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Tang NY, Walewski K, Carey-Ballough R, Sykes E, Sun Q. A suspected case of falsely low digoxin and vancomycin concentrations caused by free kappa light chains with PETINIA method. Pract Lab Med 2022; 30:e00277. [PMID: 35541501 PMCID: PMC9079242 DOI: 10.1016/j.plabm.2022.e00277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 10/24/2022] Open
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Falsely Undetectable Vancomycin Levels in a Pediatric Patient With Chronic Granulomatous Disease. Pediatr Infect Dis J 2022; 41:302-303. [PMID: 34803136 DOI: 10.1097/inf.0000000000003412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A child with chronic granulomatous disease on vancomycin treatment had V trough levels that became undetectable, as measured in our hospital's clinical laboratory by a commonly employed particle-enhanced turbidometric inhibition assay. An alternative laboratory method yielded appropriate results. Recognizing and resolving erroneously low V trough levels could prevent needless adjustments in dosing that could increase risk for acute kidney injury.
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Shipkova M, Jamoussi H. Therapeutic Drug Monitoring of Antibiotic Drugs: The Role of the Clinical Laboratory. Ther Drug Monit 2022; 44:32-49. [PMID: 34726200 DOI: 10.1097/ftd.0000000000000934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/08/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of anti-infective drugs is an increasingly complex field, given that in addition to the patient and drug as 2 usual determinants, its success is driven by the pathogen. Pharmacodynamics is related both to the patient (toxicity) and bacterium (efficacy or antibiotic susceptibility). The specifics of TDM of antimicrobial drugs stress the need for multidisciplinary knowledge and expertise, as in any other field. The role and the responsibility of the laboratory in this interplay are both central and multifaceted. This narrative review highlights the role of the clinical laboratory in the TDM process. METHODS A literature search was conducted in PubMed and Google Scholar, focusing on the past 5 years (studies published since 2016) to limit redundancy with previously published review articles. Furthermore, the references cited in identified publications of interest were screened for additional relevant studies and articles. RESULTS The authors addressed microbiological methods to determine antibiotic susceptibility, immunochemical and chromatographic methods to measure drug concentrations (primarily in blood samples), and endogenous clinical laboratory biomarkers to monitor treatment efficacy and toxicity. The advantages and disadvantages of these methods are critically discussed, along with existing gaps and future perspectives on strategies to provide clinicians with as reliable and useful results as possible. CONCLUSIONS Although interest in the field has been the driver for certain progress in analytical technology and quality in recent years, laboratory professionals and commercial providers persistently encounter numerous unresolved challenges. The main tasks that need tackling include broadly and continuously available, easily operated, and cost-effective tests that offer short turnaround times, combined with reliable and easy-to-interpret results. Various fields of research are currently addressing these features.
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Affiliation(s)
- Maria Shipkova
- Competence Center for Therapeutic Drug Monitoring, SYNLAB Holding Germany GmbH, SYNLAB MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
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Smelter DF, Trisler MJ, McCreary EK, Baker M, Copeland K, Dilworth TJ, Rose WE. Long-Acting Lipoglycopeptides Can Interfere With Vancomycin Therapeutic Drug Monitoring. J Clin Pharmacol 2021; 62:472-478. [PMID: 34564865 DOI: 10.1002/jcph.1975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/22/2021] [Indexed: 11/07/2022]
Abstract
Oritavancin and dalbavancin are long-acting lipoglycopeptides with activity against susceptible gram-positive bacteria, including methicillin-resistant Staphylococcus aureus. Though similar in structure to traditional glycopeptide antibiotics like vancomycin, these antibiotics have terminal half-lives >10 days, and, as a result, there is potential for administration of vancomycin to a patient while oritavancin or dalbavancin are still appreciably present in serum. Given the structural similarities, this creates an opportunity for lab assay interference when performing therapeutic drug monitoring for vancomycin. Following higher-than-expected serum vancomycin concentrations in a patient who received both oritavancin and vancomycin within a short time frame, we evaluated the potential for lipoglycopeptide interference with clinical vancomycin assays. Five platforms covering 3 immunoassay technologies were used to quantify vancomycin concentrations in serum spiked with oritavancin or dalbavancin. Oritavancin generated spurious vancomycin concentrations (20%-84% increase) in both enzyme-multiplied immunoassay technique and a particle-enhanced turbidimetric inhibition immunoassay. However, the improper detection of oritavancin was not consistent across all particle-enhanced turbidimetric inhibition immunoassay platforms. Dalbavancin interference was not detected on any of the platforms tested. The interference from oritavancin may result in falsely elevated vancomycin concentrations and, subsequently, inappropriately adjusted vancomycin doses.
