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Alakeel YS, Alahmed Y, Alanazi G, Alawbathani B, Alshutwi K, Almeshary M, Aldhahri F, Alshakrah M. An evaluation of the empirical vancomycin dosing guide in pediatric cardiology. BMC Pediatr 2024; 24:575. [PMID: 39261805 PMCID: PMC11389283 DOI: 10.1186/s12887-024-05048-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/02/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND Higher doses of vancomycin are currently prescribed due to the emergence of bacterial tolerance and resistance. This study aimed to evaluate the efficacy and safety of the currently adopted vancomycin dosing guide in pediatric cardiology. METHODS This was a single-center prospective cohort study with pediatric cardiac patients, younger than 14 years, from June 2020 to March 2021. The patients received intravenous vancomycin (40 mg/kg/day divided every 6-8 h) according to the department's vancomycin medication administration guide (MAG) for at least three days. RESULTS In total, 88 cardiac patients were included, with a median age of 0.82 years (IQR: 0.25-2.9), and 51 (58%) received cardiopulmonary bypass surgery (CPB). The majority (71.6%, n = 61) achieved a serum vancomycin level within the therapeutic range (7-20 mg/L). Infants, young children, and children exposed to CPB surgery had an increased incidence of subtherapeutic vancomycin levels, [7 (29.2%); P = 0.033], [13 (54.2%); P = 0.01], and [21 (87.5%); P = 0.009] respectively. After the treatment, 8 (10%) patients had an elevated Serum creatinine (SCr) and 2 (2.5%) developed acute kidney injury (AKI). However, no significant difference was found between the patients developing AKI or an elevated SCr and the group who did not, in terms of clinical, therapeutic, and demographic characteristics, except for the decreased incidence of SCr elevation in patients receiving an ACE inhibitor, [4 (36.4%); P = 0.036]. CONCLUSION Our institution followed MAG recommendations; however, subtherapeutic serum concentrations were evident in infants, young children, and CPB patients. Strategies to prevent AKI should be investigated, as the possible causes have not been identified in this study.
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Affiliation(s)
- Yousif S Alakeel
- Department Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.
| | - Yazeed Alahmed
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pediatrics, College of Medicine, Qassim University, Qassim, Saudi Arabia
| | - Ghadah Alanazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Bushra Alawbathani
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Kadi Alshutwi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Meshary Almeshary
- Department Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Fahad Aldhahri
- Department Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Meshal Alshakrah
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Saudi Medication Safety Center, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
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Lim WXS, Seah XFV, Thoon KC, Han Z. Comparison of Vancomycin Trough-Based and 24-Hour Area Under the Curve Over Minimum Inhibitory Concentration (AUC/MIC)-Based Therapeutic Drug Monitoring in Pediatric Patients. J Pediatr Pharmacol Ther 2023; 28:430-438. [PMID: 38130493 PMCID: PMC10731924 DOI: 10.5863/1551-6776-28.5.430] [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: 06/05/2022] [Accepted: 10/07/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Vancomycin 24-hour area under the curve over minimum inhibitory concentration (AUC/MIC) monitoring has been recommended over trough-based monitoring in pediatric patients. This study compared the proportion of target attainment between vancomycin AUC/MIC and trough-based methods, and identified risk factors for subtherapeutic initial extrapolated targets. METHODS This was a retrospective, observational study conducted at KK Women's and Children's Hospital (KKH), Singapore. Patients aged 1 month to 18 years with stable renal function who received intravenous vancomycin between January 2014 and October 2017, with at least 2 vancomycin serum concentrations obtained after the first dose of vancomycin, were included. Using a pharmacokinetic software, namely Adult and Pediatric Kinetics (APK), initial extrapolated steady-state troughs and 24-hour AUC were determined by using a one-compartmental model. Statistical tests included Wilcoxon rank sum test, McNemar test, logistic regression, and classification and regression tree (CART) analysis. RESULTS Of the 82 pediatric patients included, a significantly larger proportion of patients achieved therapeutic targets when the AUC/MIC-based method (24, 29.3%) was used than with the trough-based method (9, 11.0%; p < 0.01). Patients with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 or with age <13 years had an increased risk of obtaining subtherapeutic targets. However, empiric vancomycin doses of 60 mg/kg/day would be sufficient to achieve serum therapeutic targets, using the AUC/MIC-based method. CONCLUSION The AUC/MIC-based vancomycin monitoring may be preferred because a larger proportion of patients could achieve initial therapeutic targets. Future prospective studies with larger sample size will be required to determine the optimal vancomycin strategy for pediatric patients.
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Affiliation(s)
- Wan Xuan Selina Lim
- Department of Pharmacy (WXSL, XFVS), KK Women's and Children's Hospital, Singhealth, Singapore
| | - Xue Fen Valerie Seah
- Department of Pharmacy (WXSL, XFVS), KK Women's and Children's Hospital, Singhealth, Singapore
| | - Koh Cheng Thoon
- Department of Infectious Diseases (KCT), Pediatrics, KK Women's and Children's Hospital, Singhealth, Singapore
| | - Zhe Han
- Department of Pharmacy (ZH), National University of Singapore, Singapore
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Volpicelli L, Venditti M, Oliva A. Acute bacterial skin and skin structure infections in pediatric patients: potential role of dalbavancin. Expert Rev Anti Infect Ther 2023; 21:329-341. [PMID: 36803139 DOI: 10.1080/14787210.2023.2182769] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
INTRODUCTION Acute bacterial skin and skin structure infections (ABSSSIs) are a subtype of skin and soft tissue infections (SSTI), usually sustained by Gram-positive bacteria, whose incidence is high among children. ABSSSIs are responsible for a considerable number of hospitalizations. Moreover, as multidrug resistant (MDR) pathogens become widespread, the pediatric category seems burdened with an increased risk of resistance and treatment failure. AREAS COVERED To obtain a view on the status of the field, we describe the clinical, epidemiological, and microbiological aspects of ABSSSI in children. Old and new treatment options were critically revised with a focus on the pharmacological characteristics of dalbavancin. Evidence on the use of dalbavancin in children was collected, analyzed, and summarized. EXPERT OPINION Many of the therapeutic options available at the moment are characterized by the need for hospitalization or repeated intravenous infusions, safety issues, possible drug-drug interactions, and reduced efficacy on MDRs. Dalbavancin, the first long-acting molecule with strong activity against methicillin-resistant and also many vancomycin-resistant pathogens represents a game changer for adult ABSSSI. In pediatric settings, the available literature is still limited, but a growing body of evidence supports dalbavancin use in children with ABSSSI, demonstrating this drug to be safe and highly efficacious.
