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Iida M, Horita Y, Asaoka M, Ohashi K, Noda M, Wachino C, Hirose T, Nomura Y, Hisada Y, Nagamizu M, Kawahara M, Morishita N, Kondo M, Hotta Y, Nakamura A, Furukawa-Hibi Y. Evaluation of target area under the concentration-time curve of vancomycin in an initial dosing design: a retrospective cohort study. J Antimicrob Chemother 2024:dkae249. [PMID: 39028649 DOI: 10.1093/jac/dkae249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 07/03/2024] [Indexed: 07/21/2024] Open
Abstract
OBJECTIVES Area under the concentration-time curve (AUC)-guided dosing of vancomycin was introduced in a clinical setting; however, the target range of non-steady-state AUCs, such as Day 1 AUC and Day 2 AUC, remains controversial. Therefore, we sought to determine pharmacokinetic parameter thresholds and identify independent risk factors associated with acute kidney injury (AKI) to establish a safe initial dosing design for vancomycin administration. METHODS A single-centre, retrospective, cohort study of hospitalized patients treated with vancomycin was conducted to determine the threshold of both non-steady-state AUCs (Day 1 and 2 AUCs) and trough levels at the first blood sampling point (therapeutic drug monitoring, TDM). In addition, independent risk factors associated with AKI were evaluated using univariate and multivariate logistic regression analyses. RESULTS The thresholds for predicting AKI were estimated as 456.6 mg·h/L for AUC0-24h, 554.8 mg·h/L for AUC24-48h, 1080.8 mg·h/L for AUC0-48h and 14.0 μg/mL for measured trough levels, respectively. In a multivariate analysis, Day 2 AUC ≥ 554.8 mg·h/L [adjusted odds ratio (OR), 57.16; 95% confidence interval (CI), 11.95-504.05], piperacillin/tazobactam (adjusted OR, 15.84; 95% CI, 2.73-127.70) and diuretics (adjusted OR, 4.72; 95% CI, 1.13-21.01) were identified as risk factors for AKI. CONCLUSIONS We identified thresholds for both AUCs in the non-steady-state and trough levels at the first TDM. Our results highlight the importance of monitoring not only the AUC but also trough levels during vancomycin treatment to reduce the likelihood of AKI.
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Affiliation(s)
- Moeko Iida
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Yasuhiro Horita
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Division of Infection Prevention and Control, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Minami Asaoka
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Kazuki Ohashi
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Division of Infection Prevention and Control, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Masato Noda
- Department of Pharmacy, Nagoya City University East Medical Center, 1-2-23 Wakamizu, Chikusa-ku, Nagoya, Aichi 464-8547, Japan
| | - Chiharu Wachino
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University East Medical Center, 1-2-23 Wakamizu, Chikusa-ku, Nagoya, Aichi 464-8547, Japan
| | - Toa Hirose
- School of Pharmacy, Aichi Gakuin University, 1-100 Kusumoto-cho, Chikusa-ku, Nagoya, Aichi 464-8650, Japan
| | - Yuki Nomura
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Yoshinori Hisada
- Department of Pharmacy, Nagoya City University West Medical Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya, Aichi 462-8508, Japan
| | - Masaya Nagamizu
- Department of Pharmacy, Nagoya City University West Medical Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya, Aichi 462-8508, Japan
| | - Masami Kawahara
- School of Pharmacy, Aichi Gakuin University, 1-100 Kusumoto-cho, Chikusa-ku, Nagoya, Aichi 464-8650, Japan
| | - Nobuyuki Morishita
- Department of Pharmacy, Nagoya City University West Medical Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya, Aichi 462-8508, Japan
| | - Masahiro Kondo
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University East Medical Center, 1-2-23 Wakamizu, Chikusa-ku, Nagoya, Aichi 464-8547, Japan
| | - Yuji Hotta
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Atsushi Nakamura
- Division of Infection Prevention and Control, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Yoko Furukawa-Hibi
- Department of Clinical Pharmaceutics, Graduate School of Medical Sciences, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
- Department of Pharmacy, Nagoya City University Hospital, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
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Hanai Y, Hashi H, Hanawa K, Endo A, Miyazaki T, Yamaguchi T, Harada S, Yokoo T, Uekusa S, Namiki T, Yokoyama Y, Asakawa D, Isoda R, Enoki Y, Taguchi K, Matsumoto K, Matsuo K. Predictive Value of Vancomycin AUC 24/MIC Ratio for 30-day Mortality in Patients with Severe or Complicated Methicillin-Resistant Staphylococcus aureus Infections: A Multicenter Retrospective Study. Pharm Res 2024; 41:1381-1389. [PMID: 38886259 DOI: 10.1007/s11095-024-03728-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/09/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Although vancomycin is typically employed against methicillin-resistant Staphylococcus aureus (MRSA) infections, the optimal ratio of 24-h area under the concentration-time curve to minimum inhibitory concentration (AUC24/MIC) for severe or complicated infections lacks clear guideline recommendations. This study aimed to determine the target AUC24/MIC ratio associated with treatment outcomes of infections treated with vancomycin. METHODS This retrospective multicenter cohort study included adult patients receiving ≥ 5 days of vancomycin for severe/complicated MRSA infections (e.g., osteoarticular, pulmonary, endocarditis, etc.) between January 2018 and December 2023. The primary outcome was 30-day mortality, with secondary outcomes including clinical success, microbiological eradication, and nephrotoxicity. Receiver operating characteristic (ROC) curve analysis was used to identify the AUC24/MIC cutoff for 30-day mortality. Multivariate regression analysis was used to determine association between AUC24/MIC and outcomes. RESULTS This study included 82 patients. ROC identified a target AUC24/MIC of ≥ 505 for 30-day mortality. The overall 30-day mortality rate (22.0%) was significantly higher for below average AUC24/MIC cutoff (34.1%) than for above AUC24/MIC cutoff group (9.8%). Multivariate analysis confirmed AUC24/MIC of < 505 as an independent predictor (adjusted odds ratio, 5.001; 95% confidence interval, 1.335-18.75). The clinical success rate differed significantly between below- and above-cutoff groups, whereas microbiological eradication tended to favor the above-cutoff group. The nephrotoxicity rates were comparable between groups. CONCLUSIONS In treating severe/complicated MRSA infections, vancomycin AUC24/MIC ratio ≥ 505 was independently associated with favorable 30-day mortality. Given the retrospective nature of this study, further prospective studies are essential to confirm the reliability of the target AUC24/MIC ratios.
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Affiliation(s)
- Yuki Hanai
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Chiba, Japan.
| | - Hideki Hashi
- Department of Pharmacy, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Kazumi Hanawa
- Department of Pharmacy, Kameda Medical Center, Chiba, Japan
| | - Aiju Endo
- Department of Pharmacy, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Taito Miyazaki
- Department of General Medicine and Emergency Care (Infectious Diseases), Toho University Omori Medical Center, Tokyo, Japan
| | - Tetsuo Yamaguchi
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo, Japan
| | - Sohei Harada
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo, Japan
| | - Takuya Yokoo
- Department of Pharmacy, Toho University Omori Medical Centre, Tokyo, Japan
| | - Shusuke Uekusa
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Chiba, Japan
| | - Takaya Namiki
- Department of Pharmacy, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | | | - Daiki Asakawa
- Department of Pharmacy, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Ryo Isoda
- Department of Pharmacy, Toho University Omori Medical Centre, Tokyo, Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Tokyo, Japan
| | - Kazuhiro Matsuo
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Chiba, Japan
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Yang W, Zhang K, Chen Y, Fan Y, Zhang J. Is It Still Beneficial to Monitor the Trough Concentration of Vancomycin? A Quantitative Meta-Analysis of Nephrotoxicity and Efficacy. Antibiotics (Basel) 2024; 13:497. [PMID: 38927164 PMCID: PMC11200798 DOI: 10.3390/antibiotics13060497] [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: 04/24/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
This study conducted a quantitative meta-analysis to investigate the association of vancomycin indicators, particularly area under the curve over 24 h (AUC24) and trough concentrations (Ctrough), and their relationship with both nephrotoxicity and efficacy. Literature research was performed in PubMed and Web of Science on vancomycin nephrotoxicity and efficacy in adult inpatients. Vancomycin Ctrough, AUC24, AUC24/minimum inhibitory concentration (MIC), nephrotoxicity evaluation and treatment outcomes were extracted. Logistic regression and Emax models were conducted, stratified by evaluation criterion for nephrotoxicity and primary outcomes for efficacy. Among 100 publications on nephrotoxicity, 29 focused on AUC24 and 97 on Ctrough, while of 74 publications on efficacy, 27 reported AUC24/MIC and 68 reported Ctrough. The logistic regression analysis indicated a significant association between nephrotoxicity and vancomycin Ctrough (odds ratio = 2.193; 95% CI 1.582-3.442, p < 0.001). The receiver operating characteristic curve had an area of 0.90, with a cut-off point of 14.55 mg/L. Additionally, 92.3% of the groups with a mean AUC24 within 400-600 mg·h/L showed a mean Ctrough of 10-20 mg/L. However, a subtle, non-statistically significant association was observed between the AUC24 and nephrotoxicity, as well as between AUC24/MIC and Ctrough concerning treatment outcomes. Our findings suggest that monitoring vancomycin Ctrough remains a beneficial and valuable approach to proactively identifying patients at risk of nephrotoxicity, particularly when Ctrough exceeds 15 mg/L. Ctrough can serve as a surrogate for AUC24 to some extent. However, no definitive cut-off values were identified for AUC24 concerning nephrotoxicity or for Ctrough and AUC24/MIC regarding efficacy.
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Affiliation(s)
- Wanqiu Yang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Kaiting Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yuancheng Chen
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China;
| | - Yaxin Fan
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
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Knight JM, Iso T, Perez KK, Swan JT, Janak CE, Ikwuagwu JO, Musick WL. Risk of Acute Kidney Injury Based on Vancomycin Target Trough Attainment Strategy: Area-Under-the-Curve-Guided Bayesian Software, Nomogram, or Trough-Guided Dosing. Ann Pharmacother 2024; 58:110-117. [PMID: 37144736 DOI: 10.1177/10600280231171373] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Guidelines support area-under-the-curve (AUC) monitoring for vancomycin dosing which may lower overall doses and reduce acute kidney injury (AKI). OBJECTIVE The aim of this study was to compare incidence of AKI across 3 vancomycin dosing modalities: AUC-targeted Bayesian pharmacokinetic software, AUC-targeted empiric dosing nomogram, and trough-guided dosing using clinical pharmacists' judgment. METHODS This retrospective study included adult patients with a pharmacy dosing consult who received ≥1 dose of vancomycin and ≥1 serum vancomycin level documented between January 1, 2018, and December 31, 2019. Patients with baseline serum creatinine ≥2 mg/dL, weight ≥100 kg, receiving renal replacement therapy, AKI prior to vancomycin therapy, or vancomycin ordered only for surgical prophylaxis were excluded. The primary analysis was incidence of AKI adjusted for baseline serum creatinine, age, and intensive care unit admission. A secondary outcome was adjusted incidence of an abnormal trough value (<10 or >20 μg/mL). RESULTS The study included 3459 encounters. Incidence of AKI was 21% for Bayesian software (n = 659), 22% for the nomogram (n = 303), and 32% for trough-guided dosing (n = 2497). Compared with trough-guided dosing, incidence of AKI was lower in the Bayesian (adjusted odds ratio [OR] = 0.72, 95% confidence interval [CI]: 0.58-0.89) and the nomogram (adjusted OR = 0.71, 95% CI: 0.53-0.95) groups. Compared with trough-guided dosing, abnormal trough values were less common in the Bayesian group (adjusted OR = 0.83, 95% CI: 0.69-0.98). CONCLUSION AND RELEVANCE Study results suggest that use of AUC-guided Bayesian software reduces the incidence of AKI and abnormal trough values compared with trough-guided dosing.
