Area under the Curve-Based Dosing of Vancomycin in Critically Ill Patients Using 6-Hour Urine Creatinine Clearance Measurement

Abstract

Background. The area under the curve- (AUC-) guided vancomycin dosing is the best strategy for individualized therapy in critical illnesses. Since AUC can be calculated directly using drug clearance (CLvan), any parameter estimating CLvan will be able to achieve the goal of 24-hour AUC (AUC24 h). The present study was aimed to determine CLvan based on 6-hour urine creatinine clearance measurement in critically ill patients with normal renal function. Method. 23 adult critically ill patients with an estimated glomerular filtration rate (eGFR) ≥60 mL/min who received vancomycin infusion were enrolled in this pilot study. Vancomycin pharmacokinetic parameters were determined for each patient using serum concentration data and a one-compartment model provided by MONOLIX software using stochastic approximation expectation-maximization (SAEM) algorithm. Correlation of CLvan with the measured creatinine clearance in 6-hour urine collection (CL6 h) and estimated creatinine clearance by the Cockcroft–Gault formula (CLCG) was investigated. Results. Data analysis revealed that CL6 h had a stronger correlation with CLvan rather than CLCG (r = 0.823 vs. 0.594; p < 0.001 vs. 0.003). The relationship between CLvan and CL6 h was utilized to develop the following equation for estimating CLvan: CLvan (mL/min) = ─137.4 + CL6 h (mL/min) + 2.5 IBW (kg) (R2 = 0.826, p < 0.001 ). Regarding the described model, the following equation can be used to calculate the empirical dose of vancomycin for achieving the therapeutic goals in critically ill patients without renal impairment: total daily dose of vancomycin (mg) = (─137.4CL6-h (mL/min) + 2.5 IBW (kg)) × 0.06 AUC24 h (mg.hr/L). Conclusion. For AUC estimation, CLvan can be obtained by collecting urine in a 6-hour period with good approximation in critically ill patients with normal renal function.

Adherence to practice guidelines for the management of febrile neutropenia in patients undergoing hematopoietic stem cell transplantation: An observational study in a referral center in Iran

“…26,27 Therefore, it seems that rationalization of vancomycin use requires some appropriate interventions like guideline review sessions besides the application of TDM services. 28,29 In the present study, we found that the duration of hospitalization was significantly shorter in the patients who were correctly treated compared with those who were not. It seems that adherence to guideline recommendations not only prevents the irrational use of antibiotics, but it also improves patients' outcomes.…”

Acute Stroke and Atrial Fibrillation: Risk of Incorrect NOAC Dosage When Estimating Renal Function From Plasma Creatinine Only

“…Figure 1E shows deviation points across all NOACs. The risk of a wrong dosage (Figure 1F, mean and 95% CI) was 6.9% (4.8-9.5), 26% (23)(24)(25)(26)(27)(28)(29)(30)(31), 38% (33)(34)(35)(36)(37)(38)(39)(40)(41)(42), and 20% (16)(17)(18)(19)(20)(21)(22)(23) for apixaban, edoxaban, dabigatran, and rivaroxaban, respectively. When pooling the risks, a common risk for incorrect NOAC dosage of 23% (22)(23)(24)(25) when relying on eGFR CKD-EPI was determined from the data.…”

“…This has been done for other studies as well. For instance, when dosing vancomycin in critically ill patients, CrCl has been shown to outperform eGFR ( 17 ). While, compared to eGFR approaches, CrCl has the advantage of adding urine creatinine as a second parameter, its accuracy can be impairedby both methodological errors like tubular secretion of creatinine ( 18 ) and execution errors (e.g., collection time and logistics).…”

Antibiotic therapy in sepsis: No next time for a second chance!

“…The PK of the antibiotics and their plasma concentrations may also be affected as a result of medical interventions such as renal replacement therapy (RRT), extracorporeal membrane oxygenation (ECMO) and plasma exchange (PEX) 9 . Table 1 provides an overview of the PK alterations of antibiotics in patients with sepsis, along with practical dosing recommendations accounting for these alterations 10‐13 …”

“…Inappropriate dosing of antibiotics is related to the occurrence of serious complications, including adverse drug reactions and the increased number of multidrug‐resistant (MDR) pathogens, as well as poor control of infection 27,28 . Table 2 summarizes the standard/conventional vs. recommended initial doses of the commonly used IV empirical antibiotics in sepsis based on several studies and our routine practice in ICUs 13,29‐31 …”