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Affiliation(s)
- Lorenzo Volpicelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Roma, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Roma, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome Roma, Italy
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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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Alakeel YS, Alanazi GA, Alawbathani BS, Alshutwi KI, Alahmed YS. Vancomycin dosing required to achieve a therapeutic level in children post-surgical correction of congenital heart disease. Medicine (Baltimore) 2022; 101:e30145. [PMID: 36254077 PMCID: PMC9575798 DOI: 10.1097/md.0000000000030145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The vancomycin dosing range for safe and effective treatment remains uncertain for children who had corrective surgery for a congenital heart disease (CHD). We aimed to determine the vancomycin dosing requirements for this subgroup of patients. This prospective cohort study included children younger than 14 years old with CHD who received intravenous vancomycin for at least 3 days at the Pediatric Cardiology section of King Abdulaziz Medical City, Riyadh. In total, 140 pediatric patients with CHD were included with a median age of 0.57 years (interquartile range 0.21-2.2). The mean vancomycin total daily dose (TDD), 37.71 ± 6.8 mg/kg/day, was required to achieve a therapeutic trough concentration of 7-20 mg/L. The patient's age group and the care setting were significant predictors of the vancomycin dosing needs. Neonates required significantly lower doses of 34 ± 6.03 mg/kg/day (P = .002), and young children higher doses of 43.97 ± 9.4 mg/kg/day (P = .003). The dosage requirements were independent of the type of cardiac lesion, cardiopulmonary surgery exposure, sex, and BMI percentile. However, the patients in the pediatric cardiac ward required higher doses of vancomycin 41.08 ± 7.06 mg/kg/day (P = .039). After the treatment, 11 (8.5%) patients had an elevated Scr, and 3 (2.3%) patients developed AKI; however, none of the patients' sociodemographic factors or clinical variables, or vancomycin therapy characteristics was significantly associated with the renal dysfunction. Overall, the vancomycin TDD requirements are lower in pediatric post-cardiac surgery compared to non-cardiac patients and are modulated by several factors.
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Affiliation(s)
- Yousif S. Alakeel
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- * Correspondence: Yousif S. Alakeel, PharmD, MPH, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia (e-mail: )
| | - Ghadah A. Alanazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Bushra S. Alawbathani
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Kadi I. Alshutwi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yazeed S. Alahmed
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pediatrics, College of Medicine, Qassim University, Qassim, Saudi Arabia
- Division of Pediatric Cardiology, Cardiac Sciences, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
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Relationship between Vancomycin Trough Serum Concentrations and Clinical Outcomes in Children: a Systematic Review and Meta-Analysis. Antimicrob Agents Chemother 2022; 66:e0013822. [PMID: 35862741 PMCID: PMC9380573 DOI: 10.1128/aac.00138-22] [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] [Indexed: 11/20/2022] Open
Abstract
To systematically evaluate the relationships between vancomycin trough serum concentrations and clinical outcomes in children using meta-analysis. Several databases, including PubMed, Elsevier, Web of Science, EMBASE, Medline, clinicaltrials.gov, the Cochrane Library, and three Chinese databases (Wanfang Data, China National Knowledge Infrastructure, and SINOMED), were comprehensively searched to obtain research articles on vancomycin use in children from inception through December 2021. All studies were screened and evaluated using the Cochrane systematic review method. Then, the feature information was extracted for meta-analysis. The evaluated results included clinical efficacy, vancomycin-associated nephrotoxicity, hepatotoxicity, ototoxicity, mortality, and microbial clearance. A total of 35 studies involving 4820 children were included in the analysis. The meta-analysis showed that compared with children with vancomycin trough concentrations <10 μg/mL, those with vancomycin trough concentrations ≥10 μg/mL had a higher clinical efficacy rate [OR: 2.23, 95% CI: 1.29 to 3.84, P = 0.004] and higher incidences of nephrotoxicity [OR: 2.76, 95% CI: 1.51 to 5.07, P = 0.001], ototoxicity [OR: 1.87, 95% CI: 1.08 to 3.23, P = 0.02] and microbial clearance [OR: 2.36, 95% CI: 1.53 to 3.64, P = 0.0001]. All-cause mortality [OR: 1.07, 95% CI: 0.45 to 2.53, P = 0.88] and hepatotoxicity [OR: 0.84, 95% CI: 0.46 to 1.53, P = 0.57] were similar between the two groups. Subgroup analysis showed that compared with children with vancomycin trough concentrations of 10 to 15 μg/mL, those with vancomycin trough concentrations >15 μg/mL had a higher incidence of nephrotoxicity [OR: 2.64, 95% CI: 1.28 to 5.43, P = 0.008], but there was no significant difference in clinical efficacy [OR: 0.85, 95% CI: 0.30 to 2.44, P = 0.76]. A vancomycin trough concentration of 10 to 15 μg/mL can improve clinical efficacy in children. Additionally, avoidance of trough concentrations >15 μg/mL can reduce the incidence of adverse reactions.