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Affiliation(s)
| | - Tomona Iso
- Department of Pharmacy, Houston Methodist, Houston, TX, USA
- Department of Surgery, Houston Methodist, Houston, TX, USA
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | | | - Joshua T Swan
- Department of Pharmacy, Houston Methodist, Houston, TX, USA
- Department of Surgery, Houston Methodist, Houston, TX, USA
- Center for Outcomes Research, Houston Methodist, Houston, TX, USA
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5
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Islam I. Vancomycin AUC-Based Dosing Practices in a Non-Teaching Community Hospital and Associated Outcomes: A One-Year Survey of Uniform Targets for Infections with or without MRSA. PHARMACY 2024; 12:15. [PMID: 38251409 PMCID: PMC10801466 DOI: 10.3390/pharmacy12010015] [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: 12/23/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Intravenous (IV) vancomycin area under the curve (AUC)-based dosing is used uniformly for Gram-positive organisms in non-teaching community hospitals. However, evidence for using vancomycin AUC-based dosing for non-methicillin-resistant Staphylococcus aureus (non-MRSA) and less serious infections is limited in the literature. A gap in the literature also exists with respect to comparisons between the outcomes that can be derived using the regimens suggested by Bayesian programs and target doses of the AUC of 400-499 and 500-600. METHODS A retrospective review of all patients hospitalized in a non-teaching community hospital who used AUC-based vancomycin was performed over a 1-year period. RESULTS Only 17.6% of the included patients had confirmed MRSA. The values for the overall early response rate, 30-day all-cause mortality, and rate of acute kidney injury (AKI) were 50.3%, 11.3%, and 3.8%, respectively, in this population. In regression analysis, compared to non-MRSA infections, a significantly higher rate of early response was seen in patients with MRSA (unadjusted OR = 2.68, 95% CI [1.06-6.76] p = 0.04). Patients in the AUC 400-499 group had a non-significant higher incidence of 30 d mortality and new AKI compared to patients in the AUC 500-600 group. In our Kaplan-Meier survival analysis, there was no statistically significant difference between the comparison groups. CONCLUSIONS Early response was lower in patients with non-MRSA compared to patients with MRSA despite achieving the AUC target. There was no apparent difference in clinical outcomes between the higher and lower AUC groups. Further large-scale research is needed to confirm these findings.
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Affiliation(s)
- Iftekharul Islam
- Department of Pharmacy, MedStar Montgomery Medical Center, Olney, MD 20832, USA
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Li F, Gao Y, Cheng W, Su X, Yang R. Gut fungal mycobiome: A significant factor of tumor occurrence and development. Cancer Lett 2023; 569:216302. [PMID: 37451425 DOI: 10.1016/j.canlet.2023.216302] [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: 05/20/2023] [Revised: 06/28/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023]
Abstract
A variety of bacteria, viruses, fungi, protists, archaea and protozoa coexists within the mammalian gastrointestinal (GI) tract such as that fungi are detectable in all intestinal and colon segments in almost all healthy adults. Although fungi can cause infectious diseases, they are also related to gut and systemic homeostasis. Importantly, through transformation of different forms such as from yeast to hyphae, interaction among gut microbiota such as fungal and bacterial interaction, host factors such as immune and host derived factors, and fungus genetic and epigenetic factors, fungi can be transformed from commensal into pathogenic lifestyles. Recent studies have shown that fungi play a significant role in the occurrence and development of tumors such as colorectal cancer. Indeed, evidences have shown that multiple species of different fungi exist in different tumors. Studies have also demonstrated that fungi are related to the occurrence and development of tumors, and also survival of patients. Here we summarize recent advances in the transformation of fungi from commensal into pathogenic lifestyles, and the effects of gut pathogenic fungi on the occurrence and development of tumors such as colorectal and pancreatic cancers.
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Affiliation(s)
- Fan Li
- Translational Medicine Institute, Affiliated Tianjin Union Medical Center of Nankai University, Nankai University, Tianjin, 300071, China; Department of Immunology, Nankai University School of Medicine, Nankai University, Tianjin, 300071, China; State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, 300071, China
| | - Yunhuan Gao
- Translational Medicine Institute, Affiliated Tianjin Union Medical Center of Nankai University, Nankai University, Tianjin, 300071, China; Department of Immunology, Nankai University School of Medicine, Nankai University, Tianjin, 300071, China; State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, 300071, China
| | - Wenyue Cheng
- Translational Medicine Institute, Affiliated Tianjin Union Medical Center of Nankai University, Nankai University, Tianjin, 300071, China; Department of Immunology, Nankai University School of Medicine, Nankai University, Tianjin, 300071, China; State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, 300071, China
| | - Xiaomin Su
- Translational Medicine Institute, Affiliated Tianjin Union Medical Center of Nankai University, Nankai University, Tianjin, 300071, China; Department of Immunology, Nankai University School of Medicine, Nankai University, Tianjin, 300071, China; State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, 300071, China
| | - Rongcun Yang
- Translational Medicine Institute, Affiliated Tianjin Union Medical Center of Nankai University, Nankai University, Tianjin, 300071, China; Department of Immunology, Nankai University School of Medicine, Nankai University, Tianjin, 300071, China; State Key Laboratory of Medicinal Chemical Biology, Nankai University, Tianjin, 300071, China.
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Chang J, Tasellari A, Wagner JL, Scheetz MH. Contemporary pharmacologic treatments of MRSA for hospitalized adults: rationale for vancomycin versus non-vancomycin therapies as first line agents. Expert Rev Anti Infect Ther 2023; 21:1309-1325. [PMID: 37876291 DOI: 10.1080/14787210.2023.2275663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/23/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA) remains an important pathogen in the hospital setting and causes significant morbidity and mortality each year. Since the initial discovery over 60 years ago, vancomycin has remained a first-line treatment for many different types of MRSA infections. However, significant concerns related to target attainment and nephrotoxicity have spurred efforts to develop more effective agents in the last two decades. AREAS COVERED Newer anti-MRSA antibiotics that have been approved since 2000 include linezolid, daptomycin, and ceftaroline. As clinical evidence has accumulated, these newer agents have become more frequently used, and some are now recommended as co-first-line options (along with vancomycin) in clinical practice guidelines. For this review, a scoping review of the literature was conducted to support our findings and recommendations. EXPERT OPINION Vancomycin remains an important standard of care for MRSA infections but is limited with respect to nephrotoxicity and rapid target attainment. Newer agents such as linezolid, daptomycin, and ceftaroline have specific indications for treating different types of MRSA infections; however, newer agents also have unique attributes which require consideration during therapy.
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Affiliation(s)
- Jack Chang
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, IL, USA
| | - Ardita Tasellari
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
| | - Jamie L Wagner
- School of Pharmacy, University of Mississippi, Jackson, MS, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, IL, USA
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8
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Perrine J, Bennett K, Siegrist E, Bradford C, Schwier NC. Potential Failure of Vancomycin Dosing Using AUC/MIC in a Patient With Purulent Methicillin-Resistant Staphylococcus aureus Pericarditis. J Pharm Technol 2023; 39:95-98. [PMID: 37051284 PMCID: PMC10084408 DOI: 10.1177/87551225221149732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Objective: The objective of this case report is to describe utilization of area under the curve (AUC)/minimum inhibitory concentration (MIC) vancomycin dosing with variable MIC results in a patient with methicillin-resistant Staphylococcus aureus (MRSA) purulent pericarditis. Case: A 57-year-old Caucasian male presented with cardiac tamponade and pulmonary emboli. Echocardiogram showed moderate-large pericardial effusion with signs of early tamponade physiology. Pericardiocentesis removed serosanguinous, straw yellow fluid. Blood and pericardial cultures revealed MRSA. Patient was then initiated on vancomycin with an initial AUC of 415. MIC of repeat blood cultures were inconsistent. After 8 days of persistent bacteremia, patient was transitioned to daptomycin and ceftaroline with blood culture clearance within 48 hours. Discussion/Conclusion: Guidelines recommend AUC/MIC vancomycin dosing in patients with MRSA bacteremia. Literature regarding treatment of MRSA purulent pericarditis is limited to case reports. Evidence shows variation in MIC results dependent on analysis methods. Further studies on obtaining accurate MIC values and use of AUC/MIC dosing for MRSA purulent pericarditis are prudent to provide appropriate therapy in these patients as mortality is high.
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Affiliation(s)
- Jordan Perrine
- Department of Pharmacy: Clinical &
Administrative Sciences, College of Pharmacy, The University of Oklahoma Health Sciences
Center, Oklahoma City, OK, USA
| | - Kiya Bennett
- Department of Pharmacy: Clinical &
Administrative Sciences, College of Pharmacy, The University of Oklahoma Health Sciences
Center, Oklahoma City, OK, USA
| | - Emily Siegrist
- Department of Pharmacy, OU Health University
of Oklahoma Medical Center, Oklahoma City, OK, USA
| | - Caitlyn Bradford
- Department of Pharmacy Practice and
Administration, Philadelphia College of Pharmacy, Saint Joseph’s University, Philadelphia,
PA, USA
| | - Nicholas C. Schwier
- School of Pharmacy and Pharmaceutical
Sciences, Binghamton University State University of New York, Johnson City, NY, USA
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Dalton BR. What Is the Best Vancomycin Therapeutic Drug Monitoring Parameter to Assess Efficacy? A Critical Review of Experimental Data and Assessment of the Need for Individual Patient Minimum Inhibitory Concentration Value. Microorganisms 2023; 11:microorganisms11030567. [PMID: 36985141 PMCID: PMC10051726 DOI: 10.3390/microorganisms11030567] [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: 01/19/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/30/2023] Open
Abstract
Therapeutic drug monitoring is recommended for the use of vancomycin, but a recent widely publicized US medical society consensus statement has changed the suggested optimal method(s) of dose adjustment. Specifically, 24 h area under the curve (AUC24)-based monitoring is has been recommended for vancomycin in preference to monitoring of trough concentrations. One reason cited for this change is the claim that AUC24 is a superior correlate to efficacy than trough (Cmin). Evidence from a number of retrospective analyses have been critically reviewed and determined to have weaknesses. This narrative review focuses on the experimental studies performed in vivo in animal models of infection and in vitro to determine the extent to which these data may provide a compelling distinction between pharmacokinetic/pharmacodynamics (PKPD) parameters that may translate to clinical use in therapeutic drug monitoring. Animal in vivo studies have been presented at conferences, but no original peer reviewed studies could be found that compare various PKPD parameters. These conference proceeding findings were supportive but unconvincing, even though they were favorably presented subsequently in review articles and clinical practice guidelines. In vitro data are somewhat conflicting, but the range of concentrations may play a role in the discrepancies found. It has been suggested that MIC may be assumed to have a value of 1 mg/L; however, it can be demonstrated that this assumption may lead to considerable discrepancy from results with an actual MIC value. The AUC24 parameter has been weighed against the percentage of time above the MIC (%T > MIC) as a comparative PKPD parameter, yet this may be an inappropriate comparison for vancomycin since all clinically useful dosing provides 100% T > MIC. Regardless, there is a distinction between clinical TDM parameters and PKPD parameters, so, in practice, the change to AUC24:MIC based on animal experiments and in vitro evidence for vancomycin may be premature.
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Affiliation(s)
- Bruce R Dalton
- Pharmacy Department, Alberta Health Services, Calgary, AB T2N 2T9, Canada
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10
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Erstad BL, Matthias KR, Nix DE. Vancomycin dosing in patients with obesity. Am J Health Syst Pharm 2022; 79:2058-2069. [PMID: 35981345 DOI: 10.1093/ajhp/zxac229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Kathryn R Matthias
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - David E Nix
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
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11
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Bian X, Qu X, Zhang J, Nang SC, Bergen PJ, Tony Zhou Q, Chan HK, Feng M, Li J. Pharmacokinetics and pharmacodynamics of peptide antibiotics. Adv Drug Deliv Rev 2022; 183:114171. [PMID: 35189264 PMCID: PMC10019944 DOI: 10.1016/j.addr.2022.114171] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 01/23/2022] [Accepted: 02/16/2022] [Indexed: 01/05/2023]
Abstract
Antimicrobial resistance is a major global health challenge. As few new efficacious antibiotics will become available in the near future, peptide antibiotics continue to be major therapeutic options for treating infections caused by multidrug-resistant pathogens. Rational use of antibiotics requires optimisation of the pharmacokinetics and pharmacodynamics for the treatment of different types of infections. Toxicodynamics must also be considered to improve the safety of antibiotic use and, where appropriate, to guide therapeutic drug monitoring. This review focuses on the pharmacokinetics/pharmacodynamics/toxicodynamics of peptide antibiotics against multidrug-resistant Gram-negative and Gram-positive pathogens. Optimising antibiotic exposure at the infection site is essential for improving their efficacy and minimising emergence of resistance.
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Affiliation(s)
- Xingchen Bian
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China
| | - Xingyi Qu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Sue C Nang
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Phillip J Bergen
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Meiqing Feng
- School of Pharmacy, Fudan University, Shanghai, China
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia.
