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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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Muriel CM, García-Goez JF, Ortega D, Martínez D, Rosselli D. Risk factors for therapeutic failure in adults with methicillin-resistant Staphylococcus aureus (MRSA) infection treated with vancomycin in a high-complexity hospital in Cali, Colombia. LE INFEZIONI IN MEDICINA 2024; 32:45-51. [PMID: 38456024 PMCID: PMC10917555 DOI: 10.53854/liim-3201-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/24/2024] [Indexed: 03/09/2024]
Abstract
Objective To determine the risk factors associated with therapeutic failure of vancomycin in hospitalized adult patients with methicillin-resistant Staphylococcus aureus (MRSA) infections. Design Case-control study. Setting Conducted in a high complexity hospital in Cali, Colombia. Participants Adult hospitalized from January 1, 2015, to December 31, 2021, with MRSA infections with confirmed microbiological isolation. Methods Cases were patients with therapeutic failure of vancomycin (mortality, poor clinical improvement, change of antibiotic used, early relapse, or persistence of positive blood cultures) and control patients were those who did not present failure. Significant variables from the bivariate analysis were included in a multiple analysis with an asymmetric logistic regression model. Results A total of 105 patients were included in the study, 28 in the treatment group and 77 in the control group. The median age was 49 years and 59 (56%) of participants were men. The following variables: age (OR 1.034; 95% CI 1.007-1.061, p=0.011), osteomyelitis/ septic arthritis (OR 6.035; 95% CI 2.282-15.956, p=0.000) and minimum inhibitory concentration (MIC) (OR 5.971; 95% CI 1.321-26.979, p=0.020) were found to be independent risk factors associated with therapeutic failure of vancomycin. Vancomycin trough levels were not different between cases and controls (OR 0.976; 95% CI 0.911-1.044, p=0.478). Conclusions When a multiple analysis was performed to control for confounding factors, only 3 variables were found to be significant and were considered risk factors for therapeutic failure of vancomycin in adult patients with MRSA infection: age, MIC, and osteomyelitis/ septic arthritis.
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Affiliation(s)
| | | | - Delia Ortega
- Pontificia Universidad Javeriana, Cali, Colombia
| | - Diana Martínez
- Institute of Statistics, Universidad del Valparaiso, Chile
| | - Diego Rosselli
- Pontificia Universidad Javeriana, Cali, Colombia
- Clinical Epidemiology and Biostatistics Department, Pontificia Universidad Javeriana, Bogotá, Colombia
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Area-Under-Curve-Guided Versus Trough-Guided Monitoring of Vancomycin and Its Impact on Nephrotoxicity: A Systematic Review and Meta-Analysis. Ther Drug Monit 2023:00007691-990000000-00088. [PMID: 36728329 DOI: 10.1097/ftd.0000000000001075] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/07/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Conventionally, vancomycin trough levels have been used for therapeutic drug monitoring (TDM). Owing to the increasing evidence of trough levels being poor surrogates of area under the curve (AUC) and the advent of advanced pharmacokinetics software, a paradigm shift has been made toward AUC-guided dosing. This study aims to evaluate the impact of AUC-guided versus trough-guided TDM on vancomycin-associated nephrotoxicity. METHODS A systematic review was conducted using PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Google scholar, and Cochrane library databases; articles published from January 01, 2009, to January 01, 2021, were retrieved and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Studies that evaluated trough-guided or AUC-guided vancomycin TDM and vancomycin-associated nephrotoxicity were included. Random-effects models were used to compare the differences in nephrotoxicity. RESULTS Of the 1191 retrieved studies, 57 were included. Most studies included adults and older adults (n = 47, 82.45%). The pooled prevalence of nephrotoxicity was lower in AUC-guided TDM [6.2%; 95% confidence interval (CI): 2.9%-9.5%] than in trough-guided TDM (17.0%; 95% CI: 14.7%-19.2%). Compared with the trough-guided approach, the AUC-guided approach had a lower risk of nephrotoxicity (odds ratio: 0.53; 95% CI: 0.32-0.89). The risk of nephrotoxicity was unaffected by the AUC derivation method. AUC thresholds correlated with nephrotoxicity only within the first 96 hours of therapy. CONCLUSIONS The AUC-guided approach had a lower risk of nephrotoxicity, supporting the updated American Society of Health-System Pharmacists guidelines. Further studies are needed to evaluate the optimal AUC-derivation methods and clinical utility of repeated measurements of the AUC and trough levels of vancomycin.