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Tuan HM, Anh NT, Quan KT, Thang NV, Huy VQ. Effect of Initial Vancomycin Dose and Creatinine Clearance on the Attainment of Target Trough Concentration in Children. Curr Pediatr Rev 2022; 18:318-325. [PMID: 35255798 DOI: 10.2174/1573396318666220307115307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/20/2021] [Accepted: 01/12/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Vancomycin is a glycopeptide antibiotic that is used to treat serious grampositive infections. However, therapeutic drug monitoring for vancomycin is not performed routinely in Vietnam in clinical practices. Monitoring of serum vancomycin concentration or trough levels is necessary to ensure the efficacy and safety of vancomycin therapy. OBJECTIVE This study aims to determine the impact of initial vancomycin dose and creatinine clearance on target trough attainment in hospitalized Vietnamese children. METHODS A prospective study with patients who received vancomycin for at least three days was conducted. Subsequently, demographic data, clinical diagnosis, vancomycin dosage, and serum creatinine levels were recorded. The vancomycin trough level was collected and creatinine clearance and adjusted vancomycin doses were calculated. RESULTS A total of 40 eligible patients were enrolled. Patients' mean age, body weight, and height were 1.4 years old, 9.8 kg, and 75.5 cm, respectively. The mean vancomycin dose was 55.83 ± 19.34 mg/kg/day. The mean creatinine clearance was 80.18 ± 29.14 ml/min. The median trough level was 11.09 (7.84 - 16.46) μg/ml. There was no significant difference in the mean initial and the adjusted vancomycin doses (p = 0.062). However, there were statistically significant differences of initial (p = 0.004) or adjusted doses (p = 0.016) between groups of creatinine clearance. The trough vancomycin concentration was not statistically significant (p = 0.406) between these groups. CONCLUSION Target trough vancomycin level may be associated with creatinine clearance but did not proportionally correspond to the vancomycin dose. Therefore, monitoring vancomycin trough levels is necessary to achieve the target trough and to ensure vancomycin efficacy and safety in treating severely infected Vietnamese children.
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Affiliation(s)
- Ha Manh Tuan
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Nguyen Tuan Anh
- Molecular Biomedical Center, University Medical Center, Ho Chi Minh City, Vietnam
| | - Kim Tran Quan
- American International Hospital, Thu Duc City, Vietnam
| | | | - Vu Quang Huy
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
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van der Veen A, Somers A, Vanhaesebrouck S, Ter Heine R, Brüggemann R, Allegaert K, De Cock P. Variation in vancomycin dosing and therapeutic drug monitoring practices in neonatal intensive care units. Int J Clin Pharm 2021; 44:564-569. [PMID: 34727280 DOI: 10.1007/s11096-021-01345-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 10/19/2021] [Indexed: 11/29/2022]
Abstract
Background Vancomycin is a frequently used antibiotic in neonates. However, there is no consensus guideline on the optimal dosing regimen and therapeutic drug monitoring (TDM) practices in this patient population. Objective To document the variability in the current dosing and TDM practices in neonatal intensive care units (NICU). Setting Belgian and Dutch NICUs. Method An online questionnaire was disseminated by e-mail to potential respondents. Main outcome measure Differences in vancomycin dosing and TDM practices in comparison with a reference source, the Dutch Paediatric Formulary. Results Eighteen NICUs (response rate 62%) participated. Eleven different dosing regimens are applied, with 83% using intermittent dosing regimens. Stratifying covariates used to determine the (initial) dosage include gestational age, postnatal age, serum creatinine, concurrent use of non-steroidal anti-inflammatory drugs, birth weight and current weight. Large variability is observed with regard to TDM practice as well, both for the concentration target range and the times of (re)sampling. Dosing calculators are more commonly used in the Netherlands than Belgium. Conclusion Significant inter-centre variability in dosing and TDM practices was found. The development of international consensus guidelines is required to optimize therapy. Dosing calculators to guide dosing are not yet considered as part of standard-of-care.
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Affiliation(s)
- Anouk van der Veen
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan, 10, 9000, Ghent, Belgium
| | - Annemie Somers
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan, 10, 9000, Ghent, Belgium.,Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | | | - Rob Ter Heine
- Department of Pharmacy and Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger Brüggemann
- Department of Pharmacy and Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karel Allegaert
- Department of Development and Regeneration, and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pieter De Cock
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan, 10, 9000, Ghent, Belgium. .,Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium. .,Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium.
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Alonso-Moreno M, Mejías-Trueba M, Herrera-Hidalgo L, Goycochea-Valdivia WA, Gil-Navarro MV. Efficacy and Safety of Continuous Infusion of Vancomycin in Children: A Systematic Review. Antibiotics (Basel) 2021; 10:antibiotics10080912. [PMID: 34438962 PMCID: PMC8388768 DOI: 10.3390/antibiotics10080912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022] Open
Abstract
Vancomycin is used to treat a wide variety of infections within the pediatric population. In adults, continuous infusion of vancomycin (CIV) has been evaluated as an alternative to intermittent infusion of vancomycin (IIV) with potential advantages. In children, the use of CIV is increasing; however, data is currently limited. The objective is to provide efficacy and safety evidence for CIV within this population. The review was carried out following PRISMA guidelines. A bibliographic search was performed for studies on PubMed and EMBASE. Clinical trials and observational studies that reported clinical efficacy and/or target attainment of CIV in pediatrics were included. Articles were reviewed to assess their design and target population, characteristics of vancomycin treatment and the main findings in terms of safety and efficacy. A total of 359 articles were identified, of which seven met the inclusion criteria. All of them evaluated the target attainment, six assessed safety but only three assessed clinical efficacy. The best administration method for this antibiotic within the pediatric population is still unknown due to limited evidence. However, studies conducted thus far suggest pharmacokinetic advantages for CIV. Further investigation is required, in particular for studies comparing IIV with CIV for clinical efficacy and toxicity outcomes.
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Affiliation(s)
- Marta Alonso-Moreno
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.A.-M.); (M.M.-T.)
| | - Marta Mejías-Trueba
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.A.-M.); (M.M.-T.)