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12
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Clinical Practice Guidelines for Therapeutic Drug Monitoring of Vancomycin in the Framework of Model-Informed Precision Dosing: A Consensus Review by the Japanese Society of Chemotherapy and the Japanese Society of Therapeutic Drug Monitoring. Pharmaceutics 2022; 14:pharmaceutics14030489. [PMID: 35335866 PMCID: PMC8955715 DOI: 10.3390/pharmaceutics14030489] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 01/08/2023] Open
Abstract
Background: To promote model-informed precision dosing (MIPD) for vancomycin (VCM), we developed statements for therapeutic drug monitoring (TDM). Methods: Ten clinical questions were selected. The committee conducted a systematic review and meta-analysis as well as clinical studies to establish recommendations for area under the concentration-time curve (AUC)-guided dosing. Results: AUC-guided dosing tended to more strongly decrease the risk of acute kidney injury (AKI) than trough-guided dosing, and a lower risk of treatment failure was demonstrated for higher AUC/minimum inhibitory concentration (MIC) ratios (cut-off of 400). Higher AUCs (cut-off of 600 μg·h/mL) significantly increased the risk of AKI. Although Bayesian estimation with two-point measurement was recommended, the trough concentration alone may be used in patients with mild infections in whom VCM was administered with q12h. To increase the concentration on days 1–2, the routine use of a loading dose is required. TDM on day 2 before steady state is reached should be considered to optimize the dose in patients with serious infections and a high risk of AKI. Conclusions: These VCM TDM guidelines provide recommendations based on MIPD to increase treatment response while preventing adverse effects.
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13
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Abdul-Aziz MH, Brady K, Cotta MO, Roberts JA. Therapeutic Drug Monitoring of Antibiotics: Defining the Therapeutic Range. Ther Drug Monit 2022; 44:19-31. [PMID: 34750338 DOI: 10.1097/ftd.0000000000000940] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE In the present narrative review, the authors aimed to discuss the relationship between the pharmacokinetic/pharmacodynamic (PK/PD) of antibiotics and clinical response (including efficacy and toxicity). In addition, this review describes how this relationship can be applied to define the therapeutic range of a particular antibiotic (or antibiotic class) for therapeutic drug monitoring (TDM). METHODS Relevant clinical studies that examined the relationship between PK/PD of antibiotics and clinical response (efficacy and response) were reviewed. The review (performed for studies published in English up to September 2021) assessed only commonly used antibiotics (or antibiotic classes), including aminoglycosides, beta-lactam antibiotics, daptomycin, fluoroquinolones, glycopeptides (teicoplanin and vancomycin), and linezolid. The best currently available evidence was used to define the therapeutic range for these antibiotics. RESULTS The therapeutic range associated with maximal clinical efficacy and minimal toxicity is available for commonly used antibiotics, and these values can be implemented when TDM for antibiotics is performed. Additional data are needed to clarify the relationship between PK/PD indices and the development of antibiotic resistance. CONCLUSIONS TDM should only be regarded as a means to achieve the main goal of providing safe and effective antibiotic therapy for all patients. The next critical step is to define exposures that can prevent the development of antibiotic resistance and include these exposures as therapeutic drug monitoring targets.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Kara Brady
- Adult Intensive Care Unit and Pharmacy, The Prince Charles Hospital, Brisbane, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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14
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AbuSara AK, Abdelrahman DH, Habash KI, Al-Shaer MH, Le J, Nazer LH. Vancomycin therapeutic monitoring by measured trough concentration versus Bayesian-derived area under the curve in critically ill patients with cancer. Pharmacol Res Perspect 2022; 10:e00912. [PMID: 34990089 PMCID: PMC8929348 DOI: 10.1002/prp2.912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/17/2021] [Indexed: 11/16/2022] Open
Abstract
The updated vancomycin guideline and recent studies suggested that trough concentrations may result in underestimation of the actual area under the curve (AUC), leading to excessive dosing and nephrotoxicity. With limited data available on critically ill cancer patients, this study aimed to compare the two methods in this patient population. This was a 5‐year retrospective study on patients treated with vancomycin in the intensive care unit (ICU) of a comprehensive cancer center. The measured trough concentration was compared to Bayesian‐derived AUC/minimum‐inhibitory‐concentration (MIC), considering MIC as 1. Trough concentrations of 15–20 mg/L and AUC of 400–600 mg h/L were considered the targeted goal. Multivariate analysis was performed to identify factors associated with an AUC below the targeted goal. During the study period, 316 patients were included. The mean age was 54 years ±16 (SD); most patients had solid tumors (75%), and 11% had neutropenia. A targeted goal AUC and trough were recorded in 128 (41%) patients and in 64 (20%) patients, respectively. Of the 128 patients with targeted goal AUC, 31 (24%) had targeted goal trough concentrations and 91 (71%) had trough concentrations below 15 mg/L. Furthermore, among the patients with targeted goal trough concentration (n = 64), 33 (52%) had higher than targeted goal AUC. Augmented renal clearance (ARC), defined as a calculated creatinine‐clearance ≥130 ml/min, was associated with an AUC below the targeted goal. In a cohort of critically ill patients with cancer, over two‐thirds of the patients with a targeted goal Bayesian AUC/MIC had trough concentrations below the targeted goal. ARC was associated with AUC below the targeted goal.
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Affiliation(s)
- Aseel K AbuSara
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | | | - Khader I Habash
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | - Mohammad H Al-Shaer
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
| | - Lama H Nazer
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
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15
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Castañeda X, García-De-la-Mària C, Gasch O, Pericàs JM, Soy D, Cañas-Pacheco MA, Falces C, García-González J, Hernández-Meneses M, Vidal B, Almela M, Quintana E, Tolosana JM, Fuster D, Llopis J, Dahl A, Moreno A, Marco F, Miró JM. Effectiveness of vancomycin plus cloxacillin compared with vancomycin, cloxacillin and daptomycin single therapies in the treatment of methicillin-resistant and methicillin-susceptible Staphylococcus aureus in a rabbit model of experimental endocarditis. J Antimicrob Chemother 2021; 76:1539-1546. [PMID: 33837406 DOI: 10.1093/jac/dkab069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/17/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To investigate if the addition of cloxacillin to vancomycin enhances the activity of both monotherapies for treating MSSA and MRSA experimental endocarditis (EE) in rabbits. METHODS Vancomycin plus cloxacillin was compared with the respective monotherapies and daptomycin. In vitro time-kill studies were performed using standard (105 cfu) and high (108 cfu) inocula of five MRSA, one glycopeptide-intermediate (GISA) and five MSSA strains. One MSSA (MSSA-678) and one MRSA (MRSA-277) strain were selected to be used in the in vivo model. A human-like pharmacokinetics model was applied and the equivalents of cloxacillin 2 g/4 h IV and daptomycin 6 mg/kg/day IV were administered. To optimize vancomycin activity, dosage was adjusted to achieve an AUC/MIC ≥400. RESULTS Daptomycin sterilized significantly more vegetations than cloxacillin (13/13, 100% versus 9/15, 60%; P = 0.02) and showed a trend of better activity than vancomycin (10/14, 71%; P = 0.09) and vancomycin plus cloxacillin (10/14, 71%; P = 0.09) against MSSA-678. Addition of cloxacillin to vancomycin (13/15, 87%) was significantly more effective than vancomycin (8/16, 50%; P = 0.05) and showed similar activity to daptomycin (13/18, 72%; P = 0.6) against MRSA-277. In all treatment arms, the bacterial isolates recovered from vegetations were re-tested and showed the same daptomycin susceptibility as the original strains. CONCLUSIONS Vancomycin plus cloxacillin proved synergistic and bactericidal activity against MRSA. Daptomycin was the most efficacious option against MSSA and similar to vancomycin plus cloxacillin against MRSA. In settings with high MRSA prevalence, vancomycin plus cloxacillin might be a good alternative for empirical therapy of S. aureus IE.
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Affiliation(s)
| | - Cristina García-De-la-Mària
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Oriol Gasch
- Infectious Diseases Service. Hospital Parc Tauli, Sabadell, Spain and Institut d'Investigació I Innovació Parc Taulí (I3PT), Sabadell, Spain
| | - Juan M Pericàs
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Dolors Soy
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Maria-Alejandra Cañas-Pacheco
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Carlos Falces
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Javier García-González
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Marta Hernández-Meneses
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Bàrbara Vidal
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Manel Almela
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Eduard Quintana
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Jose M Tolosana
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - David Fuster
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Jaume Llopis
- Microbiology, Genetics and Statistics Department, University of Barcelona, Barcelona, Spain
| | - Anders Dahl
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain.,Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Asuncion Moreno
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
| | - Francesc Marco
- ISGlobal, Hospital Clínic-University of Barcelona, Barcelona, Spain.,Microbiology Department, Centre Diagnostic Biomèdic (CDB), Hospital Clínic, Barcelona, Spain
| | - Jose M Miró
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona, Barcelona, Spain
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16
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McAleenan A, Ambrose PG, Bhavnani SM, Drusano GL, Hope WW, Mouton JW, Higgins JPT, MacGowan AP. Methodological features of clinical pharmacokinetic-pharmacodynamic studies of antibacterials and antifungals: a systematic review. J Antimicrob Chemother 2021; 75:1374-1389. [PMID: 32083674 DOI: 10.1093/jac/dkaa005] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/17/2019] [Accepted: 01/02/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Pharmacokinetic (PK)-pharmacodynamic (PD) indices relate measures of drug exposure to antibacterial effect. Clinical PK-PD studies aim to correlate PK-PD indices with outcomes in patients. Optimization of dosing based on pre-clinical studies means that PK-PD relationships are difficult to establish; therefore studies need to be designed and reported carefully to validate pre-clinical findings. OBJECTIVES To describe the methodological features of clinical antibacterial and antifungal PK-PD studies that reported the relationship between PK-PD indices and clinical or microbiological responses. METHODS Studies published between 1980 and 2015 were identified through systematic searches. Methodological features of eligible studies were extracted. RESULTS We identified 85 publications containing 97 PK-PD analyses. Most studies were small, with fewer than 100 patients. Around a quarter were performed on patients with infections due to a single specific pathogen. In approximately one-third of studies, patients received concurrent antibiotics/antifungals and in some other studies patients received other treatments that may confound the PK-PD-outcome relationship. Most studies measured antimicrobial concentrations in blood/serum and only four measured free concentrations. Most performed some form of regression, time-to-event analysis or used the Hill/Emax equation to examine the association between PK-PD index and outcome. Target values of PK-PD indices that predict outcomes were investigated in 52% of studies. Target identification was most commonly done using recursive partitioning or logistic regression. CONCLUSIONS Given the variability in conduct and reporting, we suggest that an agreed set of standards for the conduct and reporting of studies should be developed.
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Affiliation(s)
- Alexandra McAleenan
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol BS8 2PS, UK
| | - Paul G Ambrose
- Institute of Clinical Pharmacodynamics, 242 Broadway, Schenectady, New York 12305, USA
| | - Sujata M Bhavnani
- Institute of Clinical Pharmacodynamics, 242 Broadway, Schenectady, New York 12305, USA
| | - George L Drusano
- Institute for Therapeutic Innovation, Department of Medicine, University of Florida, UF Research and Academic Center at Lake Nowa, 6550 Sanger Road, Orlando, Florida 32827, USA
| | - William W Hope
- Centre for Antimicrobial Pharmacodynamics, Institute of Translational Medicine, University of Liverpool, Liverpool L69 4BX, UK
| | - Johan W Mouton
- Department of Medical Microbiology & Infectious Diseases, Erasmus Medical Centre, s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol BS8 2PS, UK
| | - Alasdair P MacGowan
- Bristol Centre for Antimicrobial Research & Evaluation, Infection Sciences, Pathology Science Quarter, North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
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17
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Ma NH, Walker SAN, Elligsen M, Kiss A, Palmay L, Ho G, Powis J, Bansal V, Leis JA. Retrospective multicentre matched cohort study comparing safety and efficacy outcomes of intermittent-infusion versus continuous-infusion vancomycin. J Antimicrob Chemother 2021; 75:1038-1046. [PMID: 31919504 DOI: 10.1093/jac/dkz531] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/11/2019] [Accepted: 11/30/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Patients with good renal function receiving intermittent-infusion vancomycin (IIV) may require total daily doses ≥4 g to achieve trough concentrations of 15-20 mg/L, increasing the risk of vancomycin-associated nephrotoxicity. Continuous-infusion vancomycin (CIV) may be associated with a lower risk of vancomycin-associated nephrotoxicity compared with IIV, but studies comparing safety of both dosing strategies are lacking. OBJECTIVES To compare the risk of nephrotoxicity with CIV versus IIV when target concentration ranges were the same with both dosing modalities. METHODS A retrospective multicentre matched cohort study of admitted patients between 1 January 2010 and 31 December 2016 was completed. Adult patients who received ≥48 h of vancomycin with at least one steady-state vancomycin concentration were eligible. The primary outcome was to compare the rates of nephrotoxic risk and renal injury, defined by the RIFLE criteria, between CIV and IIV. RESULTS Of 2136 patients who received vancomycin during the study period, 146 CIV patients were eligible and matched to 146 IIV patients. After adjustment of potential confounders, CIV was found to have a lower odds of developing nephrotoxic risk (OR 0.42, 95% CI 0.21-0.98, P = 0.025) and renal injury (OR 0.19, 95% CI 0.05-0.59, P = 0.004). CONCLUSIONS CIV is associated with a lower odds of nephrotoxicity compared with IIV when targeting the same concentration range and should be an alternative dosing strategy for patients who will receive prolonged therapy or require >4 g/day to achieve therapeutic levels.