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Stewart JJ, Jorgensen SCJ, Dresser L, Lau TTY, Gin A, Thirion DJG, Nishi C, Dalton B. A Canadian perspective on the revised 2020 ASHP-IDSA-PIDS-SIDP guidelines for vancomycin AUC-based therapeutic drug monitoring for serious MRSA infections. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:3-9. [PMID: 36340210 PMCID: PMC9612435 DOI: 10.3138/jammi-2020-0028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/06/2020] [Indexed: 04/13/2023]
Abstract
BACKGROUND A revised consensus guideline on therapeutic drug monitoring (TDM) of vancomycin for serious methicillin-resistant Staphylococcus aureus (MRSA) infections was recently published with endorsement of numerous American pharmacy and medical societies. Changing practice from trough TDM to area-under-the-curve-(AUC)-guided dosing was suggested. METHODS Recent literature was critically appraised to determine whether AUC TDM is appropriate for Canadian hospital practice. RESULTS Previous 2009 vancomycin consensus guidelines recommended trough levels of 15-20 mg/L for serious MRSA infections, based on relatively poor evidence for efficacy or safety. In the past decade, aggressive trough targets have led to unnecessary toxicity. Adoption of a TDM strategy using an alternative parameter (AUC) has been suggested, although the evidence for any outcome benefits is low quality. In addition, implementation would require greater resources at health care institutions in the forms of more frequent serum levels or acquisition of costly Bayesian software programs. Most studies on this subject have been observational and retrospective; therefore, relationships between TDM parameters and outcomes have not been convincingly and consistently demonstrated to be causal in nature. Despite claims to the contrary, based on few in silico experiments, available clinical data suggest correlation of trough levels and AUC is high. TDM with lower target trough levels is a simpler solution to reduce risk of toxicity. CONCLUSIONS There are serious concerns with adoption of AUC TDM of vancomycin into routine practice in Canada. Trough-based monitoring with modest reduction in target levels remains the most evidence-informed practice at this time.
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Affiliation(s)
- Jackson J Stewart
- Pharmacy Department, Alberta Health Services, Edmonton, Alberta, Canada
| | | | - Linda Dresser
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacy, Sinai Health System, Toronto, Ontario, Canada
| | - Tim TY Lau
- Pharmaceutical Sciences, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alfred Gin
- Winnipeg Regional Health Authority Regional Pharmacy Program, Winnipeg, Manitoba, Canada
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Daniel JG Thirion
- Pharmacy Department, McGill University Health Centre, Montreal, Quebec, Canada
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
| | - Cesilia Nishi
- Pharmaceutical Sciences, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Division of Infectious Diseases, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Bruce Dalton
- Pharmacy Department, Alberta Health Services, Edmonton, Alberta, Canada
- Correspondence: Dr Bruce Dalton, Alberta Health Services—Pharmacy Services, 1403 29th St NW, Calgary, Alberta T2N3Z5 Canada. Telephone: 403-919-2416. E-mail:
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Bellos I, Daskalakis G, Pergialiotis V. Relationship of vancomycin trough levels with acute kidney injury risk: an exposure–toxicity meta-analysis. J Antimicrob Chemother 2020; 75:2725-2734. [DOI: 10.1093/jac/dkaa184] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/05/2020] [Accepted: 04/13/2020] [Indexed: 02/06/2023] Open
Abstract
AbstractObjectivesNephrotoxicity represents a major complication of vancomycin administration, leading to high rates of morbidity and treatment failure. The aim of this meta-analysis was to evaluate the association between trough levels and risk of renal impairment, by defining an exposure–toxicity relationship and assessing its accuracy in predicting the development of acute kidney injury (AKI).MethodsMedline, Scopus, CENTRAL, Clinicaltrials.gov and Google Scholar databases were systematically searched from inception. Studies examining the effects of trough levels on nephrotoxicity risk in adult patients were deemed eligible.ResultsThe meta-analysis was based on 60 studies, including 13 304 patients. The development of AKI was significantly linked to both higher initial [standardized mean difference (SMD): 0.82; 95% CI: 0.65–0.98] and maximum (SMD: 1.06; 95% CI: 0.82–1.29) trough levels. Dose–response analysis indicated a curvilinear relationship between trough levels and nephrotoxicity risk (χ2 = 127.1; P value < 0.0001). A cut-off of 15 mg/L detected AKI with a sensitivity of 62.6% (95% CI: 55.6–69.2) and a specificity of 65.5% (95% CI: 58.9–71.6), while applying a 20 mg/L threshold resulted in a sensitivity of 42.9% (95% CI: 34–52.2) and a specificity of 82.5% (95% CI: 73.9–88.8).ConclusionsThe present findings suggest that the development of vancomycin-induced AKI is significantly associated with higher initial and maximum trough levels. An exposure–response relationship was defined, indicating that increasing trough levels correlate with a significant rise of nephrotoxicity risk. Future studies should verify the effectiveness of individualized pharmacokinetic tools that would enable the attainment of trough level targets and minimize the risk of renal toxicity.