| | - Laura Herrera-Hidalgo
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
- Correspondence: ; Tel.: +34-955-012-095
| | - Walter Alfredo Goycochea-Valdivia
- Unidad de Pediatría de Enfermedades Infecciosas, Reumatología e Inmunología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
| | - María Victoria Gil-Navarro
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
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Rezende RQ, Dias CAG, Ricachinevsky CP, de Lucena Capelari JP. Impact of the Implementation of a Vancomycin Protocol on Trough Serum Vancomycin Concentrations in a Pediatric Intensive Care Unit. Paediatr Drugs 2021; 23:299-305. [PMID: 33830468 DOI: 10.1007/s40272-021-00445-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vancomycin is an antibiotic that is widely used in pediatric intensive care, but the safe and effective use of this drug is challenging. OBJECTIVE This study aimed to assess the impact of a vancomycin protocol on trough serum concentrations. METHODS We conducted a retrospective quasiexperimental study in patients aged ≤ 18 years in intensive care who received vancomycin for at least 5 days. Patients were divided into two groups: before and after a protocol implemented in 2017 that suggested an initial vancomycin dose of 60 mg/kg/day, target serum levels of 15-20 μg/mL, and dose adjustments. We compared patient characteristics, target serum level achievement, and vancomycin levels over time. RESULTS Each group contained 65 patients; most were male infants with heart disease as the main reason for hospitalization. Only 29.2% of the patients had pretreatment cultures for bacteria identification recorded, with 1.5% identified as methicillin-resistant Staphylococcus aureus. For the first serum levels, 10.8% of patients in the pre-protocol group and 21.5% in the post-protocol group achieved the 15-20 μg/mL target (p = 0.153); during the first 5 days of treatment, this proportion significantly increased from 52.3 to 73.8% (p = 0.018). We observed a difference between the first and fifth levels: 8.9 μg/mL (95% confidence interval [CI] - 3.1 to 21) pre-protocol and 0.4 μg/mL (95% CI - 6.1 to 6.9) post-protocol (p = 0.175). CONCLUSIONS Reaching adequate trough vancomycin concentrations in critically ill pediatric patients remains a challenge, and clinical practice protocols allow better dose adjustment and control even when monitoring technologies are unavailable.
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Affiliation(s)
- Raíssa Queiroz Rezende
- Pediatric Intensive Care Unit, Hospital da Criança Santo Antônio, Irmandade Santa Casa de Misericórdia de Porto Alegre, Unidade de Terapia Intensiva Pediátrica, Avenida Independência, 155, Porto Alegre, RS, CEP 90035-074, Brazil.
| | - Cícero Armídio Gomes Dias
- Department of Basic Health Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Claudia Pires Ricachinevsky
- Pediatric Intensive Care Unit, Hospital da Criança Santo Antônio, Irmandade Santa Casa de Misericórdia de Porto Alegre, Unidade de Terapia Intensiva Pediátrica, Avenida Independência, 155, Porto Alegre, RS, CEP 90035-074, Brazil
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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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12
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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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13
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Moriyama H, Tsutsuura M, Kojima N, Mizukami Y, Tashiro S, Osa S, Enoki Y, Taguchi K, Oda K, Fujii S, Takahashi Y, Hamada Y, Kimura T, Takesue Y, Matsumoto K. The optimal trough-guided monitoring of vancomycin in children: Systematic review and meta-analyses. J Infect Chemother 2021; 27:781-785. [PMID: 33563525 DOI: 10.1016/j.jiac.2021.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/08/2021] [Accepted: 01/26/2021] [Indexed: 11/26/2022]
Abstract
We carried out a systematic review and meta-analysis exploring the relationship between vancomycin (VCM) trough concentrations and its effectiveness and nephrotoxicity in pediatric patients. We conducted our analysis using MEDLINE, Web of Sciences, and Cochrane Register of Controlled Trials as electronic databases (June 29, 2019). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. We identified 16 studies that were eligible for the meta-analysis. A total of 351 and 3,266 patients were included in the analysis for effectiveness and nephrotoxicity, respectively. Pediatric MRSA infection patients with VCM trough concentrations ≥ 10 μg/mL had significantly lower treatment failure rates (OR 0.54, 95% CI 0.30-0.96). The incidence of nephrotoxicity was significantly higher in trough concentrations ≥ 15 μg/mL than when they were < 15 μg/mL (OR 3.02, 95% CI 2.08-4.38). We identified the optimal VCM trough concentrations associated with effectiveness and nephrotoxicity in pediatric patients with MRSA infection. Further prospective studies are needed to find optimal dosing and monitoring strategy on VCM in pediatric population.
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Affiliation(s)
- Hiromu Moriyama
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Moeko Tsutsuura
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Nana Kojima
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Yuki Mizukami
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Sho Tashiro
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Sumika Osa
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan.
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1, Honjo, Chuo-ku, Kumamoto-shi, Kumamoto, 860-8556, Japan
| | - Satoshi Fujii
- Department of Hospital Pharmacy, Sapporo Medical University Hospital, 16-291, South 1, West 16, Chuo-ku, Sapporo-shi, Hokkaido, 060-8543, Japan
| | - Yoshiko Takahashi
- Department of Pharmacy, Hyogo College of Medicine, 1-1, Mukogawa-machi, Nishinomiya-shi, Hyogo, 663-8501, Japan
| | - Yukihiro Hamada
- Department of Pharmacy, Tokyo Women's Medical University Hospital, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Toshimi Kimura
- Department of Pharmacy, Tokyo Women's Medical University Hospital, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Yoshio Takesue
- Department of Infection Control and Prevention, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya-shi, Hyogo, 663-8501, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
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14
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A whole blood microsampling assay for vancomycin: development, validation and application for pediatric clinical study. Bioanalysis 2020; 12:1295-1310. [PMID: 32945688 DOI: 10.4155/bio-2020-0112] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: Vancomycin is a commonly used antibiotic, which requires therapeutic drug monitoring to ensure optimal treatment. Microsampling assays are attractive tools for pediatric clinical research and therapeutic drug monitoring. Results: A LC-MS/MS method for the quantification of vancomycin in human whole blood employing volumetric absorptive microsampling (VAMS®) devices (20 μl) was developed and validated. Vancomycin was stable in human whole blood VAMS under assay conditions. Stability for vancomycin was established for at least 160 days as dried microsamples at -78°C. Conclusion: This method is currently being utilized for the quantitation of vancomycin in whole blood VAMS for an ongoing pediatric clinical study and representative clinical data are reported.
