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Kenneally AM, Leonhardt KR, Schadler A, Garlitz KL. Evaluation of an Empiric Vancomycin Dosing Protocol on Goal Troughs and Acute Kidney Injury in a Neonatal Intensive Care Unit. J Pediatr Pharmacol Ther 2023; 28:335-342. [PMID: 37795281 PMCID: PMC10547050 DOI: 10.5863/1551-6776-28.4.335] [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: 03/21/2022] [Indexed: 10/06/2023]
Abstract
OBJECTIVE Review the efficacy and safety of an updated empiric vancomycin dosing protocol in a neonatal intensive care unit (NICU). METHODS Retrospective chart review including neonates with postmenstrual age (PMA) less than 40 weeks without renal dysfunction who received vancomycin per protocol at a single institution's NICU before and after implementation of an updated dosing protocol. The primary outcome is the proportion of initial therapeutic troughs. Secondary outcomes include average trough, achievement of a therapeutic trough, number of days before attainment of a therapeutic trough, and proportion of acute kidney injury (AKI) during therapy. RESULTS The 2 groups were similar in gestational age, race, birth weight, PMA, and weight at time of vancomycin initiation. The post-implementation group had a higher proportion of initial therapeutic troughs (33.0% vs 55.1%) and a lower proportion of a subtherapeutic (58.7% vs 43.8%) and supratherapeutic (8.3% vs 1.1%) initial troughs (p = 0.002). The median trough was not different (9.20 vs 10.50 mg/L; p = 0.092). There was no difference in the proportions of achieving a therapeutic trough throughout therapy (69% vs 76%; p = 0.235); however, the post-implementation group achieved a therapeutic trough 1 day earlier (3 vs 2 days; p < 0.001). There was no difference in proportions of AKI developing between the pre-implementation vs post-implementation groups (10.1% vs 5.6%; p = 0.251). CONCLUSIONS Implementation of an updated vancomycin dosing protocol yielded a higher percentage of initial therapeutic vancomycin troughs and patients reached the therapeutic range 1 day earlier without increasing the proportion of AKI.
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Affiliation(s)
- Allison M. Kenneally
- Department of Pharmacy (AMK, KRL, KLG), University of Kentucky Healthcare, Lexington, KY
| | - Kelsey R. Leonhardt
- Department of Pharmacy (AMK, KRL, KLG), University of Kentucky Healthcare, Lexington, KY
| | - Aric Schadler
- Department of Pediatrics (AS), Kentucky Children’s Hospital, Lexington, KY
| | - Karen L. Garlitz
- Department of Pharmacy (AMK, KRL, KLG), University of Kentucky Healthcare, Lexington, KY
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Alrahahleh D, Xu S, Zhu Z, Toufaili H, Luig M, Kim HY, Alffenaar JW. An Audit to Evaluate Vancomycin Therapeutic Drug Monitoring in a Neonatal Intensive Care Unit. Ther Drug Monit 2022; 44:651-658. [PMID: 35383737 DOI: 10.1097/ftd.0000000000000986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/14/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is routinely used for optimization of vancomycin therapy, because of exposure-related efficacy and toxicity, in addition to significant variability in pharmacokinetics, which leads to unpredictable drug exposure. OBJECTIVE The aim of this study was to evaluate target attainment and TDM of vancomycin in neonates. METHODS The authors conducted a retrospective study and collected data from medical records of all neonates who received vancomycin therapy in the neonatal intensive care unit between January 2019 and December 2019. The primary outcome was the proportion of vancomycin courses that reached target trough concentrations of 10-20 mg/L based on appropriate TDM samples collection. Secondary outcomes included proportion of courses with appropriate dose and dose frequency, and proportion of patients who achieved target concentrations after the first dose adjustment. RESULTS In total, 69 patients were included, with 129 vancomycin courses. The median initial vancomycin trough concentration was 12 (range: 4-36) mg/L. The target trough concentration was achieved in 75% of courses after the initial dose with appropriate TDM, and 84% of courses after TDM-guided dose adjustments. Patients were dosed appropriately in 121/129 courses and TDM was performed correctly according to protocol in 51/93 courses. A dose adjustment was performed in 18/29 courses, to increase target attainment. CONCLUSIONS This study showed that there is a need for an increase in dose to improve target attainment. There is also a need to explore more effective TDM strategies to increase the proportion of neonatal patients attaining vancomycin target trough concentrations.
