Continuous Infusion Vancomycin Through the Addition of Vancomycin to the Continuous Renal Replacement Therapy Solution in the PICU

Cies, Jeffrey J.; Moore, Wayne; Conley, Susan B.; Muneeruddin, Samina; Parker, Jason; Shea, Paul

doi:10.1097/pcc.0000000000000656

Cited by 13 publications

(16 citation statements)

References 38 publications

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“…These findings are also consistent with data for other drugs that are renally cleared, such as gentamicin, where increased doses are required in the intensive care setting secondary to an illness‐induced hyperdynamic state and consequent increased volume of distribution . Continuous infusions of vancomycin have been proposed as a solution to the poor attainment of therapeutic vancomycin concentrations with intermittent dosing . Overall, our data suggest that a more aggressive approach to vancomycin dosing in critically ill children and neonates is necessary.…”

Section: Discussionsupporting

confidence: 87%

“…36 Continuous infusions of vancomycin have been proposed as a solution to the poor attainment of therapeutic vancomycin concentrations with intermittent dosing. [37][38][39][40] Overall, our data suggest that a more aggressive approach to vancomycin dosing in critically ill children and neonates is necessary. Doses at the higher end of daily recommendations were required in older children, with 75% of children attaining therapeutic concentrations with doses >50 mg/kg/day.…”

Section: Discussionmentioning

confidence: 80%

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Vancomycin is commonly under‐dosed in critically ill children and neonates

Sosnin

Curtis

Cranswick

et al. 2019

Brit J Clinical Pharma

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Aims Vancomycin is frequently used in critically ill children in whom the drug pharmacokinetics are significantly altered as a result of changes in renal clearance and volume of distribution. Therapeutic drug monitoring (TDM) is recommended to achieve vancomycin trough concentrations between 10 and 20 mg/L. In this study we reviewed vancomycin dosing, TDM and treatment outcomes in paediatric and neonatal intensive care unit patients. Methods We reviewed the medical records of all patients receiving intravenous vancomycin in a tertiary paediatric and neonatal intensive care unit over a 10‐month period. Demographic, vancomycin dosing, TDM and drug‐related adverse effects data were collected. Results In total, 115 children received 126 courses of vancomycin and had at least 1 TDM blood sample taken at steady state. In only 38/126 (30%) courses was the target concentration (10–20 mg/L) achieved at the initial steady state trough sample. Of the 88 courses that had initial trough concentrations outside the target range, the dose was adjusted in only 49 (56%). Overall, minimum doses of 30 mg/kg/day in neonates with a corrected gestational age of <35 weeks, and 50 mg/kg/day in older children, were required to achieve target vancomycin concentrations. Vancomycin‐attributable nephrotoxicity occurred in 10/126 (8%) courses and there were no episodes of red man syndrome. Conclusion In critically ill children, individualised dosing is needed. In the absence of Bayesian model‐based dosing, in children with normal renal function, empiric vancomycin doses of at least 30 mg/kg/day in neonates of <35 weeks corrected gestational age, and 50 mg/kg/day in older children, should be considered. Optimisation of TDM practices through the development of protocols, ideally built into electronic medical records, should be considered.

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Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 80%

Vancomycin is commonly under‐dosed in critically ill children and neonates

Sosnin

Curtis

Cranswick

et al. 2019

Brit J Clinical Pharma

View full text Add to dashboard Cite

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“…15,34,39 Use of a loading dose prior to CIV initiation can also improve the time to target serum concentration achievement. [16][17][18][19][20][21][22][23]27,[29][30][31][33][34][35][36] Pawlotsky et al 27 showed that administration of a 7-mg/kg loading dose in neonates achieved a postloading dose serum concentration of 15 ± 8.1 mg/L, which was within their target range of 10 to 30 mg/L. Zhao et al 30 used a patient-tailored optimized dosing regimen that included a loading dose, achieving desired serum concentrations within 6 to 12 hours after starting CIV treatment in over 70% of neonates.…”

Section: Discussionmentioning

confidence: 99%

“…Critically Ill Children. Cies et al 35 retrospectively evaluated the achievement of target serum concentrations when CIV was administered by adding vancomycin to continuous renal replacement therapy (CRRT) solutions in 11 critically ill children with acute kidney injury in a pediatric intensive care unit (PICU) in Philadelphia (Table 2). Following a loading dose, vancomycin was added directly to CRRT solution, dialysate, and/or replacement fluid with final vancomycin concentrations ranging from 18 to 30 mg/L.…”

Section: Clinical Evidencementioning

confidence: 99%

Continuous Infusion Vancomycin in Pediatric Patients: A Critical Review of the Evidence