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15
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Olson J, Hersh AL, Sorensen J, Zobell J, Anderson C, Thorell EA. Intravenous Vancomycin Therapeutic Drug Monitoring in Children: Evaluation of a Pharmacy-Driven Protocol and Collaborative Practice Agreement. J Pediatric Infect Dis Soc 2020; 9:334-341. [PMID: 31344233 DOI: 10.1093/jpids/piz036] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Vancomycin optimization is challenging, requiring careful therapeutic drug monitoring (TDM) to avoid toxicity and ensure an efficacious concentration. Most prescriptions are empiric and often discontinued within 72 hours, which makes early TDM unnecessary. Although TDM using trough levels is common, the area under the concentration-time curve (AUC) is the preferred pharmacodynamic target. We studied the effect of a pharmacy-driven vancomycin collaborative practice agreement (CPA) at a children's hospital that delayed TDM up to 72 hours and targeted a 2-point 24-hour AUC of ≥400 mg × h/L. METHODS We retrospectively reviewed vancomycin courses in patients aged ≥30 days who received vancomycin between April 1, 2011, and August 30, 2017. We implemented the CPA on June 1, 2014. Outcomes included CPA use, use of TDM, dosage adjustments, and development of acute kidney injury; we compared courses given while monitoring only trough levels (TO-TDM) with those given while using the CPA (AUC-TDM). We performed interrupted time series analyses to account for preintervention trends. RESULTS We included 2379 courses in the TO-TDM period and 2155 in the AUC-TDM period. During AUC-TDM, 87% of the courses were managed by the CPA. In adjusted interrupted time series analyses, CPA implementation was associated with an initial change in level of -0.265 (95% confidence interval [CI], -0.336 to -0.189) TDM and an initial change in level of -0.332 (95% CI, -0.506 to -0.163) dosage adjustments. The 1-year risk of acute kidney injury decreased after CPA implementation (odds ratio, 0.695 [95% CI, 0.539-0.91]). CONCLUSION The pharmacy-driven vancomycin CPA resulted in less monitoring and fewer dose adjustments without increasing AKI.
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Affiliation(s)
- Jared Olson
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, Utah.,Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City
| | - Jeffrey Sorensen
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Murray, Utah
| | - Jeffrey Zobell
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, Utah
| | - Collin Anderson
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, Utah
| | - Emily A Thorell
- Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City
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16
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A Population Pharmacokinetics Model for Vancomycin Dosage Optimization Based on Serum Cystatin C. Eur J Drug Metab Pharmacokinet 2020; 45:535-546. [DOI: 10.1007/s13318-020-00621-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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17
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Mali NB, Tullu MS, Wandalkar PP, Deshpande SP, Ingale VC, Deshmukh CT, Gogtay NJ, Thatte UM. Steady-state Pharmacokinetics of Vancomycin in Children Admitted to Pediatric Intensive Care Unit of a Tertiary Referral Center. Indian J Crit Care Med 2020; 23:497-502. [PMID: 31911739 PMCID: PMC6900889 DOI: 10.5005/jp-journals-10071-23275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims and objectives Vancomycin is a drug of choice for various gram-positive bacterial (GPB) infections and is largely prescribed to pediatric intensive care unit (PICU) patients. Despite the different pathophysiology of these patients, limited data are available on pharmacokinetics of vancomycin. There are lack of data for critically ill Indian children; hence, study was conducted to assess the steady-state pharmacokinetics in children admitted to PICU. Materials and methods Twelve subjects (seven males, five females) aged 1–12 years were enrolled. Vancomycin (dose of 20 mg/kg per 8 hours) was infused for over 1 hour and steady-state pharmacokinetics was performed on day 3. Vancomycin concentrations were measured by the validated liquid chromatography mass spectrometry method. Pharmacokinetic parameters were calculated using Winnonlin (Version 6.3; Pharsight, St. Louis, MO). Results The steady-state mean Cssmax was 40.94 μg/mL (±15.07), and mean AUC0–8 hours was 124.15 μg/mL (±51.27). The mean t1/2 was 4.82 hours (±2.71), Vd was 12.48 L (±4.43), and Cl was 2.08 mL/minute (±0.89). The mean AUC0–24 among 12 subjects was 372.44 μg/mL (±153.82). Among 35 measured trough concentrations, 23 (65.71%) were below, 11 (31.43%) were within, and 1 (2.86%) was above the recommended range. Conclusion The pharmacokinetic parameters of vancomycin were comparable with previously reported studies. However, recommended trough levels (10–20 μg/mL) were not achievable with current recommended dosing of 60 mg/kg/day. How to cite this article Mali NB, Tullu MS, Wandalkar PP, Deshpande SP, Ingale VC, Deshmukh CT, et al. Steady-state Pharmacokinetics of Vancomycin in Children Admitted to Pediatric Intensive Care Unit of a Tertiary Referral Center. IJCCM 2019;23(11):497–502.
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Affiliation(s)
- Nitin B Mali
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Milind S Tullu
- Department of Pediatrics, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Poorwa P Wandalkar
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Siddharth P Deshpande
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Vinod C Ingale
- Department of Pediatrics, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Chandrahas T Deshmukh
- Department of Pediatrics, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Nithya J Gogtay
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Urmila M Thatte
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
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18
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Early Bayesian Dose Adjustment of Vancomycin Continuous Infusion in Children: a Randomized Controlled Trial. Antimicrob Agents Chemother 2019:AAC.01102-19. [PMID: 31591117 DOI: 10.1128/aac.01102-19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Methicillin-resistant staphylococcal infections are a global burden. Area under the serum concentration-time curve to minimum inhibitory concentration (AUC/MIC) ratio is the pharmacokinetic (PK) parameter that best predicts vancomycin efficacy. Its therapeutic range is narrow, difficult to achieve because of a wide intersubject variability, especially in children, and is not routinely targeted since the AUC is rarely available. We investigated if an early Bayesian dose adjustment would increase the rate of vancomycin target attainment, in the first 24 hours of treatment (H24), in children.We conducted a single-centre randomized controlled trial in 4 pediatric departments of Necker-Enfants Malades hospital (Paris, France). Patients aged 3 months to 17 years for whom intravenous vancomycin was started were eligible and randomized in a 1:1 ratio: routine care were compared with an early vancomycin therapeutic drug monitoring (3h after treatment initiation) followed by an early Bayesian dose adjustment using a previously published population-based PK model that included age, bodyweight and serum creatinine as covariates. The primary outcome was the proportion of patients of each group achieving vancomycin therapeutic range at H24, defined by AUC0-24/MIC≥400 and AUC0-24 ≤800mg-h/L.Ninety-nine patients were enrolled: 49 were randomized to the Bayesian group and 50 to the control group. Modified intention-to-treat analysis included 82 patients: 85% of Bayesian group patients achieved H24 vancomycin target versus 57% of control group patients (p=0.007) with no difference regarding iatrogenic events. Early Bayesian dose adjustment increased the proportion of children achieving vancomycin target at H24, which may improve clinical outcomes of methicillin-resistant staphylococcal infections.