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Affiliation(s)
- Dan F Smelter
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Michael J Trisler
- Department of Pharmacy, University of Pittsburgh Medical Center Shadyside, Pittsburgh, Pennsylvania, USA
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Matthew Baker
- Department of Pathology, University of Pittsburgh Medical Center Shadyside, Pittsburgh, Pennsylvania, USA
| | - Kenneth Copeland
- ACL Laboratories, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - Thomas J Dilworth
- Department of Pharmacy Services, Advocate Aurora Health, St. Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Warren E Rose
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Tsoi V, Bhayana V, Bombassaro AM, Tirona RG, Kittanakom S. Falsely Elevated Vancomycin Concentrations in a Patient Not Receiving Vancomycin. Pharmacotherapy 2019; 39:778-782. [DOI: 10.1002/phar.2279] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Vivian Tsoi
- St. Michael's Hospital Toronto Ontario Canada
| | - Vipin Bhayana
- London Health Sciences Centre London Ontario Canada
- Western University London Ontario Canada
| | - Anne Marie Bombassaro
- London Health Sciences Centre London Ontario Canada
- Western University London Ontario Canada
| | - Rommel G. Tirona
- London Health Sciences Centre London Ontario Canada
- Western University London Ontario Canada
| | - Saranya Kittanakom
- William Osler Health System Brampton Ontario Canada
- University of Toronto Toronto Ontario Canada
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Lima TDM, Seba KS, Gonçalves JCS, Cardoso FLL, Estrela RDCE. A Rapid and Simple HPLC Method for Therapeutic Monitoring of Vancomycin. J Chromatogr Sci 2018; 56:115-121. [PMID: 29069326 DOI: 10.1093/chromsci/bmx089] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Indexed: 01/05/2023]
Abstract
Therapeutic monitoring of the antibiotic vancomycin is important to achieve specific plasma concentration and prevent toxic effects. Several assays have been described for vancomycin determination in clinical practice, but high-performance liquid chromatography is still considered the gold standard for the quantification of vancomycin. In this study, we developed a new and rapid high-performance liquid chromatography method requiring 50 μL of plasma for the quantification of vancomycin. Acetonitrile was used for processing plasma by protein precipitation (1:2.5). Isocratic chromatographic analysis was carried out on a C18 silica-based (2.7 μm) column with the mobile phase containing 20 mM ammonium acetate/formic acid buffer (pH 4.0):methanol 88:12 (v/v). A diode array detector was used for UV detection at 240 nm. This method was validated according to the Brazilian Health Surveillance Agency legislation and International Conference on Harmonization guidelines. The measurement range was 1-100 μg/mL, analysis time was 8 min, and intermediate precision was <12%, supporting the present method as a fast, simple, and effective alternative for therapeutic monitoring of vancomycin.
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Affiliation(s)
- Tácio de Mendonça Lima
- Faculty of Pharmaceutical Sciences, University of São Paulo, Av. Professor Lineu Prestes, 580 - Cidade Universitária São Paulo- SP, CEP 05508-000, Brazil
| | - Karine Souza Seba
- National School of Public Health, Oswaldo Cruz Foundation, R. Leopoldo Bulhões, 1480 - Bonsucesso, Rio de Janeiro - RJ, CEP 21041-210, Brazil
| | - José Carlos Saraiva Gonçalves
- Faculty of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373 - Cidade Universitária, Rio de Janeiro - RJ, CEP 21941-170, Brazil
| | - Fernando Luiz Lopes Cardoso
- Hospital Infection Control Team, University Hospital Clementino Fraga Filho, R. Prof. Rodolpho Paulo Rocco, 255 - Cidade Universitária, Rio de Janeiro - RJ, CEP 21941-913, Brazil
| | - Rita de Cássia Elias Estrela
- Faculty of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373 - Cidade Universitária, Rio de Janeiro - RJ, CEP 21941-170, Brazil.,Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Av. Brasil, 4365 - Manguinhos, Rio de Janeiro - RJ, CEP 21040-360, Brazil, Brazil
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Westergreen-Thorne M, Lee SY, Shah N, Dodd A. When not to trust therapeutic drug monitoring. Oxf Med Case Reports 2016; 2016:omw064. [PMID: 27606069 PMCID: PMC5012585 DOI: 10.1093/omcr/omw064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 06/16/2016] [Accepted: 06/21/2016] [Indexed: 11/17/2022] Open
Abstract
Therapeutic drug monitoring (TDM) is the measurement of serum or plasma drug concentration to allow the individualization of dosing. We describe the case of a patient who was prescribed inappropriately large doses of vancomycin due to inaccurate TDM. Specifically, our laboratory reported progressively lower vancomycin concentrations despite dose increases. Eventually, when duplicate samples were sent to a different laboratory vancomycin concentrations were found to be in the toxic range. We hypothesize this was due to the patient generating immunoglobulin antibodies against her infection that interfered with the original TDM immunoassay. Immunogenic TDM interference has been known to rarely occur in patients with immune related comorbidities; however, if we are correct, this is a unique case as this patient did not have such a background. This case illustrates the importance of using clinical judgement when interpreting TDM as, in this case, substantial harm to the patient was likely only narrowly avoided.