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Affiliation(s)
- Nathan H Ma
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alex Kiss
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lesley Palmay
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Grace Ho
- Michael Garron Hospital, Toronto, Ontario, Canada
| | - Jeff Powis
- Michael Garron Hospital, Toronto, Ontario, Canada
| | - Vikas Bansal
- Holland Orthopaedic and Arthritic Centre, Toronto, Ontario, Canada
| | - Jerome A Leis
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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18
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Jorgensen SCJ, Spellberg B, Shorr AF, Wright WF. Should Therapeutic Drug Monitoring Based on the Vancomycin Area Under the Concentration-Time Curve Be Standard for Serious Methicillin-Resistant Staphylococcus aureus Infections?-No. Clin Infect Dis 2021; 72:1502-1506. [PMID: 33740050 DOI: 10.1093/cid/ciaa1743] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Indexed: 12/16/2022] Open
Abstract
In this counterpoint we critically appraise the evidence supporting therapeutic drug monitoring based on the vancomycin 24-hour area under the concentration-time curve (AUC24) for serious methicillin-resistant Staphylococcus aureus infections. We reveal methodologically weaknesses and inconsistencies in the data and suggest that, in the absence of clear and convincing evidence of benefit compared with modestly reducing trough targets, alternative strategies are more likely to result in superior safety and efficacy. These include focusing on fundamental antibiotic stewardship to limit vancomycin exposure overall, achieving earlier and more complete source control, and establishing alternative therapeutic options to vancomycin. Implementation of AUC24-based therapeutic drug monitoring will take resources away from these more promising, alternative solutions.
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Affiliation(s)
| | - Brad Spellberg
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Andrew F Shorr
- Division of Pulmonary and Critical Care, Department of Medicine, Washington Hospital Center, Washington, DC, USA
| | - William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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19
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Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Wong-Beringer A, Rotschafer JC, Rodvold KA, Maples HD, Lomaestro BM. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2021; 77:835-864. [PMID: 32191793 DOI: 10.1093/ajhp/zxaa036] [Citation(s) in RCA: 584] [Impact Index Per Article: 194.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, School of Medicine, Wayne State University, Detroit, MI, and Detroit Receiving Hospital, Detroit, MI
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, and Stratton VA Medical Center, Albany, NY
| | - Donald P Levine
- School of Medicine, Wayne State University, Detroit, MI, and Detroit Receiving Hospital, Detroit, MI
| | - John S Bradley
- Department of Pediatrics, Division of Infectious Diseases, University of California at San Diego, La Jolla, CA, and Rady Children's Hospital San Diego, San Diego, CA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, and Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | | | | | | | - Holly D Maples
- University of Arkansas for Medical Sciences College of Pharmacy & Arkansas Children's Hospital, Little Rock, AR
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20
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Point-Counterpoint: Should Clinical Microbiology Laboratories Report Vancomycin MICs? J Clin Microbiol 2021; 59:JCM.00239-21. [PMID: 33536296 DOI: 10.1128/jcm.00239-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTIONWith numerous reported challenges to reporting MICs for vancomycin, clinical laboratories are attempting to identify accurate methods for MIC testing. However, the issues of poor reproducibility, accuracy, and clinical utility remain a challenge. In this Point-Counterpoint, Dr. Sara Revolinski discusses the pros of reporting MICs for vancomycin, while Dr. Christopher Doern argues for the use of caution.
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21
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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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22
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Lodise TP, Rosenkranz SL, Finnemeyer M, Evans S, Sims M, Zervos MJ, Creech CB, Patel PC, Keefer M, Riska P, Silveira FP, Scheetz M, Wunderink RG, Rodriguez M, Schrank J, Bleasdale SC, Schultz S, Barron M, Stapleton A, Wray D, Chambers H, Fowler VG, Holland TL. The Emperor's New Clothes: PRospective Observational Evaluation of the Association Between Initial VancomycIn Exposure and Failure Rates Among ADult HospitalizEd Patients With Methicillin-resistant Staphylococcus aureus Bloodstream Infections (PROVIDE). Clin Infect Dis 2021; 70:1536-1545. [PMID: 31157370 DOI: 10.1093/cid/ciz460] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 05/31/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Vancomycin is the most commonly administered antibiotic in hospitalized patients, but optimal exposure targets remain controversial. To clarify the therapeutic exposure range, this study evaluated the association between vancomycin exposure and outcomes in patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. METHODS This was a prospective, multicenter (n = 14), observational study of 265 hospitalized adults with MRSA bacteremia treated with vancomycin. The primary outcome was treatment failure (TF), defined as 30-day mortality or persistent bacteremia ≥7 days. Secondary outcomes included acute kidney injury (AKI). The study was powered to compare TF between patients who achieved or did not achieve day 2 area under the curve to minimum inhibitory concentration (AUC/MIC) thresholds previously found to be associated with lower incidences of TF. The thresholds, analyzed separately as co-primary endpoints, were AUC/MIC by broth microdilution ≥650 and AUC/MIC by Etest ≥320. RESULTS Treatment failure and AKI occurred in 18% and 26% of patients, respectively. Achievement of the prespecified day 2 AUC/MIC thresholds was not associated with less TF. Alternative day 2 AUC/MIC thresholds associated with lower TF risks were not identified. A relationship between the day 2 AUC and AKI was observed. Patients with day 2 AUC ≤515 experienced the best global outcomes (no TF and no AKI). CONCLUSIONS Higher vancomycin exposures did not confer a lower TF risk but were associated with more AKI. The findings suggest that vancomycin dosing should be guided by the AUC and day 2 AUCs should be ≤515. As few patients had day 2 AUCs <400, further study is needed to define the lower bound of the therapeutic range.
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Affiliation(s)
| | | | | | - Scott Evans
- Department of Epidemiology and Biostatistics, Biostatistics Center, George Washington University, Washington, District of Columbia
| | | | | | - C Buddy Creech
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Paul Riska
- Montefiore Medical Center, Bronx, New York
| | | | - Marc Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, and Department of Pharmacology, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove.,Northwestern Memorial Hospital, Chicago, Illinois
| | | | | | - John Schrank
- Greenville Hospital System University Medical Center, South Carolina
| | | | - Sara Schultz
- Division of Infectious Diseases and HIV Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | | | | | - Dannah Wray
- Medical University of South Carolina, Charleston
| | | | - Vance G Fowler
- Duke Clinical Research Institute.,Duke University Medical Center, Durham, North Carolina
| | - Thomas L Holland
- Duke Clinical Research Institute.,Duke University Medical Center, Durham, North Carolina
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23
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Is Early Monitoring Better? Impact of Early Vancomycin Exposure on Treatment Outcomes and Nephrotoxicity in Patients with Methicillin-Resistant Staphylococcus aureus Infections. Antibiotics (Basel) 2020; 9:antibiotics9100672. [PMID: 33020463 PMCID: PMC7601693 DOI: 10.3390/antibiotics9100672] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 12/21/2022] Open
Abstract
Optimal early vancomycin target exposure remains controversial. To clarify the therapeutic exposure range, we investigated the association between vancomycin exposure and treatment outcomes or nephrotoxicity in patients with methicillin-resistant Staphylococcus aureus (MRSA) infection. This retrospective study reviewed clinical data obtained from 131 patients with MRSA infections between January 2017 and September 2019. Clinical outcomes included treatment failure, 30-day mortality, microbiological failure, and acute kidney injury. We measured serum vancomycin levels after the first dose to 48 h and estimated vancomycin exposure using the Bayesian theorem. The minimum inhibitory concentration (MIC) of antimicrobial agents was determined using the broth microdilution method. Classification and Regression Tree analyses identified day 1 and 2 exposure thresholds associated with an increased risk of failure and nephrotoxicity. Treatment failure (27.9% vs. 33.3%) and 30-day mortality (26.6% vs. 31.74%) were numerically but not significantly reduced in patients with the area under the curve (AUC)24-48h/MICBMD ≥ 698. Patients with AUCss/MICBMD ≥ 679 exhibited a significantly increased risk of acute kidney injury (27.9% vs. 10.9%, p = 0.041). These findings indicate that AUCss/MICBMD ratios > 600 may cause nephrotoxicity. AUC/MICBMD at days 1 and 2 do not appear to be significantly associated with particular clinical outcomes, but further studies are needed.
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24
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Esmaeili A, Salehi M, Makhdoomi N, H. Ardakani Y, Rajabi M, Namazi S. Evaluation of the Association between Trough and Area Under the Curve to Minimum Inhibitory Concentration Ratio (AUC24/MIC) of Vancomycin in Infected Patients with Methicillin Resistant Staphylococcus aureus (MRSA). PHARMACEUTICAL SCIENCES 2020. [DOI: 10.34172/ps.2020.70] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: The recent studies emphasized on the correlation of vancomycin antibacterial effect with pharmacokinetics properties such as the area under the curve/minimum inhibitory concentration (AUC24/MIC) ≥400 and serum trough level 15-20 mg /L in the patients with severe infection with methicillin-resistant Staphylococcus aureus (MRSA). The purpose is to assay the vancomycin pharmacokinetic properties in our population and evaluates the correlation between AUC24/MIC and trough serum level of vancomycin in given patients. Methods: The patients with a positive MRSA culture, treated with vancomycin, were enrolled in this cross-sectional study. Three plasma samples were obtained during the study including 30 min before fourth and the fifth dose as trough levels and 1 hour after the fourth dose as peak level to determine AUC24. E-TEST determined the MIC of vancomycin. Results: Thirty-eight patients with an average age of 48.33±16.44 were enrolled in this study. The mean ± SD of MIC was 0.99±0.30 mg/L. Thirty-four patients reached the adequate therapeutic range of AUC24/MIC ≥ 400 due to the standard vancomycin dosing method. In comparison, only 7 and 10 patients had the first and second trough levels in target intervals of 15-20 mg/L, respectively. Due to the receiver operating characteristic curve test (ROC test), the trough level after the fourth dose had a strong correlation with target AUC24/MIC with a sensitivity of 94.1%and specificity of 75.0%. Conclusion: This study concluded using only a trough level is not appropriate for therapeutic drug monitoring (TDM) of vancomycin. In our population, target AUC24/MIC (≥ 400) had a reasonably strong correlation with the trough level before the fifth dose which achieved with trough level ≥10.81 mg/L and MIC< 1 mg/L.
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Affiliation(s)
- Ayda Esmaeili
- Clinical Pharmacy Department, Faculty of Pharmacy, Urmia University of Medical Sciences, Urmia, Iran
| | - Mohammadreza Salehi
- Department of Infectious Diseases and Tropical Medicines, Imam Khomeini Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Nava Makhdoomi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Yalda H. Ardakani
- Biopharmaceutics and Pharmacokinetic Division, Department of Pharmaceutics, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Rajabi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
- Department of Clinical Pharmacy, University Hospitals of North Midlands NHS Trust, United Kingdom
| | - Soha Namazi
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences,Tehran, Iran
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25
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Burns AN, Goldman JL. A Moving Target-Vancomycin Therapeutic Monitoring. J Pediatric Infect Dis Soc 2020; 9:474-478. [PMID: 32716487 DOI: 10.1093/jpids/piaa078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/24/2020] [Indexed: 11/13/2022]
Abstract
Therapeutic drug monitoring (TDM) has been a common practice to optimize efficacy and safety of vancomycin. While vancomycin trough-only TDM has widely been integrated into pediatric clinical practice since 2009, recently updated vancomycin TDM guidelines published in March 2020 recommend area under the curve (AUC) based TDM for vancomycin instead of trough-only TDM. In this review, we discuss the rationale behind the change in TDM recommendations, describe two approaches for calculating vancomycin AUC in clinical practice, and address considerations for integrating vancomycin AUC TDM into pediatric clinical practice. Our primary goal is to provide pediatric clinicians with a resource for implementing vancomycin AUC monitoring into clinical care.