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19
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Sharma R, Hammerschlag MR. Treatment of Methicillin-Resistant Staphylococcus aureus (MRSA) Infections in Children: a Reappraisal of Vancomycin. Curr Infect Dis Rep 2019; 21:37. [PMID: 31486979 DOI: 10.1007/s11908-019-0695-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW In the last 50 years, vancomycin has been the agent of choice to treat infections due to methicillin-resistant Staphylococcus aureus (MRSA). However, vancomycin treatment failure is not uncommon, even when MRSA strains are fully susceptible to vancomycin. Treatment with vancomycin requires careful monitoring of drug levels as there is a potential for nephrotoxicity. Resistance to clindamycin is not infrequent, which also limits therapeutic options for treating infections due to MRSA in children. This paper reviews the current data on pharmacokinetics and pharmacodynamics and clinical efficacy of vancomycin in children. RECENT FINDINGS Resistance to vancomycin in MRSA (MIC >2 mg/L) is infrequent; there is increasing evidence in the literature that vancomycin maybe ineffective against increasing proportion of isolates with MICs between 1 and 2 mg/L. Recent studies and meta-analyses have demonstrated that strains with high vancomycin MICs are associated with poor outcomes especially in patients with bacteremia and deep tissue infections due to MRSA. This gradual increase in vancomycin MIC has been reported as MIC creep or vancomycin heteroresistance. Patients infected with MRSA isolates that exhibit MIC creep experience poorer clinical outcomes, including delayed treatment response, increased mortality, increase rate of relapse, and extended hospitalization. There are limited data to guide vancomycin dosing in children with MRSA. Although the vancomycin area under the curve AUC24/MIC ratio > 400 has been shown to predict clinical efficacy in adults, this relationship has not been documented very well for treatment outcomes in MRSA infections in children. Use of higher vancomycin dosages in attempts to achieve higher trough concentrations has been associated with increased nephrotoxicity. New recently approved antibiotics including ceftaroline, dalbavancin, and tedizolid offer a number of advantages over vancomycin to treat staphylococcal infections: improved antimicrobial activity, superior pharmacokinetics, pharmacodynamics, tolerability, and dosing, including once-daily and weekly regimens, and less need for monitoring drug levels.
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Affiliation(s)
- Roopali Sharma
- Department of Pharmacy Practice, Touro College of Pharmacy, New York, NY, USA. .,Department of Pharmacy, Downstate Medical Center, Brooklyn, NY, USA.
| | - Margaret R Hammerschlag
- Department of Pediatrics, Division of Infectious Diseases, State University of New York Downstate Medical Center, Brooklyn, NY, USA
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20
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Vancomycin-associated Nephrotoxicity and Risk Factors in Critically Ill Children Without Preexisting Renal Injury. Pediatr Infect Dis J 2019; 38:934-938. [PMID: 31232892 DOI: 10.1097/inf.0000000000002391] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND A recent systematic review concluded that critically ill pediatric patients have higher odds of vancomycin-related nephrotoxicity [odds ratio (OR): 3.61, 95% CI: 1.21-10.74]. We aimed to assess the incidence and risk factors for vancomycin-associated nephrotoxicity in critically ill children without preexisting renal injury. METHODS A cohort of children admitted to a pediatric intensive care unit, from 2011 to 2016 treated with vancomycin without preexisting renal injury. The main diagnosis, therapeutic interventions and medications administered in this period were evaluated. Generalized estimating equation models were used to assess the association between clinical covariates and the dependent variable pediatric risk, injury, failure, loss, end-stage renal disease (pRIFLE). RESULTS Hundred ten patients, representing 1177 vancomycin days, were analyzed. Vancomycin-associated nephrotoxicity was seen in 11.8%. In a multivariate model, higher vancomycin doses were not associated with poorer renal function (P = 0.08). Higher serum vancomycin levels were weakly associated with pRIFLE classification (OR: 1.05, 95% CI: 1.02-1.07). Furosemide or amphotericin B in addition to the vancomycin treatment was associated with impaired renal function (OR: 2.56, 95% CI: 1.38-4.8 and OR: 7.7 95% CI: 2.55-23, respectively). CONCLUSIONS Vancomycin-associated nephrotoxicity in acute ill children without preexisting renal injury, measured with pRIFLE, is close to 11.8%. Furosemide and amphotericin B in addition to the vancomycin treatment are strong predictors of worse pRIFLE scores. The influence of acute kidney injury status at pediatric intensive care unit admission and the method used for renal function assessment might influence the incidence of vancomycin-associated nephrotoxicity and its associated risk factors.
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21
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Regen RB, Schuman SS, Chhim RF, Arnold SR, Lee KR. Vancomycin Treatment Failure in Children With Methicillin-Resistant Staphylococcus aureus Bacteremia. J Pediatr Pharmacol Ther 2019; 24:312-319. [PMID: 31337994 DOI: 10.5863/1551-6776-24.4.312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Limited data exist regarding clinical outcomes of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections in children treated with vancomycin. Treatment success in adults correlates best with an area under the curve/minimum inhibitory concentration (AUC24/MIC) ratio ≥400. It is unknown if this relationship is useful in children. METHODS Charts of children who received vancomycin ≥5 days for MRSA bacteremia with a steady state trough were reviewed. AUC24/MIC ratios were estimated using 2 different vancomycin clearance equations. Vancomycin treatment failure was defined as persistent bacteremia ≥7 days, recurrent bacteremia within 30 days, or 30-day mortality. RESULTS There were 67 bacteremia episodes in 65 patients. Nine (13.4%) met failure criteria: persistent bacteremia (n = 6), recurrent bacteremia (n = 2), 30-day mortality (n = 1). There were no differences between patients receiving <60 mg/kg/day and ≥60 mg/kg/day of vancomycin in median trough (11.9 versus 12.3 mg/L, p = 0.1). Troughs did not correlate well with AUC24/MIC ratios (R 2 = 0.32 and 0.22). Patients receiving ≥60 mg/kg/day had greater probability of achieving ratios ≥400. There were no significant differences in median dose (p = 0.8), trough (p = 0.24), or AUC24/MIC ratios (p = 0.07 and p = 0.6) between patients with treatment success and failure. CONCLUSIONS Treatment failure was lower than previously reported in children. AUC24/MIC ratios ≥400 were frequently achieved but were not associated with treatment success, dose, or troughs. Prospective studies using standard definitions of vancomycin treatment failure are needed to understand treatment failure in children with MRSA bacteremia.