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Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Daskalakis
- First Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
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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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Miyazaki T, Yanagihara K, Kakeya H, Izumikawa K, Mukae H, Shindo Y, Yamamoto Y, Tateda K, Tomono K, Ishida T, Hasegawa Y, Niki Y, Watanabe A, Soma K, Kohno S. Daily practice and prognostic factors for pneumonia caused by methicillin-resistant Staphylococcus aureus in Japan: A multicenter prospective observational cohort study. J Infect Chemother 2019; 26:242-251. [PMID: 31575499 DOI: 10.1016/j.jiac.2019.08.018] [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] [Received: 06/18/2019] [Revised: 08/07/2019] [Accepted: 08/29/2019] [Indexed: 11/29/2022]
Abstract
Pneumonia caused by methicillin-resistant Staphylococcus aureus (MRSA) is associated with poor clinical outcomes. We surveyed clinical outcomes of MRSA pneumonia in daily practice to identify risk factors for the clinical failure and mortality in patients with MRSA pneumonia. This multicenter prospective observational study was performed across 48 Japanese medical institutions. Adult patients with culture-positive MRSA pneumonia were recruited and treated with anti-MRSA antibiotics. The relationships between clinical and microbiological characteristics and clinical outcomes at test of cure (TOC) or 30-day all-cause mortality were analyzed. In total, 199 eligible patients, including nursing and healthcare-associated pneumonia (n = 95), hospital-acquired pneumonia (n = 76), and community-acquired pneumonia (n = 25), received initial treatment with anti-MRSA agents such as vancomycin (n = 135), linezolid (n = 36), or teicoplanin (n = 22). Overall clinical failure rate at TOC and the 30-day mortality rate were 51.1% (48/94 patients) and 33.7% (66/196 patients), respectively. Multivariable logistic regression analyses for vancomycin-treated populations revealed that abnormal white blood cell count (odds ratio [OR] 4.34, 95% confidence interval [CI] 1.31-14.39) was a risk factor for clinical failure and that no therapeutic drug monitoring (OR 3.10, 95% CI 1.35-7.12) and abnormally high C-reactive protein level (OR 3.54, 95% CI 1.26-9.92) were risk factors for mortality. In conclusion, this study provides evidence that majority of MRSA pneumonia patients are initially treated with vancomycin in Japan, and the absence of therapeutic drug monitoring for vancomycin is significantly associated with the mortality in patients with MRSA pneumonia.
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Affiliation(s)
- Taiga Miyazaki
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan; Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroshi Kakeya
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoshihiro Yamamoto
- Department of Clinical Infectious Diseases, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Toyama, Japan
| | - Kazuhiro Tateda
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo, Japan
| | - Kazunori Tomono
- Division of Infection Control and Prevention, Osaka University Hospital, Osaka, Japan
| | - Tadashi Ishida
- Department of Respiratory Medicine, Kurashiki Central Hospital, Okayama, Japan
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoshihito Niki
- Division of Clinical Infectious Diseases, Department of Medicine, School of Medicine, Showa University, Tokyo, Japan
| | - Akira Watanabe
- Research Division for Development of Anti-Infective Agents, Institute of Development, Aging and Cancer, Tohoku University, Miyagi, Japan
| | - Kazui Soma
- Emergency Medical Center, Kitasato University Hospital, Kanagawa, Japan
| | - Shigeru Kohno
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
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