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Affiliation(s)
- Alaina N Burns
- Department of Pharmacy, Children's Mercy Hospital, Kansas City, Missouri, USA.,Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Jennifer L Goldman
- Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, USA
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26
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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: 11] [Impact Index Per Article: 2.8] [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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27
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Al‐Sulaiti FK, Nader A, El‐Mekaty E, Elewa H, Al‐Badriyeh D, El‐Zubair A, Saad MO, Awaisu A. Vancomycin therapeutic drug monitoring service quality indices and clinical effectiveness outcomes: A retrospective cohort and clinical audit. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Fatima K. Al‐Sulaiti
- Clinical Pharmacy and Practice Department College of Pharmacy, QU Health, Qatar University Doha Qatar
- Qatar National Research Fund Qatar Foundation Doha Qatar
| | - Ahmed Nader
- Clinical Pharmacology and Pharmacometrics Division Abbvie Chicago USA
| | - Eman El‐Mekaty
- Infectious Diseases Department, Communicable Disease Center Hamad Medical Corporation Doha Qatar
- Clinical Pharmacy Department Al‐Wakrah Hospital, Hamad Medical Corporation Doha Qatar
| | - Hazem Elewa
- Clinical Pharmacy and Practice Department College of Pharmacy, QU Health, Qatar University Doha Qatar
| | - Daoud Al‐Badriyeh
- Clinical Pharmacy and Practice Department College of Pharmacy, QU Health, Qatar University Doha Qatar
| | - Ahmed El‐Zubair
- Clinical Pharmacy Department Al‐Khor Hospital, Hamad Medical Corporation Doha Qatar
| | - Mohamed O. Saad
- Clinical Pharmacy Department Al‐Wakrah Hospital, Hamad Medical Corporation Doha Qatar
| | - Ahmed Awaisu
- Clinical Pharmacy and Practice Department College of Pharmacy, QU Health, Qatar University Doha Qatar
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28
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Should Therapeutic Monitoring of Vancomycin Based on Area under the Curve Become Standard Practice for Patients with Confirmed or Suspected Methicillin-Resistant Staphylococcus aureus Infection? Can J Hosp Pharm 2020; 73:232-237. [PMID: 32616951 PMCID: PMC7308155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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29
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Pais GM, Liu J, Zepcan S, Avedissian SN, Rhodes NJ, Downes KJ, Moorthy GS, Scheetz MH. Vancomycin-Induced Kidney Injury: Animal Models of Toxicodynamics, Mechanisms of Injury, Human Translation, and Potential Strategies for Prevention. Pharmacotherapy 2020; 40:438-454. [PMID: 32239518 PMCID: PMC7331087 DOI: 10.1002/phar.2388] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/21/2020] [Accepted: 03/02/2020] [Indexed: 12/13/2022]
Abstract
Vancomycin is a recommended therapy in multiple national guidelines. Despite the common use, there is a poor understanding of the mechanistic drivers and potential modifiers of vancomycin-mediated kidney injury. In this review, historic and contemporary rates of vancomycin-induced kidney injury (VIKI) are described, and toxicodynamic models and mechanisms of toxicity from preclinical studies are reviewed. Aside from known clinical covariates that worsen VIKI, preclinical models have demonstrated that various factors impact VIKI, including dose, route of administration, and thresholds for pharmacokinetic parameters. The degree of acute kidney injury (AKI) is greatest with the intravenous route and higher doses that produce larger maximal concentrations and areas under the concentration curve. Troughs (i.e., minimum concentrations) have less of an impact. Mechanistically, preclinical studies have identified that VIKI is a result of drug accumulation in proximal tubule cells, which triggers cellular oxidative stress and apoptosis. Yet, there are several gaps in the knowledge that may represent viable targets to make vancomycin therapy less toxic. Potential strategies include prolonging infusions and lowering maximal concentrations, administration of antioxidants, administering agents that decrease cellular accumulation, and reformulating vancomycin to alter the renal clearance mechanism. Based on preclinical models and mechanisms of toxicity, we propose potential strategies to lessen VIKI.
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Affiliation(s)
- Gwendolyn M. Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois
- Pharmacometrics Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Jiajun Liu
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois
- Pharmacometrics Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Sanja Zepcan
- Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois
| | - Sean N. Avedissian
- Antiviral Pharmacology Laboratory, University of Nebraska Medical Center (UNMC) Center for Drug Discovery, UNMC, Omaha, Nebraska
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska
| | - Nathaniel J. Rhodes
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois
- Pharmacometrics Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Kevin J. Downes
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ganesh S. Moorthy
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Marc H. Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois
- Pharmacometrics Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
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30
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Dalton BR, Rajakumar I, Langevin A, Ondro C, Sabuda D, Griener TP, Dersch-Mills D, Rennert-May E. Vancomycin area under the curve to minimum inhibitory concentration ratio predicting clinical outcome: a systematic review and meta-analysis with pooled sensitivity and specificity. Clin Microbiol Infect 2019; 26:436-446. [PMID: 31756451 DOI: 10.1016/j.cmi.2019.10.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Vancomycin is a first-line antibiotic for methicillin-resistant Staphylococcus aureus infections or other Gram-positive infections. The area under the curve (AUC) to minimum inhibitory concentration (MIC) ratio is proposed as a therapeutic drug-monitoring parameter. How well clinical efficacy is predicted by this measure has not been established. OBJECTIVE Determine the test performance characteristics (TPC) of AUC:MIC of vancomycin for prediction of positive outcome. DATA SOURCES PubMed and Ovid Medline (1946 to 2018) and EMBASE (1974 to 2018). Study Eligibility Criteria and Participants: Studies of patients treated with vancomycin for any type of infection in peer reviewed publications. All patient populations were included. INTERVENTIONS Vancomycin AUC:MIC or AUC was related to patient clinical outcome. METHODS Searches of medical databases using relevant terms were performed. Screening, study reviewing, data extracting and assessing data quality was performed independently by two reviewers. Studies were stratified by type of primary outcome for calculation of pooled sensitivity, specificity and construction of hierarchical summary receiver operating characteristic (HSROC) curves. RESULTS Nineteen studies including 1699 patients were meta-analysed. Pooled sensitivity and specificity were 0.77 (95% CI 0.67-0.84) and 0.62 (95% CI 0.53-0.71) respectively for the seven studies with primary outcome of mortality and 0.65 (95% CI 0.53-0.75), 0.58 (95% CI 0.48-0.67) for studies with composite or clinical cure outcome (n = 12). HSROC curves suggested considerable heterogeneity. An additional 11 studies were described but could not be included for meta-analysis because data were not available. The majority of these studies (9/11) failed to demonstrate a relationship between AUC:MIC and positive clinical outcome. CONCLUSIONS Vancomycin AUC:MIC performance was modest and inconsistent. Analysis was limited by studies without sufficient data; therefore, meta-analytic results may overestimate TPC values. Given this, as well as the lack of standardization of methods, widespread adoption of AUC:MIC as the preferred vancomycin monitoring parameter may be premature.
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Affiliation(s)
- B R Dalton
- Pharmacy Services, Alberta Health Services, Calgary, Alberta, Canada.
| | - I Rajakumar
- Pharmacy Services, Alberta Health Services, Calgary, Alberta, Canada
| | - A Langevin
- Pharmacy Services, Alberta Health Services, Calgary, Alberta, Canada
| | - C Ondro
- Pharmacy Services, Alberta Health Services, Calgary, Alberta, Canada
| | - D Sabuda
- Pharmacy Services, Alberta Health Services, Calgary, Alberta, Canada
| | - T P Griener
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada
| | - D Dersch-Mills
- Pharmacy Services, Alberta Health Services, Calgary, Alberta, Canada
| | - E Rennert-May
- Section of Infectious Diseases, Department of Medicine, University of Calgary, Calgary, Canada
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31
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Liang X, Fan Y, Yang M, Zhang J, Wu J, Yu J, Tao J, Lu G, Zhang H, Wang R, Wen X, Li H, Zhang F, Hang J, Shen L, Zhang Z, Lin Q, Fu F, Wu S, Shen B, Huang W, Chang C, Zhang H, Huang Q, Shi Y, Ren H, Yuan Q, Song X, Luo X, Zhang H. A Prospective Multicenter Clinical Observational Study on Vancomycin Efficiency and Safety With Therapeutic Drug Monitoring. Clin Infect Dis 2019; 67:S249-S255. [PMID: 30423040 DOI: 10.1093/cid/ciy680] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Vancomycin is a first-line antibiotic used for the treatment of severe gram-positive bacterial infections. Clinical guidelines recommend that the vancomycin trough concentration be 10-15 mg/L for regular infections and 15-20 mg/L for severe infections. We investigated whether increasing the vancomycin concentration would result in better clinical outcomes with sustainable adverse effects (AEs) in the Chinese population. Methods A prospective, open, multicenter clinical observational study was performed in patients with gram-positive bacterial infections from 13 teaching hospitals. Patients received vancomycin therapeutic drug monitoring. Clinical, microbiological, and laboratory data were collected. Results In total, 510 patients were enrolled, and 470 were evaluable, of whom 370 were adults and 100 were children; 35.53% had methicillin-resistant Staphylococcus aureus infections (vancomycin 50% minimum inhibitory concentration [MIC50] = 1, 90% minimum inhibitory concentration [MIC90] = 1), and 23.19% had Enterococcus species infections (vancomycin MIC50 = 1, MIC90 = 2). The average trough concentration was 10.54 ± 8.08 mg/L in adults and 6.74 ± 8.93 mg/L in children. The infection was eradicated in 86.22% of adults and 96% of children. Thirty-six vancomycin-related nephrotoxicity cases were reported in the enrolled population. No severe AEs or deaths were related to vancomycin therapy. Logistic regression analysis showed that trough concentration had no relationship with clinical outcomes (adults P = .75, children P = .68) but was correlated with adult nephrotoxicity (P < .0001). Vancomycin trough concentration had an applicable cut point at 13 mg/L. Conclusions Our study shows that vancomycin trough concentration has no statistical correlation with clinical outcomes, and is an indicator of nephrotoxicity in the observed population. We found no evidence that increasing vancomycin trough concentration to 15-20 mg/L can benefit Chinese patients with complicated infections. Clinical Trials Registration ChiCTR-OPC-16007920.