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Affiliation(s)
| | - Sook Yan Lee
- Renal Unit, Renal Admin Block, Kent & Canterbury Hospital, Canterbury , Kent XT3 1RX , UK
| | - Nilesh Shah
- Renal Unit, Renal Admin Block, Kent & Canterbury Hospital, Canterbury , Kent XT3 1RX , UK
| | - Alan Dodd
- Laboratory Medicine, William Harvey Hospital, Ashford , Kent TN24 0LZ , UK
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Usman M, Hempel G. Development and validation of an HPLC method for the determination of vancomycin in human plasma and its comparison with an immunoassay (PETINIA). SPRINGERPLUS 2016; 5:124. [PMID: 26933623 PMCID: PMC4759449 DOI: 10.1186/s40064-016-1778-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 02/12/2016] [Indexed: 11/10/2022]
Abstract
Vancomycin (VAN) is among those antibiotics for which therapeutic drug monitoring is highly recommended. For this purpose a reliable method with small sample volume was required for quantification of VAN in human plasma. Therefore, a selective and sensitive method of high performance liquid chromatography was developed and validated. The separation was carried out isocratically by using a mobile phase NH4H2PO4 (50 mM, pH 2.2)–acetonitrile (88:12, v/v) at a flow rate of 0.36 mL/min on a nucleodur C18 column (125 mm × 4.6 mm, 5 µm) with UV detection at 205 nm. Sample preparation was done by deproteination of plasma with 70 % perchloric acid and a liquid/liquid extraction. Validation was performed according to the European Medicines Agency guideline. The method showed linearity over the range of 0.25–60 mg/L with a coefficient of determination r2 ≥ 0.999 and a lower limit of quantification of 0.25 mg/L. No interference was observed in blank plasma samples at the retention time of VAN. The percentage relative recovery and coefficient of variation (CV%) values for accuracy and precision were within the acceptable limits. Stability was proved at room temperature for 24 h, after repeated freeze and thaw cycles and storage at −20 °C for 3 months. A good correlation was observed (r = 0.947) by comparing with the results of an immunoassay (PETINIA, Siemens) in 289 samples. In conclusion the method proved simple, sensitive and cost effective for quantification of VAN in human plasma.
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Affiliation(s)
- Muhammad Usman
- Department of Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, University of Muenster, Corrensstrasse 48, 48149 Muenster, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, University of Muenster, Corrensstrasse 48, 48149 Muenster, Germany
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Dimeski G, Bassett K, Brown N. Paraprotein interference with turbidimetric gentamicin assay. Biochem Med (Zagreb) 2015; 25:117-24. [PMID: 25672475 PMCID: PMC4401306 DOI: 10.11613/bm.2015.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 01/15/2015] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION Gentamicin due to its low level of resistance and rapid bactericidal activity is commonly used to treat gram-negative bacteria. However, due to its toxic effects it needs to be monitored. To date, no interference has been reported with gentamicin assays. MATERIALS AND METHODS A patient with leg cellulitis and sepsis received a single dose of gentamicin and a sample was sent for gentamicin analysis. The sample showed high blank absorbance readings on Beckman DxC800 and DC800 analysers with various dilutions. A second sample was received and analysed on a Roche Cobas system to obtain a result. A third sample was received 107 hours later with the same results and this sample was then analysed neat and post ethanol precipitation on all the turbidimetric assays available on the DxC800 analyser. RESULTS The high blank absorbance was observed upon addition of the reactive reagents due to protein precipitation. Although not obvious from the patient protein results, it was shown the presence of high IgM paraprotein, 18.9 g/L (reference range 0.4-2.3 g/L) was the cause of precipitation, giving high blank readings. Of all the other turbidimetric assays, only vancomicin and valproate showed similar high blank absorbance readings. To be able to provide more rapid results it was shown ethanol could be used as a precipitant of proteins in both calibrators and patient samples with acceptable recovery. CONCLUSION IgM paraprotein was identified as the cause of interference with the gentamicin, vancomicin and valproate assays. Protein interference in these assays can be overcome by precipitation with ethanol.
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Affiliation(s)
- Goce Dimeski
- Department of Chemical Pathology, Pathology Queensland, Princess Alexandra Hospital, Brisbane, Australia
| | - Kendra Bassett
- Department of Chemical Pathology, Pathology Queensland, Princess Alexandra Hospital, Brisbane, Australia
| | - Nigel Brown
- Department of Chemical Pathology, Pathology Queensland, Princess Alexandra Hospital, Brisbane, Australia
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Possible False-Negative Results on Therapeutic Drug Monitoring of Phenytoin Using a Particle Enhanced Turbidimetric Inhibition Immunoassay in a Patient With a High Level of IgM. Ther Drug Monit 2014; 36:553-5. [DOI: 10.1097/ftd.0000000000000067] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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