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22
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Bidu NS, Fernandes BJ, Dias EJ, Filho JN, Bastos RE, Godoy AL, Azeredo FJ, Pedreira JN, Couto RD. Vancomycin Therapeutic Regime Adjustment in Newborns and Infants with Bacterial Infection: Case Series. Curr Pharm Biotechnol 2019; 20:346-351. [DOI: 10.2174/1389201020666190319161511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/29/2018] [Accepted: 03/12/2019] [Indexed: 11/22/2022]
Abstract
Background:
Vancomycin is used mostly to overcome infections caused by methicillinresistant
microorganisms. There are no well-established administration protocols for neonates and infants,
so the leak of a specific administration regime in that population may lead to serum concentrations
beyond the specified range.
Objective:
This case series evaluated the pharmacokinetics adjustment from a vancomycin therapeutic
regimen prescribed to neonates and infants with bacterial infection at a neonatal public hospital intensive-
care-unit, with the primary purpose to verify cases of nephrotoxicity.
Methods:
Three neonates and four infants taking vancomycin therapy, hospitalized in a public hospital
from November 2014 to March 2015, were included in the study. Vancomycin serum concentrations
were determined by particle-enhanced-turbidimetric inhibition-immunoassay. The vancomycin concentrations
were used for dose adjustment by USC*Pack-PC-Collection®, a non-parametric maximization
program. The trough serum concentration range of 10 to 20mg.L-1 was considered therapeutic.
Results:
Three patients had serum concentration outside the reference-range, one with subtherapeutic,
and two with supratherapeutic concentrations. All patients had concomitant use of drugs which interfered
with vancomycin distribution and excretion pharmacokinetics parameters, including drugs that
may enhance nephrotoxicity. One patient showed signs of acute renal damage, by low vancomycin and
creatinine estimated clearances.
Conclusion:
The pharmacokinetic adjustment has been proven to be a useful and necessary tool to
increase therapeutic efficacy and treatment benefits. The standard dose of vancomycin can be used to
initiate therapy in neonates and infants admitted to the ICU, but after reaching the drug steady state,
the dosing regimen should be individualized and guided by pharmacokinetic parameters.
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Affiliation(s)
- Nadielle S. Bidu
- Pharmacy Postgraduate Program, Faculty of Pharmacy, Federal University of Bahia/UFBA, Salvador, Bahia, Brazil
| | - Bruno J.D. Fernandes
- Clinical Biochemistry Laboratory, Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Bahia/UFBA, Salvador, Bahia, Brazil
| | | | | | - Regina E.A. Bastos
- Department of Pediatrics, Hospital Roberto Santos, Salvador, Bahia, Brazil
| | - Ana L.P.C. Godoy
- Pharmacy Postgraduate Program, Faculty of Pharmacy, Federal University of Bahia/UFBA, Salvador, Bahia, Brazil
| | - Francine J. Azeredo
- Pharmacy Postgraduate Program, Faculty of Pharmacy, Federal University of Bahia/UFBA, Salvador, Bahia, Brazil
| | - Joice N.R. Pedreira
- Pharmacy Postgraduate Program, Faculty of Pharmacy, Federal University of Bahia/UFBA, Salvador, Bahia, Brazil
| | - Ricardo D. Couto
- Pharmacy Postgraduate Program, Faculty of Pharmacy, Federal University of Bahia/UFBA, Salvador, Bahia, Brazil
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23
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The Relationship Between Vancomycin Trough Concentrations and AUC/MIC Ratios in Pediatric Patients: A Qualitative Systematic Review. Paediatr Drugs 2018; 20:153-164. [PMID: 29344778 DOI: 10.1007/s40272-018-0282-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND In adults, the area under the concentration-time curve (AUC) divided by the minimum inhibitory concentration (MIC) is associated with better clinical and bacteriological response to vancomycin in patients with methicillin-resistant Staphylococcus aureus who achieve target AUC/MIC ≥ 400. This target is often extrapolated to pediatric patients despite the lack of similar evidence. The impracticalities of calculating the AUC in practice means vancomycin trough concentrations are used to predict the AUC/MIC. OBJECTIVE This review aimed to determine the relationship between vancomycin trough concentrations and AUC/MIC in pediatric patients. METHODS We searched the MEDLINE and Embase databases, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials using the medical subject heading (MeSH) terms vancomycin and AUC and pediatric* or paediatric*. Articles were included if they were published in English and reported a relationship between vancomycin trough concentrations and AUC/MIC. RESULTS Of 122 articles retrieved, 11 met the inclusion criteria. One trial reported a relationship between vancomycin trough concentrations, AUC/MIC, and clinical outcomes but was likely underpowered. Five studies found troughs 6-10 mg/l were sufficient to attain an AUC/MIC > 400 in most general hospitalized pediatric patients. One study in patients undergoing cardiothoracic surgery found a trough of 18.4 mg/l achieved an AUC/MIC > 400. Two oncology studies reported troughs ≥ 15 mg/l likely attained an AUC/MIC ≥ 400. In critical care patients: one study found a trough of 9 mg/l did not attain the AUC/MIC target; another found 7 mg/l corresponded to an AUC/MIC of 400. CONCLUSIONS Potential vancomycin targets varied based on the population studied but, for general hospitalized pediatric patients, troughs of 6-10 mg/l are likely sufficient to achieve AUC/MIC ≥ 400. For MIC ≥ 2 mg/l, higher troughs are likely necessary to achieve an AUC/MIC ≥ 400. More research is needed to determine the relationships between vancomycin trough concentrations, AUC/MIC, and clinical outcomes.