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Affiliation(s)
- Xiaoyu Liang
- Institute of Antibiotics, Huashan Hospital, Fudan University.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University.,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai
| | - Yaxing Fan
- Institute of Antibiotics, Huashan Hospital, Fudan University.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University.,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai
| | - Minjie Yang
- Institute of Antibiotics, Huashan Hospital, Fudan University
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University.,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai
| | - Jufang Wu
- Institute of Antibiotics, Huashan Hospital, Fudan University
| | - Jicheng Yu
- Institute of Antibiotics, Huashan Hospital, Fudan University
| | - Jinhao Tao
- Department of Critical Care Medicine, Children's Hospital of Fudan University, Shanghai
| | - Guoping Lu
- Department of Critical Care Medicine, Children's Hospital of Fudan University, Shanghai
| | - Huifang Zhang
- Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiaotong University
| | - Ruilan Wang
- Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiaotong University
| | - Xiaoxing Wen
- Department of Respiration, Zhongshan Hospital, Fudan University, Shanghai
| | - Huayin Li
- Department of Respiration, Zhongshan Hospital, Fudan University, Shanghai
| | - Fengying Zhang
- Department of Respiration, Putuo People's Hospital, Tongji University
| | - Jingqin Hang
- Department of Respiration, Putuo People's Hospital, Tongji University
| | - Lihua Shen
- Intensive Care Unit, Fudan University Shanghai Cancer Center
| | - Zhongwei Zhang
- Intensive Care Unit, Fudan University Shanghai Cancer Center
| | - Qionghua Lin
- Intensive Care Unit, Fudan University Shanghai Cancer Center
| | - Fengming Fu
- Intensive Care Unit, Fudan University Shanghai Cancer Center
| | - Shengbin Wu
- Department of Nephrology, Shanghai Ninth People's Hospital
| | - Bo Shen
- Department of Nephrology, Shanghai Ninth People's Hospital
| | - Weifeng Huang
- Department of Critical Care Medicine, Shanghai Sixth People's Hospital, Shanghai Jiaotong University
| | - Chunkang Chang
- Department of Hematology, Shanghai Sixth People's Hospital, Shanghai Jiaotong University
| | - Hong Zhang
- Clinical Laboratory, Children's Hospital of Shanghai Jiaotong University
| | - Qiwei Huang
- Department of Neonatology, Children's Hospital of Shanghai Jiaotong University
| | - Yifan Shi
- Department of Nephrology, Ruijin Hospital, Shanghai Jiaotong University
| | - Hong Ren
- Department of Nephrology, Ruijin Hospital, Shanghai Jiaotong University
| | - Qing Yuan
- Department of Respiration, Shanghai Tenth People's Hospital, Tongji University
| | - Xiaolian Song
- Department of Respiration, Shanghai Tenth People's Hospital, Tongji University
| | - Xuming Luo
- Department of Respiration, Putuo Hospital, Shanghai University of Traditional Chinese Medicine
| | - Hong Zhang
- Department of Pharmacy, Tongji Hospital, Tongji University, Shanghai, People's Republic of China
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Shen K, Yang M, Fan Y, Liang X, Chen Y, Wu J, Yu J, Zhang H, Wang R, Zhang F, Hang J, Wen X, Li H, Shen L, Zhang Z, Wu S, Shen B, Huang W, Chang C, Shen Y, Ren H, Yuan Q, Song X, Luo X, Zhang H, Yang W, Yang J, Zhang J. Model-based Evaluation of the Clinical and Microbiological Efficacy of Vancomycin: A Prospective Study of Chinese Adult In-house Patients. Clin Infect Dis 2019; 67:S256-S262. [PMID: 30423042 DOI: 10.1093/cid/ciy667] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Our aims in this prospective study were to evaluate the correlations between pharmacokinetic/pharmacodynamic (PK/PD) indices and the clinical/microbiological efficacy of vancomycin and to identify an appropriate PK/PD target in the Chinese population to guide vancomycin treatment in the clinic. Methods Adult patients from 11 hospitals in China with gram-positive infections who received vancomycin therapy for ≥5 days and who were under therapeutic drug monitoring (TDM) were enrolled in this study. A 1-compartment population PK model was established and validated. The correlations between PK/PD indices (Cmin, Cmax, 0-24 hour area under the curve (AUC0-24), and AUC0-24/minimum inhibitory concentration (MIC) and clinical outcomes (clinical efficacy and bacterial eradication) were evaluated. Results In total, 402 adult Chinese patients were enrolled. Among them, 380 patients were evaluable for PK analysis, and 334 were evaluable for PK/PD analysis. In the final population PK model, creatinine clearance (CLCR) was the significant covariate on CL (typical value, 3.87 L/hour; between-subject variability (BSV), 12.5%), and age was the significant covariate on volume of distribution (V) (typical value, 45.1 L; BSV, 24.8%). The univariate analysis showed that Cmax, AUC0-24, and AUC0-24/MIC were significantly different or marginally significantly different (P values were 0.009, 0.0385, and 0.0509, respectively) between microbiological outcome groups with coagulase-negative Staphylococcus infections. However, there were no significant differences (P > .05) in the above PK parameters by multivariate logistic regression analysis, indicating there was no independently associated factor. Conclusions No significant correlations were identified between PK/PD indices and the clinical or microbiological efficacy of vancomycin in Chinese patients. The necessity of vancomycin TDM based on trough concentration and the current treatment target of AUC0-24/MIC ≥400 need to be further evaluated and confirmed in additional prospective studies.
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Affiliation(s)
- Kai Shen
- Institute of Antibiotics, Huashan Hospital, Fudan University.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University.,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission of People's Republic of China
| | - Minjie Yang
- Institute of Antibiotics, Huashan Hospital, Fudan University.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University
| | - Yaxin Fan
- Institute of Antibiotics, Huashan Hospital, Fudan University.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University
| | - Xiaoyu Liang
- Institute of Antibiotics, Huashan Hospital, Fudan University.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University
| | - Yuancheng Chen
- Institute of Antibiotics, Huashan Hospital, Fudan University.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University
| | - Jufang Wu
- Institute of Antibiotics, Huashan Hospital, Fudan University.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University
| | - Jicheng Yu
- Institute of Antibiotics, Huashan Hospital, Fudan University.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University
| | - Huifang Zhang
- Department of Critical Care Medicine, Shanghai General Hospital of Fudan University
| | - Ruilan Wang
- Department of Critical Care Medicine, Shanghai General Hospital of Fudan University
| | - Fengying Zhang
- Department of Respiration, Putuo Hospital, Tongji University
| | - Jingqing Hang
- Department of Respiration, Putuo Hospital, Tongji University
| | | | - Huayin Li
- Department of Respiration, Zhongshan Hospital
| | - Lihua Shen
- Intensive Care Unit, Shanghai Tumor Hospital, Fudan University
| | - Zhongwei Zhang
- Intensive Care Unit, Shanghai Tumor Hospital, Fudan University
| | - Shengbin Wu
- Department of Respiration, Zhongshan Hospital
| | - Bo Shen
- Department of Nephrology, Shanghai Ninth People's Hospital
| | - Weifeng Huang
- Department of Critical Care Medicine, Shanghai Sixth People's Hospital
| | - Chunkang Chang
- Department of Hematology, Shanghai Sixth People's Hospital
| | - Yuqi Shen
- Department of Nephrology, Ruijin Hospital, Shanghai Jiaotong University
| | - Hong Ren
- Department of Nephrology, Ruijin Hospital, Shanghai Jiaotong University
| | - Qing Yuan
- Department of Respiration, Shanghai Tenth Hospital, Tongji University
| | - Xiaolian Song
- Department of Respiration, Shanghai Tenth Hospital, Tongji University
| | - Xuming Luo
- Department of Respiration, Putuo Hospital, Shanghai University of Traditional Chinese Medicine
| | - Hong Zhang
- Department of Pharmacy, Tongji Hospital, Tongji University
| | | | | | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University.,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission of People's Republic of China
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Clinical Pharmacokinetics and Pharmacodynamics of Telavancin Compared with the Other Glycopeptides. Clin Pharmacokinet 2019; 57:797-816. [PMID: 29332251 PMCID: PMC5999141 DOI: 10.1007/s40262-017-0623-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Telavancin was discovered by modifying the chemical structure of vancomycin and belongs to the group of lipoglycopeptides. It employs its antimicrobial potential through two distinct mechanisms of action: inhibition of bacterial cell wall synthesis and induction of bacterial membrane depolarization and permeabilization. In this article we review the clinically relevant pharmacokinetic and pharmacodynamic data of telavancin. For comparison, the pharmacokinetic and pharmacodynamic data of the other glycopeptides are presented. Although, in contrast to the newer lipoglycopeptides, telavancin demonstrates a relatively short half-life and rapid total clearance, its apparent volume of distribution (Vd) is almost identical to that of dalbavancin. The accumulation of telavancin after repeated dosing is only marginal, whereas the pharmacokinetic values of the other glycopeptides show much greater differences after administration of multiple doses. Despite its high plasma-protein binding of 90% and relatively low Vd of approximately 11 L, telavancin shows near complete equilibration of the free fraction in plasma with soft tissue. The ratio of the area under the plasma concentration-time curve from time zero to 24 h (AUC24) of unbound plasma concentrations to the minimal inhibitory concentration (MIC) required to inhibit growth of 90% of organisms (MIC90) of Staphylococcus aureus and S. epidermidis of telavancin are sufficiently high to achieve pharmacokinetic/pharmacodynamic targets indicative for optimal bacterial killing. Considering both the AUC24/MIC ratios of telavancin and the near complete equilibration of the free fraction in plasma with soft tissue, telavancin is an appropriate antimicrobial agent to treat soft tissue infections caused by Gram-positive pathogens. Although the penetration of telavancin into epithelial lining fluid (ELF) requires further investigations, the AUC24/MIC ratio for S. aureus indicates that bactericidal activity in the ELF could be expected.
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Al-Sulaiti FK, Nader AM, Saad MO, Shaukat A, Parakadavathu R, Elzubair A, Al-Badriyeh D, Elewa H, Awaisu A. Clinical and Pharmacokinetic Outcomes of Peak-Trough-Based Versus Trough-Based Vancomycin Therapeutic Drug Monitoring Approaches: A Pragmatic Randomized Controlled Trial. Eur J Drug Metab Pharmacokinet 2019; 44:639-652. [PMID: 30919233 PMCID: PMC6746691 DOI: 10.1007/s13318-019-00551-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Vancomycin therapeutic drug monitoring (TDM) is based on achieving 24-h area under the concentration-time curve to minimum inhibitory concentration cure breakpoints (AUC24/MIC). Approaches to vancomycin TDM vary, with no head-to-head randomized controlled trial (RCT) comparisons to date. OBJECTIVES We aimed to compare clinical and pharmacokinetic outcomes between peak-trough-based and trough-only-based vancomycin TDM approaches and to determine the relationship between vancomycin AUC24/MIC and cure rates. METHODS A multicentered pragmatic parallel-group RCT was conducted in Hamad Medical Corporation hospitals in Qatar. Adult non-dialysis patients initiated on vancomycin were randomized to peak-trough-based or trough-only-based vancomycin TDM. Primary endpoints included vancomycin AUC24/MIC ratio breakpoint for cure and clinical effectiveness (therapeutic cure vs therapeutic failure). Descriptive, inferential, and classification and regression tree (CART) statistical analyses were applied. NONMEM.v.7.3 was used to conduct population pharmacokinetic analyses and AUC24 calculations. RESULTS Sixty-five patients were enrolled [trough-only-based-TDM (n = 35) and peak-trough-based-TDM (n = 30)]. Peak-trough-based TDM was significantly associated with higher therapeutic cure rates compared to trough-only-based TDM [76.7% vs 48.6%; p value = 0.02]. No statistically significant differences were observed for all-cause mortality, neutropenia, or nephrotoxicity between the two groups. Compared to trough-only-based TDM, peak-trough-based TDM was associated with less vancomycin total daily doses by 12.05 mg/kg/day (p value = 0.027). CART identified creatinine clearance (CLCR), AUC24/MIC, and TDM approach as significant determinants of therapeutic outcomes. All patients [n = 19,100%] with CLCR ≤ 7.85 L/h, AUC24/MIC ≤ 1256, who received peak-trough-based TDM achieved therapeutic cure. AUC24/MIC > 565 was identified to be correlated with cure in trough-only-based TDM recipients [n = 11,84.6%]. No minimum AUC24/MIC breakpoint was detected by CART in the peak-trough-based group. CONCLUSION Maintenance of target vancomycin exposures and implementation of peak-trough-based vancomycin TDM may improve vancomycin-associated cure rates. Larger scale RCTs are warranted to confirm these findings.
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Affiliation(s)
- Fatima Khalifa Al-Sulaiti
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, P.O. Box 2713, Doha, Qatar
- Qatar National Research Fund, Qatar Foundation, Doha, Qatar
| | | | - Mohamed Omar Saad
- Clinical Pharmacy Department, Al-Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Adila Shaukat
- Infectious Diseases Department, Al-Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rakesh Parakadavathu
- Infectious Diseases Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Elzubair
- Clinical Pharmacy Department, Al-Khor Hospital, Hamad Medical Corporation, Al-Khor, Qatar
| | - Daoud Al-Badriyeh
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Hazem Elewa
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Ahmed Awaisu
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, P.O. Box 2713, Doha, Qatar.