Girand¹

2020

The Journal of Pediatric Pharmacology and Therapeutics

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OBJECTIVE To evaluate the use of continuous infusion vancomycin in pediatric patients. DATA SOURCES AND STUDY SELECTION PubMed, Cochrane Library, International Pharmaceutical Abstracts, and Google Scholar were searched to identify relevant published articles (1977 to November 2019) using the following search terms: vancomycin, neonates, pediatrics, infusion, continuous, administration, children, nephrotoxicity, pharmacokinetics, and pharmacodynamics. All English-language primary references that evaluated continuous infusion vancomycin in pediatric patients were included in this review. DATA SYNTHESIS Vancomycin is typically administered with intermittent infusions, but continuous infusion is an alternative delivery method used to improve achievement of target serum concentrations. Fifteen articles were reviewed that evaluated continuous infusion vancomycin in pediatric patients. Study data were heterogeneous with limited evidence to support improved clinical or microbiologic outcomes as compared with intermittent dosing. Potential benefits and limitations of continuous infusions are discussed. CONCLUSIONS Currently available evidence is lacking to support routine implementation of continuous infusion vancomycin in pediatric patients. However, it is a therapeutic option in certain clinical conditions and could be beneficial for individuals with serious Gram-positive infections where rapid achievement of target serum concentrations is critical. Continuous infusions may also benefit individuals who do not achieve target concentrations or who experience significant red man syndrome with traditional dosing, particularly when high daily doses are required. Optimal dosing and ideal target serum concentrations have not been established and may vary for different populations. Future prospective randomized clinical trials should be performed to identify optimal dosing and monitoring regimens and determine comparative safety and efficacy with traditional intermittent dosing in various pediatric populations.

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“…Pharmacokinetics and pharmacodynamics are essential factors when treating any infection and are known to undergo changes for patients in the PICU and with CRRT. [7][8][9][10][11][12][13][14][15][16][17][18][19] Therefore, the purpose of this case report is to describe the pharmacokinetics of continuous infusion doripenem in a pediatric patient receiving CRRT. The Drexel University College of Medicine Institutional Review Board approved this case report.…”

Section: Introductionmentioning

confidence: 99%

Therapeutic Drug Monitoring of Continuous Infusion Doripenem in a Pediatric Patient on Continuous Renal Replacement Therapy

Cies¹,

Moore²,

Conley³

et al. 2017

The Journal of Pediatric Pharmacology and Therapeutics

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An 11-year-old African American male with severe combined immunodeficiency variant, non-cystic fibrosis bronchiectasis, pancreatic insufficiency, chronic mycobacterium avium-intracellulare infection, chronic sinusitis, and malnutrition presented with a 1-week history of fevers. He subsequently developed respiratory decompensation and cefepime was discontinued and doripenem was initiated. Doripenem was the carbapenem used due to a national shortage of meropenem. By day 7 the patient (24.7 kg) had a positive fluid balance of 6925 mL (28% FO), and on days 7 into 8 developed acute kidney injury evidenced by an elevated serum creatinine of 0.68 mg/dL, an increase from the baseline of 0.28 mg/dL. On day 9, the patient was initiated on continuous renal replacement therapy (CRRT) and the doripenem dosing was changed to a continuous infusion of 2.5 mg/kg/hr (60 mg/kg/day). Approximately 12.5 hours after the start of the doripenem a serum concentration was obtained, which was 4.01 mg/L corresponding to a clearance of 10.5 mL/min/kg. The pediatric dosing and pharmacokinetic data available for doripenem suggest a clearance estimate of 4.4 to 4.8 mL/min/kg, and the adult clearance estimate is 2.4 to 3.78 mL/min/kg. The calculated clearance in our patient of 10.5 mL/min/kg is over double the highest clearance estimate in the pediatric literature. This case demonstrates that doripenem clearance is significantly increased with CRRT in comparison with the published pediatric and adult data. An appropriate pharmacodynamic outcome (time that free drug concentration > minimum inhibitory concentration) can be achieved by continuous infusion doripenem with concurrent therapeutic drug monitoring.

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Continuous Infusion Vancomycin Through the Addition of Vancomycin to the Continuous Renal Replacement Therapy Solution in the PICU

Cited by 13 publications

References 38 publications

Vancomycin is commonly under‐dosed in critically ill children and neonates

Vancomycin is commonly under‐dosed in critically ill children and neonates

Continuous Infusion Vancomycin in Pediatric Patients: A Critical Review of the Evidence

Therapeutic Drug Monitoring of Continuous Infusion Doripenem in a Pediatric Patient on Continuous Renal Replacement Therapy

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