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Hoegy D, Goutelle S, Garnier N, Rénard C, Faure-Conter C, Bergeron C, Bertrand Y, Bleyzac N. Continuous intravenous vancomycin in children with normal renal function hospitalized in hematology-oncology: prospective validation of a dosing regimen optimizing steady-state concentration. Fundam Clin Pharmacol 2018; 32:323-329. [PMID: 29315849 DOI: 10.1111/fcp.12344] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 12/16/2017] [Accepted: 12/22/2017] [Indexed: 01/26/2023]
Abstract
Continuous intravenous (IV) infusion has been shown to be the best option to administer vancomycin because of its time-dependent bactericidal activity. Available IV vancomycin dosing guidelines in pediatrics with normal renal function leads to less than 50% of patients achieving a vancomycin serum concentration (Css) in the target range (15-20 mg/L). The primary objective of this study was to prospectively validate an age-based dosing regimen in pediatric oncology-hematology. The secondary objective was to investigate the influence on Css attainment of different variables. A continuous IV dosing nomogram was built by retrospective study (2000-2010) on Bayesian dosing adjustments performed in 161 patients. This study assessed the prospective validation of this age-based nomogram and the influence on Css attainment of variables as the gender, underlying disease (oncology or hematology), and hematopoietic stem cell transplantation (HSCT) before receiving vancomycin therapy. A total of 94 patients aged from 4.3 months to 17.9 years old with normal renal function were eligible for the prospective validation. Fifty-five of those patients (58.5%) achieved the target range of vancomycin Css. There was no significant difference between age groups (P = 0.816) and no influence of gender (P = 0.500). There was a nonsignificant trend to a better target attainment in oncology patients (69.2% vs. hematology 54.4%, P = 0.142) and patients who did not undergo HSCT (63.3% vs. 33.3%, P = 0.031). This study proposed an age-based nomogram prospectively validated which near 60% of patients of each age class achieving the target range of Css.
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Affiliation(s)
- Delphine Hoegy
- Institut d'Hématologie et d'Oncologie Pédiatrique, 1 Place Pr J. Renaut 69008, Lyon, France.,Hospices Civiles de Lyon, Lyon, France.,EA4129, Laboratoire Parcours santé systémique, 7-9 rue G. Paradin 69008, Lyon, France
| | - Sylvain Goutelle
- Hospices Civiles de Lyon, Lyon, France.,Laboratoire de Biométrie et Biologie Evolutive, UMR CNRS 5558, 43 bd du 11 novembre 1918 69622, Villeurbanne Cedex, France.,Université Lyon I, Villeurbanne, France.,Pharmacie, Groupe Hospitalier Nord, Lyon, France
| | - Nathalie Garnier
- Institut d'Hématologie et d'Oncologie Pédiatrique, 1 Place Pr J. Renaut 69008, Lyon, France.,Hospices Civiles de Lyon, Lyon, France
| | - Cécile Rénard
- Institut d'Hématologie et d'Oncologie Pédiatrique, 1 Place Pr J. Renaut 69008, Lyon, France.,Hospices Civiles de Lyon, Lyon, France
| | - Cécile Faure-Conter
- Institut d'Hématologie et d'Oncologie Pédiatrique, 1 Place Pr J. Renaut 69008, Lyon, France.,Centre Léon Bérard, Lyon, France
| | - Christophe Bergeron
- Institut d'Hématologie et d'Oncologie Pédiatrique, 1 Place Pr J. Renaut 69008, Lyon, France.,Centre Léon Bérard, Lyon, France
| | - Yves Bertrand
- Institut d'Hématologie et d'Oncologie Pédiatrique, 1 Place Pr J. Renaut 69008, Lyon, France.,Hospices Civiles de Lyon, Lyon, France.,Université Lyon I, Villeurbanne, France
| | - Nathalie Bleyzac
- Institut d'Hématologie et d'Oncologie Pédiatrique, 1 Place Pr J. Renaut 69008, Lyon, France.,Hospices Civiles de Lyon, Lyon, France.,EMR 3738 Optimisation Thérapeutique en Oncologie et Onco-hématologie, Lyon, France
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Determining the optimal vancomycin daily dose for pediatrics: a meta-analysis. Eur J Clin Pharmacol 2017; 73:1341-1353. [DOI: 10.1007/s00228-017-2306-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/17/2017] [Indexed: 10/19/2022]
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Miloslavsky M, Galler MF, Moawad I, Actis J, Cummings BM, El Saleeby CM. The Impact of Pediatric-Specific Vancomycin Dosing Guidelines: A Quality Improvement Initiative. Pediatrics 2017; 139:peds.2016-2423. [PMID: 28562258 DOI: 10.1542/peds.2016-2423] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There are limited data guiding vancomycin dosing practices in the pediatric population to target the goal troughs recommended by national vancomycin guidelines. In this study, we sought to improve adherence to guideline trough targets through a quality improvement intervention. METHODS A retrospective analysis was first conducted to assess baseline performance. A multidisciplinary team then developed and implemented a standardized dosing algorithm recommending 15 mg/kg per dose for mild and moderate infections (goal trough: 10-15 µg/mL) and 20 mg/kg per dose for severe infections (goal trough: 15-20 µg/mL), both delivered every 6 hours (maximum single dose: 750 mg). The impact of the intervention was evaluated prospectively using standard statistics and quality improvement methodology. The outcome measures included the percentage of patients with an initial therapeutic trough and the time to therapeutic trough. RESULTS A total of 116 patients (49 preintervention, 67 postintervention) were included. Postintervention, there was a significant increase in the percentage of patients with an initial therapeutic trough (6.1% to 20.9%, P = .03) and in the percentage of patients with initial troughs between 10 and 20 µg/mL (8.2% to 40.3%, P < .001). The time to therapeutic trough decreased from 2.78 to 1.56 days (P = .001), with the process control chart showing improved control postintervention. Vancomycin-related toxicity was unchanged by the intervention (6.1% versus 4.5%; P = .70). CONCLUSIONS Using quality improvement methodology with standardized higher initial vancomycin doses, we demonstrated improved adherence to national trough guidelines without noted safety detriment.
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Affiliation(s)
| | | | | | | | | | - Chadi M El Saleeby
- Departments of Pediatrics, .,Divisions of Hospital Medicine.,Infectious Diseases, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts
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