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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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Readiness to implement vancomycin monitoring based on area under the concentration–time curve: A cross-sectional survey of a national health consortium. Am J Health Syst Pharm 2019; 76:889-894. [DOI: 10.1093/ajhp/zxz070] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Heil EL, Claeys KC, Mynatt RP, Hopkins TL, Brade K, Watt I, Rybak MJ, Pogue JM. Making the change to area under the curve–based vancomycin dosing. Am J Health Syst Pharm 2018; 75:1986-1995. [DOI: 10.2146/ajhp180034] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Emily L. Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, and Department of Pharmacy, University of Maryland Medical Center, Baltimore MD
| | - Kimberly C. Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, and Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Ryan P. Mynatt
- Department of Pharmacy, Detroit Receiving Hospital, Detroit Medical Center, Detroit, MI
| | - Teri L. Hopkins
- Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, TX
| | - Karrine Brade
- Department of Pharmacy, Boston Medical Center, Boston, MA
| | - Ian Watt
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Michael J. Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Wayne State University, Detroit, MI, and Department of Pharmacy, Detroit Receiving Hospital, Detroit Medical Center, Detroit, MI
| | - Jason M. Pogue
- Department of Pharmacy, Sinai Grace Hospital, Detroit Medical Center, Detroit, MI
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Heriot GS, Tong SYC, Cheng AC, Liew D. Benefit of Echocardiography in Patients With Staphylococcus aureus Bacteremia at Low Risk of Endocarditis. Open Forum Infect Dis 2018; 5:ofy303. [PMID: 30555848 PMCID: PMC6288770 DOI: 10.1093/ofid/ofy303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 11/22/2018] [Indexed: 12/12/2022] Open
Abstract
Background The risk of endocarditis among patients with Staphylococcus aureus bacteremia is not uniform, and a number of different scores have been developed to identify patients whose risk is less than 5%. The optimal echocardiography strategy for these patients is uncertain. Methods We used decision analysis and Monte Carlo simulation using input parameters taken from the existing literature. The model examined patients with S aureus bacteremia whose risk of endocarditis is less than 5%, generally those with nosocomial or healthcare-acquired bacteremia, no intracardiac prosthetic devices, and a brief duration of bacteremia. We examined 6 echocardiography strategies, including the use of transesophageal echocardiography, transthoracic echocardiography, both modalities, and neither. The outcome of the model was 90-day survival. Results The optimal echocardiography strategy varied with the risk of endocarditis and the procedural mortality associated with transesophageal echocardiography. No echocardiography strategy offered an absolute benefit in 90-day survival of more than 0.5% compared with the strategy of not performing echocardiography and treating with short-course therapy. Strategies using transesophageal echocardiography were never preferred if the mortality of this procedure was greater than 0.5%. Conclusions In patients identified to be at low risk of endocarditis, the choice of echocardiography strategy appears to exert a very small influence on 90-day survival. This finding may render test-treatment trials unfeasible and should prompt clinicians to focus on other, more important, management considerations in these patients.
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Affiliation(s)
- George S Heriot
- School of Public Health and Preventative Medicine, Monash University Victoria, Australia.,Victorian Infectious Diseases Service, The Royal Melbourne Hospital, and The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Victoria, Australia
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, and The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Victoria, Australia.,Menzies School of Health Research, Royal Darwin Hospital, Northern Territory, Australia
| | - Allen C Cheng
- School of Public Health and Preventative Medicine, Monash University Victoria, Australia.,Department of Infectious Diseases, Alfred Health, Victoria, Australia.,Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Victoria, Australia
| | - Danny Liew
- School of Public Health and Preventative Medicine, Monash University Victoria, Australia
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Implementation of a two-point pharmacokinetic AUC-based vancomycin therapeutic drug monitoring approach in patients with methicillin-resistant Staphylococcus aureus bacteraemia. Int J Antimicrob Agents 2018; 52:805-810. [DOI: 10.1016/j.ijantimicag.2018.08.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/07/2018] [Accepted: 08/25/2018] [Indexed: 02/05/2023]
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40
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Review and Validation of Bayesian Dose‐Optimizing Software and Equations for Calculation of the Vancomycin Area Under the Curve in Critically Ill Patients. Pharmacotherapy 2018; 38:1174-1183. [DOI: 10.1002/phar.2191] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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41
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Prospective evaluation of vancomycin pharmacokinetics in a heterogeneous critically ill population. Diagn Microbiol Infect Dis 2018; 92:346-351. [PMID: 30025969 DOI: 10.1016/j.diagmicrobio.2018.06.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 05/21/2018] [Accepted: 06/21/2018] [Indexed: 11/21/2022]
Abstract
Rich pharmacokinetic data on vancomycin in critically ill patients are lacking. The purpose of this study was to evaluate the pharmacokinetics of vancomycin in this population using rich pharmacokinetic sampling. Nineteen critically ill patients received individualized vancomycin doses by intermittent infusion to achieve target trough concentrations (15-20 mg/L). Blood samples were collected following the third or later dose of vancomycin. Serial blood samples were collected at 30 min following initiation of the vancomycin infusion; at the end of the infusion; serially at 60, 120, 300, and 480 min after the infusion finished; and immediately prior to the next dose. Vancomycin concentration-time profiles at steady state were fit to a noncompartmental model to determine the pharmacokinetic parameters. Vancomycin trough concentration was correlated to AUC0-24 (r = 0.83, P < 0.001). Total body weight was a predictor of volume of distribution (r = 0.43, P = 0.03). Age, serum creatinine, and creatinine clearance (CrCl) were found to be predictors for vancomycin clearance (r = -0.67, -0.52, and, 0.72, respectively). CrCl was the best predictor of vancomycin systemic clearance, and addition of other variables to a multivariate model failed to improve model fit. Vancomycin trough concentration may not be an adequate surrogate of AUC0-24. Additional research is needed to determine dosing strategies to optimize AUC0-24 while limiting toxicity.
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Hoo GSR, Liew YX, Kwa ALH. Optimisation of antimicrobial dosing based on pharmacokinetic and pharmacodynamic principles. Indian J Med Microbiol 2018; 35:340-346. [PMID: 29063877 DOI: 10.4103/ijmm.ijmm_17_278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
While suboptimal dosing of antimicrobials has been attributed to poorer clinical outcomes, clinical cure and mortality advantages have been demonstrated when target pharmacokinetic (PK) and pharmacodynamic (PD) indices for various classes of antimicrobials were achieved to maximise antibiotic activity. Dosing optimisation requires a good knowledge of PK/PD principles. This review serves to provide a foundation in PK/PD principles for the commonly prescribed antibiotics (β-lactams, vancomycin, fluoroquinolones and aminoglycosides), as well as dosing considerations in special populations (critically ill and obese patients). PK principles determine whether an appropriate dose of antimicrobial reaches the intended pathogen(s). It involves the fundamental processes of absorption, distribution, metabolism and elimination, and is affected by the antimicrobial's physicochemical properties. Antimicrobial pharmacodynamics define the relationship between the drug concentration and its observed effect on the pathogen. The major indicator of the effect of the antibiotics is the minimum inhibitory concentration. The quantitative relationship between a PK and microbiological parameter is known as a PK/PD index, which describes the relationship between dose administered and the rate and extent of bacterial killing. Improvements in clinical outcomes have been observed when antimicrobial agents are dosed optimally to achieve their respective PK/PD targets. With the rising rates of antimicrobial resistance and a limited drug development pipeline, PK/PD concepts can foster more rational and individualised dosing regimens, improving outcomes while simultaneously limiting the toxicity of antimicrobials.
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Affiliation(s)
| | - Yi Xin Liew
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Andrea Lay-Hoon Kwa
- Department of Pharmacy, Singapore General Hospital; Emerging Infectious Diseases, Duke-National University of Singapore; Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
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43
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Stoessel AM, Hale CM, Seabury RW, Miller CD, Steele JM. The Impact of AUC-Based Monitoring on Pharmacist-Directed Vancomycin Dose Adjustments in Complicated Methicillin-Resistant Staphylococcus aureus Infection. J Pharm Pract 2018; 32:442-446. [PMID: 29554847 DOI: 10.1177/0897190018764564] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study aimed to assess the impact of area under the curve (AUC)-based vancomycin monitoring on pharmacist-initiated dose adjustments after transitioning from a trough-only to an AUC-based monitoring method at our institution. METHODS A retrospective cohort study of patients treated with vancomycin for complicated methicillin-resistant Staphylococcus aureus (MRSA) infection between November 2013 and December 2016 was conducted. The frequency of pharmacist-initiated dose adjustments was assessed for patients monitored via trough-only and AUC-based approaches for trough ranges: 10 to 14.9 mg/L and 15 to 20 mg/L. RESULTS Fifty patients were included: 36 in the trough-based monitoring and 14 in the AUC-based-monitoring group. The vancomycin dose was increased in 71.4% of patients when troughs were 10 to 14.9 mg/L when a trough-only approach was used and in only 25% of patients when using AUC estimation (P = .048). In the AUC group, the dose was increased only when AUC/minimum inhibitory concentration (MIC) <400; unchanged regimens had an estimated AUC/MIC ≥400. The AUC-based monitoring did not significantly increase the frequency of dose reductions when trough concentrations were 15 to 20 mg/L (AUC: 33.3% vs trough: 4.6%; P = .107). CONCLUSIONS The AUC-based monitoring resulted in fewer patients with dose adjustments when trough levels were 10 to 14.9 mg/L. The AUC-based monitoring has the potential to reduce unnecessary vancomycin exposure and warrants further investigation.
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Affiliation(s)
- Andrew M Stoessel
- 1 Department of Pharmacy, Upstate University Hospital, Syracuse, New York, NY, USA
| | - Cory M Hale
- 2 Department of Pharmacy, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Robert W Seabury
- 1 Department of Pharmacy, Upstate University Hospital, Syracuse, New York, NY, USA
| | - Christopher D Miller
- 1 Department of Pharmacy, Upstate University Hospital, Syracuse, New York, NY, USA.,3 Department of Medicine, Upstate Medical University, Syracuse, New York, NY, USA
| | - Jeffrey M Steele
- 1 Department of Pharmacy, Upstate University Hospital, Syracuse, New York, NY, USA.,3 Department of Medicine, Upstate Medical University, Syracuse, New York, NY, USA
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The ratio of pre-dialysis vancomycin trough serum concentration to minimum inhibitory concentration is associated with treatment outcomes in methicillin-resistant Staphylococcus aureus bacteremia. PLoS One 2018; 13:e0193585. [PMID: 29505620 PMCID: PMC5837094 DOI: 10.1371/journal.pone.0193585] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 02/14/2018] [Indexed: 11/25/2022] Open
Abstract
Background Vancomycin is a standard treatment for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and its efficacy is closely linked to the recommended serum trough concentration of 15–20 mg/L. However, it is unknown how the pre-dialysis trough serum concentration (Cpre-HD) correlates with MRSA eradication in renal failure patients undergoing intermittent hemodialysis (HD). Objective To evaluate the relationship between Cpre-HD and the treatment outcomes in this population. Materials and methods A retrospective study was conducted to enroll renal failure patients undergoing HD who had received vancomycin treatment for MRSA bacteremia during January 2013 to June 2016. Treatment failure was defined as persistent bacteremia after ≥ 7 days of vancomycin therapy or recurrent MRSA infection within 30 days. Patient characteristics, vancomycin dosing regimen, Cpre-HD, vancomycin minimum inhibitory concentration (MIC), and subsequent culture data were reviewed. The receiver operating characteristic (ROC) curve was used to find the optimal cut-off point of Cpre-HD. Results 42 patients were enrolled and 64% had treatment failure. Although there were no significant differences in demographics or Cpre-HD between the two groups, Cpre-HD/MIC was significantly higher in the success group than that in the failure group (22.80±10.90 vs. 14.94±6.11, p = 0.019). The area under the ROC curve was 0.74, while the sensitivity, specificity, positive predictive value, and negative predictive value were 67%, 78%, 62.5%, and 81%, respectively, at the optimal Cpre-HD/MIC of ≧ 18.6. Conclusions Cpre-HD/MIC was associated with vancomycin treatment outcome in MRSA bacteremia, and targeting to achieve a Cpre-HD/MIC of ≧ 18.6 may improve treatment outcomes in renal failure patients who are on intermittent HD.
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Prospective Trial on the Use of Trough Concentration versus Area under the Curve To Determine Therapeutic Vancomycin Dosing. Antimicrob Agents Chemother 2018; 62:AAC.02042-17. [PMID: 29203493 DOI: 10.1128/aac.02042-17] [Citation(s) in RCA: 218] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 11/30/2017] [Indexed: 01/25/2023] Open
Abstract
We hypothesized that dosing vancomycin to achieve trough concentrations of >15 mg/liter overdoses many adults compared to area under the concentration-time curve (AUC)-guided dosing. We conducted a 3-year, prospective study of vancomycin dosing, plasma concentrations, and outcomes. In year 1, nonstudy clinicians targeted trough concentrations of 10 to 20 mg/liter (infection dependent) and controlled dosing. In years 2 and 3, the study team controlled vancomycin dosing with BestDose Bayesian software to achieve a daily, steady-state AUC/MIC ratio of ≥400, with a maximum AUC value of 800 mg · h/liter, regardless of trough concentration. For Bayesian estimation of AUCs, we used trough samples in years 1 and 2 and optimally timed samples in year 3. We enrolled 252 adults who were ≥18 years old with ≥1 available vancomycin concentration. Only 19% of all trough concentrations were therapeutic versus 70% of AUCs (P < 0.0001). After enrollment, median trough concentrations by year were 14.4, 9.7, and 10.9 mg/liter (P = 0.005), with 36%, 7%, and 6% over 15 mg/liter (P < 0.0001). Bayesian AUC-guided dosing in years 2 and 3 was associated with fewer additional blood samples per subject (3.6, 2.0, and 2.4; P = 0.003), shorter therapy durations (8.2, 5.4, and 4.7 days; P = 0.03), and reduced nephrotoxicity (8%, 0%, and 2%; P = 0.01). The median inpatient stay was 20 days among nephrotoxic patients versus 6 days (P = 0.002). There was no difference in efficacy by year, with 42% of patients having microbiologically proven infections. Compared to trough concentration targets, AUC-guided, Bayesian estimation-assisted vancomycin dosing was associated with decreased nephrotoxicity, reduced per-patient blood sampling, and shorter length of therapy, without compromising efficacy. These benefits have the potential for substantial cost savings. (This study has been registered at ClinicalTrials.gov under registration no. NCT01932034.).