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Affiliation(s)
- Dua'a Alrahahleh
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
| | - Sophia Xu
- Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia
| | - Zhaowen Zhu
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Hassan Toufaili
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Melissa Luig
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia ; and
| | - Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW, Australia
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW, Australia
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Alrahahleh D, Xu S, Luig M, Kim HY, Alffenaar JW. Dosing of vancomycin and target attainment in neonates: a systematic review. Int J Antimicrob Agents 2022; 59:106515. [PMID: 35031450 DOI: 10.1016/j.ijantimicag.2021.106515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/03/2021] [Accepted: 12/22/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Neonatal infections caused by Gram-positive bacteria are commonly treated with vancomycin. However, there is a lack of agreement on the optimal vancomycin dosing regimen and corresponding vancomycin exposure to correlate with efficacy and toxicity. OBJECTIVES This review aimed to evaluate dosing of vancomycin in neonates, therapeutic target attainment and clinical toxicity and efficacy outcomes. METHODS Two electronic databases - Embase and PubMed (Medline) - were systematically searched between 1995-2020. Studies that reported dosing regimens, drug concentrations, toxicity, and efficacy of vancomycin in neonates were eligible for inclusion. Descriptive analysis and a narrative synthesis were performed. RESULTS The systematic review protocol was registered with the PROSPERO International Prospective Register of Systematic reviews in 2020 (registration number: CRD42020219568). Twenty-four studies were included for final analysis. Overall, the data from the included studies showed a great degree of heterogeneity. Therapeutic drug monitoring practices were different between institutions. Although most studies used trough concentration with a target range of 10-20 mg/L, target attainment was different across the studies. The probability of target attainment was < 80% in all tested dosing algorithms. Few studies reported on vancomycin efficacy and toxicity. CONCLUSION This is a comprehensive overview of dosing strategies of vancomycin in neonates. There was inadequate evidence to propose an optimal therapeutic regimen in the newborn population, based on the data obtained, due to the heterogeneity in the design and objectives of the included studies. Consistent and homogeneous comparative randomised clinical trials are needed to identify a dosing regimen with a probability of target attainment of > 90% without toxicity.
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Affiliation(s)
- Dua'A Alrahahleh
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Westmead Hospital, Westmead, NSW, Australia
| | - Sophia Xu
- Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia
| | - Melissa Luig
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
| | - Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Westmead Hospital, Westmead, NSW, Australia; Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW, Australia
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Westmead Hospital, Westmead, NSW, Australia; Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW, Australia.
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Endo A, Nemoto A, Hanawa K, Ishikawa T, Koshiishi M, Maebayashi Y, Hasebe Y, Naito A, Kobayashi Y, Isobe K, Kawano Y, Hanawa T. Index for the appropriate vancomycin dosing in premature neonates and infants. Pediatr Int 2022; 64:e14905. [PMID: 34197665 PMCID: PMC9255595 DOI: 10.1111/ped.14905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/13/2021] [Accepted: 06/30/2021] [Indexed: 12/03/2022]
Abstract
BACKGROUND In neonates, vancomycin (VCM) is used to treat Gram-positive bacterial infections. However, VCM blood concentrations are affected by gestational age, bodyweight (BW), and renal function. The initial VCM dose adjustment can therefore be difficult, and few reports have evaluated this issue. In this study, we investigated the factors determining the appropriate VCM dosing schedule in neonates, especially premature infants. METHODS The VCM dosage and trough concentrations were retrospectively investigated from the initial treatment to maintenance therapy in neonatal intensive care unit patients who underwent therapeutic drug monitoring. We examined the average single-administration VCM dosage during maintenance therapy. We then compared the actual VCM dose with that calculated using an index comprising six items that influence the VCM daily dose (postnatal age, gestational age, BW, serum creatinine level, urine output, and lactate level). RESULTS Twenty premature infants were included. The average BW of patients at the initial VCM administration was 975 g. During maintenance therapy, the average VCM dose was 8.4 mg/kg, and the median trough concentration was 12.4 μg/mL. When we applied the six-item index, 18 of 20 patients (90%) had concordant results between the actual VCM dosing schedule and the VCM calculated using the index. CONCLUSIONS The average VCM dose and six-item index can facilitate the transition from the initial VCM dose to an appropriate dose in many cases and contribute to early treatment in low-birthweight infants with more variable BW, distribution volumes, and renal function. In conclusion, our six-item index may help standardize VCM administration in premature infants.
