faster, 4 vs. 6 days (HR, 2.69; 95% CI 1.27-5.7; p = 0.01), and had shorter courses of vancomycin, 5 vs. 8 days (HR, 2.52; 95% CI 1.38-4.6; p = 0.003). Attaining initial target troughs in <5 days versus ≥5 days was associated with improved clinical outcomes. All cause in-hospital mortality, and vancomycin treatment failure occurred at comparable rates between groups. CONCLUSIONS Interventions designed to decrease the time to reach initial target vancomycin troughs can improve clinical outcomes in gram positive infections, and in particular MRSA infections.
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Affiliation(s)
- Anthony P Cardile
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Christopher Tan
- Department of Pharmacy, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Michael B Lustik
- Department of Clinical Investigation, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Amy N Stratton
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Cristian S Madar
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Jun Elegino
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Günther Hsue
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA ; Department of Infectious Diseases, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
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20
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Norton K, Ingram PR, Heath CH, Manning L. Risk factors for nephrotoxicity in patients receiving outpatient continuous infusions of vancomycin in an Australian tertiary hospital. J Antimicrob Chemother 2013; 69:805-8. [PMID: 24107387 DOI: 10.1093/jac/dkt402] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To assess the risk factors for nephrotoxicity caused by vancomycin continuous infusion in a predominantly Caucasian outpatient population. METHODS This was a retrospective cohort study of 155 patient episodes from December 2006 to December 2011. RESULTS Vancomycin-associated nephrotoxicity (VN) occurred in 26 of 155 (17%) patient episodes. After adjustment for baseline renal function, maximum steady-state vancomycin concentrations ≥32 mg/L [OR 8.7 (95% CI 3.1-29.6), P < 0.001] and angiotensin receptor blockade [OR 9.78 (95% CI 3.1-39.4), P < 0.001] were independently associated with VN. The cumulative dose and duration of vancomycin therapy were not independent predictors of VN. CONCLUSIONS Cessation of angiotensin receptor-blocking medications in selected patient groups, enhanced monitoring and establishing target steady-state concentrations <30 mg/L to avoid excessive vancomycin exposure may reduce the risk of VN.
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Affiliation(s)
- Katherine Norton
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia (WA), Australia
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Matsumoto K, Takesue Y, Ohmagari N, Mochizuki T, Mikamo H, Seki M, Takakura S, Tokimatsu I, Takahashi Y, Kasahara K, Okada K, Igarashi M, Kobayashi M, Hamada Y, Kimura M, Nishi Y, Tanigawara Y, Kimura T. Practice guidelines for therapeutic drug monitoring of vancomycin: a consensus review of the Japanese Society of Chemotherapy and the Japanese Society of Therapeutic Drug Monitoring. J Infect Chemother 2013; 19:365-80. [DOI: 10.1007/s10156-013-0599-4] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 04/01/2013] [Indexed: 11/28/2022]
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22
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Potential utility for nomogram-based vancomycin dosing. Int J Infect Dis 2012; 17:e355-6. [PMID: 23218547 DOI: 10.1016/j.ijid.2012.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 11/02/2012] [Indexed: 11/22/2022] Open
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