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Zasowski EJ, Murray KP, Trinh TD, Finch NA, Pogue JM, Mynatt RP, Rybak MJ. Identification of Vancomycin Exposure-Toxicity Thresholds in Hospitalized Patients Receiving Intravenous Vancomycin. Antimicrob Agents Chemother 2018; 62:e01684-17. [PMID: 29084753 PMCID: PMC5740375 DOI: 10.1128/aac.01684-17] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 10/24/2017] [Indexed: 12/21/2022] Open
Abstract
Evidence supports vancomycin therapeutic-drug monitoring by area under the concentration-time curve (AUC), but data to establish an AUC upper limit are limited and published nephrotoxicity thresholds range widely. The objective of this analysis was to examine the association between initial vancomycin AUC and nephrotoxicity. This was a multicenter, retrospective cohort study of adult patients receiving intravenous vancomycin from 2014 to 2015. Nephrotoxicity was defined as a serum creatinine increase of 0.5 mg/liter and 50% from baseline on consecutive measurements. Vancomycin exposure profile during the initial 48 h of therapy was estimated using maximum a posteriori probability Bayesian estimation. Vancomycin AUC and minimum-concentration (Cmin) thresholds most strongly associated with nephrotoxicity were identified via classification and regression tree (CART) analysis. Predictive performances of CART-derived and other candidate AUC thresholds was assessed through positive and negative predictive value and receiver operating characteristic curves. Poisson regression was used to quantify the association between exposure thresholds and nephrotoxicity while adjusting for confounders. Among 323 patients included, nephrotoxicity was significantly higher in patients with AUCs from 0 to 48 h (AUC0-48) of ≥1,218 mg · h/liter, AUC0-24 of ≥677 mg · h/liter, AUC24-48 of ≥683 mg · h/liter, and day 1 Cmin (Cmin24) of ≥18.8 mg/liter. Vancomycin exposure in excess of these thresholds was associated with a 3- to 4-fold-increased risk of nephrotoxicity in Poisson regression. The predictive performance of AUC for nephrotoxicity was maximized at daily AUC values between 600 and 800 mg · h/liter. Although these data support an AUC range for vancomycin-associated nephrotoxity rather than a single threshold, available evidence suggests that a daily AUC limit of 700 mg · h/liter is reasonable.
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Affiliation(s)
- Evan J Zasowski
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Kyle P Murray
- Department of Pharmacy Services, Huron Valley Sinai Hospital, Commerce Charter Township, Michigan, USA
| | - Trang D Trinh
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Clinical Pharmacy, UCSF School of Pharmacy, San Francisco, California, USA
| | - Natalie A Finch
- Department of Pharmacy Services, Detroit Receiving Hospital, Detroit, Michigan, USA
| | - Jason M Pogue
- Department of Pharmacy Services, Sinai-Grace Hospital, Detroit, Michigan, USA
| | - Ryan P Mynatt
- Department of Pharmacy Services, Detroit Receiving Hospital, Detroit, Michigan, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy Services, Detroit Receiving Hospital, Detroit, Michigan, USA
- Department of Medicine, Division of Infectious Diseases, School of Medicine, Wayne State University, Detroit, Michigan, USA
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A Quasi-Experiment To Study the Impact of Vancomycin Area under the Concentration-Time Curve-Guided Dosing on Vancomycin-Associated Nephrotoxicity. Antimicrob Agents Chemother 2017; 61:AAC.01293-17. [PMID: 28923869 DOI: 10.1128/aac.01293-17] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/09/2017] [Indexed: 12/11/2022] Open
Abstract
Evidence suggests that maintenance of vancomycin trough concentrations at between 15 and 20 mg/liter, as currently recommended, is frequently unnecessary to achieve the daily area under the concentration-time curve (AUC24) target of ≥400 mg · h/liter. Many patients with trough concentrations in this range have AUC24 values in excess of the therapeutic threshold and within the exposure range associated with nephrotoxicity. On the basis of this, the Detroit Medical Center switched from trough concentration-guided dosing to AUC-guided dosing to minimize potentially unnecessary vancomycin exposure. The primary objective of this analysis was to assess the impact of this intervention on vancomycin-associated nephrotoxicity in a single-center, retrospective quasi-experiment of hospitalized adult patients receiving intravenous vancomycin from 2014 to 2015. The primary analysis compared the incidence of nephrotoxicity between patients monitored by assessment of the AUC24 and those monitored by assessment of the trough concentration. Multivariable logistic and Cox proportional hazards regression examined the independent association between the monitoring strategy and nephrotoxicity. Secondary analysis compared vancomycin exposures (total daily dose, AUC, and trough concentrations) between monitoring strategies. Overall, 1,280 patients were included in the analysis. After adjusting for severity of illness, comorbidity, duration of vancomycin therapy, and concomitant receipt of nephrotoxins, AUC-guided dosing was independently associated with lower nephrotoxicity by both logistic regression (odds ratio, 0.52; 95% confidence interval [CI], 0.34 to 0.80; P = 0.003) and Cox proportional hazards regression (hazard ratio, 0.53; 95% CI, 0.35 to 0.78; P = 0.002). AUC-guided dosing was associated with lower total daily vancomycin doses, AUC values, and trough concentrations. Vancomycin AUC-guided dosing was associated with reduced nephrotoxicity, which appeared to be a result of reduced vancomycin exposure.
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Comparative Pharmacodynamics of Telavancin and Vancomycin in the Neutropenic Murine Thigh and Lung Infection Models against Staphylococcus aureus. Antimicrob Agents Chemother 2017; 61:AAC.00281-17. [PMID: 28416551 DOI: 10.1128/aac.00281-17] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/11/2017] [Indexed: 02/06/2023] Open
Abstract
The pharmacodynamics of telavancin and vancomycin were compared using neutropenic murine thigh and lung infection models. Four Staphylococcus aureus strains were included. The telavancin MIC ranged from 0.06 to 0.25 mg/liter, and the vancomycin MIC ranged from 1 to 4 mg/liter. The plasma pharmacokinetics of escalating doses (1.25, 5, 20, and 80 mg/kg of body weight) of telavancin and vancomycin were linear over the dose range. Epithelial lining fluid (ELF) pharmacokinetics for each drug revealed that penetration into the ELF mirrored the percentage of the free fraction (the fraction not protein bound) in plasma for each drug. Telavancin (0.3125 to 80 mg/kg/6 h) and vancomycin (0.3125 to 1,280 mg/kg/6 h) were administered by the subcutaneous route in treatment studies. Dose-dependent bactericidal activity against all four strains was observed in both models. A sigmoid maximum-effect model was used to determine the area under the concentration-time curve (AUC)/MIC exposure associated with net stasis and 1-log10 kill relative to the burden at the start of therapy. The 24-h plasma free drug AUC (fAUC)/MIC values associated with stasis and 1-log kill were remarkably congruent. Net stasis for telavancin was noted at fAUC/MIC values of 83 and 40.4 in the thigh and lung, respectively, and 1-log kill was noted at fAUC/MIC values of 215 and 76.4, respectively. For vancomycin, the fAUC/MIC values for stasis were 77.9 and 45.3, respectively, and those for 1-log kill were 282 and 113, respectively. The 24-h ELF total drug AUC/MIC targets in the lung model were very similar to the 24-h plasma free drug AUC/MIC targets for each drug. Integration of human pharmacokinetic data for telavancin, the results of the MIC distribution studies, and the pharmacodynamic targets identified in this study suggests that the current dosing regimen of telavancin is optimized to obtain drug exposures sufficient to treat S. aureus infections.
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Qian X, Du G, Weng C, Zhou H, Zhou X. Evaluation of the variability and safety of serum trough concentrations of vancomycin in patients admitted to the intensive care unit. Int J Infect Dis 2017; 60:17-22. [PMID: 28457752 DOI: 10.1016/j.ijid.2017.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/06/2017] [Accepted: 04/19/2017] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To examine the variability and safety of serum trough concentrations of vancomycin in patients admitted to the intensive care unit (ICU) and to analyze the factors influencing the trough concentration. METHODS Data were collected retrospectively from ICU patients receiving vancomycin treatment at a fixed dose of 2g/day due to unobtainable weight data, at Changzhou No. 2 People's Hospital, between 2012 and 2015. Vancomycin trough concentrations were compared between groups stratified by sex, age, and estimated glomerular filtration rate (eGFR). RESULTS The vancomycin trough concentration varied significantly among ICU patients on a fixed dose of 2g/day. Only 16.9% of ICU patients met the concentration target of 15-20mg/l, while 25% of patients showed supratherapeutic concentrations. A higher proportion of female patients than male patients showed supratherapeutic concentrations (40.4% vs. 15.5%). The trough concentration was positively correlated with age (y=0.279x-2.085; R2=0.186) and negatively correlated with eGFR (y=-0.2x+33.776; R2=0.366). Vancomycin-related nephrotoxicity occurred at an incidence of 5.9%. CONCLUSIONS These results suggest that the fixed-dose regimen is not appropriate for ICU patients in view of the low incidence of target trough concentrations and the high incidence of supratherapeutic concentrations. The dose should be individualized based on weight, age, and renal function to improve outcomes and patient safety.
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Affiliation(s)
- Xiaodan Qian
- Department of Pharmacy, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, 213003, China
| | - Guantao Du
- Department of Pharmacy, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, 213003, China
| | - Chunmei Weng
- Department of Pharmacy, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, 213003, China
| | - Haijun Zhou
- Drug Clinical Trial Institution, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, 213003, China.
| | - Xianju Zhou
- Drug Clinical Trial Institution, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, 213003, China; Laboratory of Neurological Diseases, Department of Neurology, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, Jiangsu Province, 213003, China.
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Martirosov DM, Bidell MR, Pai MP, Scheetz MH, Rosenkranz SL, Lodise TP. Relationship between vancomycin exposure and outcomes among patients with MRSA bloodstream infections with vancomycin Etest® MIC values of 1.5mg/L: A pilot study. Diagn Microbiol Infect Dis 2017; 88:259-263. [PMID: 28449844 DOI: 10.1016/j.diagmicrobio.2017.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/09/2017] [Accepted: 03/11/2017] [Indexed: 10/19/2022]
Abstract
Data suggest that vancomycin is less effective for methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) with vancomycin Etest® MIC (MICEtest) ≥1.5 mg/L. No published studies have evaluated the relationship between vancomycin exposure and outcomes among patients with MRSA BSIs vancomycin MICEtest ≥1.5 mg/L. This study was a retrospective cohort of 71 hospitalized, adult, non-dialysis patients with MRSA BSIs treated with vancomycin. All but three patients had a vancomycin MICEtest of 1.5 mg/L. Achievement of CART-derived AUC24-48h of at least 550 mg*h/L (AUC24-48h/MIC of 366 mg*h/L) was associated with a lower incidence of treatment failure. In multivariate analyses, the risk ratio was 0.45 for the CART-derived AUC24-48h threshold, indicating that achievement of the CART-derived AUC24-48h threshold of 550 was associated with a 2-fold decrease in treatment failure. These findings suggest a potential association between vancomycin exposure and outcomes in patients with MRSA BSIs with MICEtest ≥1.5 mg/L. As this study was retrospective, these findings provide the basis for a future large-scale, multi-center prospective study.
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Affiliation(s)
- D M Martirosov
- Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY 12008, USA
| | - M R Bidell
- Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY 12008, USA
| | - M P Pai
- Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY 12008, USA
| | - M H Scheetz
- Midwestern University Chicago College of Pharmacy, 555 31st Street, Downers Grove, IL 60515, USA
| | - S L Rosenkranz
- Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - T P Lodise
- Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY 12008, USA.
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