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Affiliation(s)
- Aiju Endo
- Department of Pharmacy, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Atsushi Nemoto
- Department of Neonatology, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Kazumi Hanawa
- Department of Pharmacy, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Takahiro Ishikawa
- Department of Pharmacy, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Mai Koshiishi
- Department of Pharmacy, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Yuki Maebayashi
- Department of Neonatology, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Yohei Hasebe
- Department of Neonatology, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Atsushi Naito
- Department of Neonatology, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Yoshifumi Kobayashi
- Department of Pharmacy, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Katsuhiko Isobe
- Department of Pharmacy, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Yayoi Kawano
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba, Japan
| | - Takehisa Hanawa
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba, Japan
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Mejías-Trueba M, Alonso-Moreno M, Herrera-Hidalgo L, Gil-Navarro MV. Target Attainment and Clinical Efficacy for Vancomycin in Neonates: Systematic Review. Antibiotics (Basel) 2021; 10:347. [PMID: 33805874 PMCID: PMC8064372 DOI: 10.3390/antibiotics10040347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/14/2021] [Accepted: 03/21/2021] [Indexed: 01/22/2023] Open
Abstract
Vancomycin is commonly used as a treatment for neonatal infections. However, there is a lack of consensus establishing the optimal vancomycin therapeutic regimen and defining the most appropriate PK/PD parameter correlated with the efficacy. A recent guideline recommends AUC-guided therapeutic dosing in treating serious infections in neonates. However, in clinical practice, trough serum concentrations are commonly used as a surrogate PKPD index for AUC24. Despite this, target serum concentrations in a neonatal population remain poorly defined. The objective is to describe the relationship between therapeutic regimens and the achievement of clinical or pharmacokinetic outcomes in the neonatal population. The review was carried out following PRISMA guidelines. A bibliographic search was manually performed for studies published on PubMed and EMBASE. Clinical efficacy and/or target attainment and the safety of vancomycin treatment were evaluated through obtaining serum concentrations. A total of 476 articles were identified, of which 20 met the inclusion criteria. All of them evaluated the target attainment, but only two assessed the clinical efficacy. The enormous variability concerning target serum concentrations is noteworthy, which translates into a difficulty in determining which therapeutic regimen achieves the best results. Moreover, there are few studies that analyze clinical efficacy results obtained after reaching predefined trough serum concentrations, this information being essential for clinical practice.
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Affiliation(s)
- Marta Mejías-Trueba
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.M.-T.); (M.A.-M.)
| | - Marta Alonso-Moreno
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.M.-T.); (M.A.-M.)
| | - Laura Herrera-Hidalgo
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
| | - Maria Victoria Gil-Navarro
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
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Hartman SJF, Orriëns LB, Zwaag SM, Poel T, de Hoop M, de Wildt SN. External Validation of Model-Based Dosing Guidelines for Vancomycin, Gentamicin, and Tobramycin in Critically Ill Neonates and Children: A Pragmatic Two-Center Study. Paediatr Drugs 2020; 22:433-444. [PMID: 32507958 PMCID: PMC7383037 DOI: 10.1007/s40272-020-00400-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Dutch Pediatric Formulary (DPF) increasingly bases its guidelines on model-based dosing simulations from pharmacokinetic studies. This resulted in nationwide dose changes for vancomycin, gentamicin, and tobramycin in 2015. OBJECTIVE We aimed to evaluate target attainment of these altered, model-based doses in critically ill neonates and children. METHODS This was a retrospective cohort study in neonatal intensive care unit (NICU) and pediatric ICU (PICU) patients receiving vancomycin, gentamicin, or tobramycin between January 2015 and March 2017 in two university hospitals. The first therapeutic drug monitoring concentration for each patient was collected, as was clinical and dosing information. Vancomycin and tobramycin target trough concentrations were 10-15 and ≤ 1 mg/L, respectively. Target gentamicin trough and peak concentrations were < 1 and 8-12 mg/L, respectively. RESULTS In total, 482 patients were included (vancomycin [PICU] n = 62, [NICU] n = 102; gentamicin [NICU] n = 97; tobramycin [NICU] n = 221). Overall, median trough concentrations were within the target range for all cohorts but showed large interindividual variability, causing nontarget attainment. Trough concentrations were outside the target range in 66.1%, 60.8%, 14.7%, and 23.1% of patients in these four cohorts, respectively. Gentamicin peak concentrations were outside the range in 69% of NICU patients (term neonates 87.1%, preterm infants 57.1%). Higher creatinine concentrations were associated with higher vancomycin and tobramycin trough concentrations. CONCLUSION This study illustrates the need to validate model-based dosing advice in the real-world setting as both sub- and supratherapeutic concentrations of vancomycin, gentamicin, and tobramycin were very prevalent. Our data underline the necessity for further individualization by addressing the high interindividual variability to improve target attainment.
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Affiliation(s)
- Stan J. F. Hartman
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Lynn B. Orriëns
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Samanta M. Zwaag
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Tim Poel
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Marika de Hoop
- grid.489189.50000 0001 0708 7338Royal Dutch Pharmacists Association (KNMP), Den Haag, The Netherlands ,Dutch Knowledge Center Pharmacotherapy for Children, The Hague, The Netherlands
| | - Saskia N. de Wildt
- grid.10417.330000 0004 0444 9382Department of Pharmacology and Toxicology and Department of Intensive Care, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands ,grid.5645.2000000040459992XIntensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands ,Dutch Knowledge Center Pharmacotherapy for Children, The Hague, The Netherlands
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