Evaluation of a pediatric continuous-infusion vancomycin therapy guideline

McKamy, Susan; Chen, Tempe; Lee, Michelle; Ambrose, Peter

doi:10.2146/ajhp120072

Cited by 20 publications

(25 citation statements)

References 27 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…For vancomycin, continuous infusion has not been shown to improve clinical outcomes in adults but has been associated with decreased nephrotoxicity in a meta-analysis [106]. Similarly, continuous-infusion vancomycin has been associated with few adverse effects and no nephrotoxicity in children [107].…”

Section: Evidence Summarymentioning

confidence: 99%

Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

Barlam

Cosgrove

Abbo

et al. 2016

Clinical Infectious Diseases

2,241

1,971

View full text Add to dashboard Cite

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

show abstract

Section: Evidence Summarymentioning

confidence: 99%

Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

Barlam

Cosgrove

Abbo

et al. 2016

Clinical Infectious Diseases

2,241

1,971

View full text Add to dashboard Cite

show abstract

“…Despite the large number of proposed vancomycin dosing regimens currently available for neonates and infants (10,11,(37)(38)(39)(40)(41), studies reporting on the results of therapeutic drug monitoring show that the target trough concentrations are difficult to attain in clinical practice (42)(43)(44)(45). In accordance with reported clinical practice in adults, continu-ous dosing has also been investigated in neonates, infants, and children (31,34,(46)(47)(48)(49).…”

mentioning

confidence: 99%

Towards Rational Dosing Algorithms for Vancomycin in Neonates and Infants Based on Population Pharmacokinetic Modeling

Janssen

Välitalo

Allegaert

et al. 2016

Antimicrob Agents Chemother

View full text Add to dashboard Cite

iBecause of the recent awareness that vancomycin doses should aim to meet a target area under the concentration-time curve (AUC) instead of trough concentrations, more aggressive dosing regimens are warranted also in the pediatric population. In this study, both neonatal and pediatric pharmacokinetic models for vancomycin were externally evaluated and subsequently used to derive model-based dosing algorithms for neonates, infants, and children. For the external validation, predictions from previously published pharmacokinetic models were compared to new data. Simulations were performed in order to evaluate current dosing regimens and to propose a model-based dosing algorithm. The AUC/MIC over 24 h (AUC 24 /MIC) was evaluated for all investigated dosing schedules (target of >400), without any concentration exceeding 40 mg/liter. Both the neonatal and pediatric models of vancomycin performed well in the external data sets, resulting in concentrations that were predicted correctly and without bias. For neonates, a dosing algorithm based on body weight at birth and postnatal age is proposed, with daily doses divided over three to four doses. For infants aged <1 year, doses between 32 and 60 mg/kg/day over four doses are proposed, while above 1 year of age, 60 mg/kg/day seems appropriate. As the time to reach steady-state concentrations varies from 155 h in preterm infants to 36 h in children aged >1 year, an initial loading dose is proposed. Based on the externally validated neonatal and pediatric vancomycin models, novel dosing algorithms are proposed for neonates and children aged <1 year. For children aged 1 year and older, the currently advised maintenance dose of 60 mg/kg/day seems appropriate. In the pediatric population, drugs are often administered in an off-label or unlicensed manner (1). While pediatric dosing regimens are mostly empirically derived using extrapolations based on body weight (2, 3), it has been shown before that dosing in children should be guided by the understanding of developmental changes in the pharmacokinetic and/or pharmacodynamic relation of drugs (2, 4, 5). More specifically, translation of results from pharmacokinetic modeling studies has been shown to result in individualized dosing guidelines for many different drugs in pediatric clinical practice (5-9).The antibacterial agent vancomycin is commonly used to treat infections caused by Gram-positive organisms, like methicillinresistant Staphylococcus aureus (MRSA) and amoxicillin-resistant Enterococcus species, in both adults and pediatric patients (10). In neonates, MRSA infection is relatively rare, and coagulase-negative staphylococci are the most commonly identified infectious organisms necessitating vancomycin treatment (11,12). For vancomycin, it has been shown that bacterial killing of S. aureus is best predicted by the area under the concentration-time curve over 24 h (AUC 24 ) divided by the MIC for the infecting pathogen (AUC 24 / MIC) (13-15). In adult patients, an AUC 24 /MIC of Ն400 resulted in a superior clinical and...

show abstract

“…In 2012, McKamy et al, described a dosing guideline that converted pediatric patients at a single institution from intermittent vancomycin dosing to continuous vancomycin for patients who had two consecutive subtherapeutic trough concentrations. Patients had to have either pneumonia or osteomyelitis due to gram‐positive organisms, including MRSA.…”

Section: Discussionmentioning

confidence: 99%

“…Continuous vancomycin therapy has been previously reported to maximize the antimicrobial effects of vancomycin while avoiding the toxicities associated with dose escalation and elevated peak concentrations, although the efficacy of this approach was not reported. 1 Here we describe the successful use of continuous vancomycin in a pediatric cystic fibrosis (CF) patient with MRSA who had a significant drug allergy profile.…”

Section: Introductionmentioning

confidence: 99%

“…The majority of studies evaluating continuous vancomycin are in adult patients, and most evaluate nephrotoxicity and adverse effects, as opposed to clinical efficacy, as the primary endpoint [2][3]. These previous studies have demonstrated that continuous vancomycin does not result in an increased incidence of nephrotoxicity, and in some studies, the incidence was significantly less when compared to intermittent vancomycin.In 2012, McKamy et al,1 described a dosing guideline that converted pediatric patients at a single institution from intermittent vancomycin dosing to continuous vancomycin for patients who had two consecutive subtherapeutic trough concentrations. Patients had to have either pneumonia or osteomyelitis due to gram-positive organisms, including MRSA.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Continuous vancomycin in a pediatric cystic fibrosis patient

McKinzie

Esther

Vece

2017

Pediatric Pulmonology

View full text Add to dashboard Cite

Continuous vancomycin has been previously reported to maximize antimicrobial activity while avoiding toxicities associated with dose escalation, but the efficacy of this dosing strategy has not been reported. This case report describes the successful use of continuous vancomycin, including improvement in lung function and avoidance of nephrotoxicity, demonstrated in a pediatric cystic fibrosis (CF) patient with MRSA.Vancomycin is a glycopeptide antibiotic that is effective against grampositive organisms, including methicillin-resistant Staphylococcus aureus (MRSA). Based on its time-dependent antimicrobial activity, maximal bactericidal effects occur when the concentration of vancomycin remains significantly above the bacterial minimum inhibitory concentration (MIC).However, targeting higher peak concentrations to maximize time above MIC is associated with more adverse effects, such as nephrotoxicity.Continuous vancomycin therapy has been previously reported to maximize the antimicrobial effects of vancomycin while avoiding the toxicities associated with dose escalation and elevated peak concentrations, although the efficacy of this approach was not reported. 1 Here we describe the successful use of continuous vancomycin in a pediatric cystic fibrosis (CF) patient with MRSA who had a significant drug allergy profile. | CASEA 12-year-old girl with CF was admitted to the inpatient pediatric pulmonary service for treatment of a CF pulmonary exacerbation.Her pulmonary function tests (PFTs) on admission were percent predicted (pp) FVC 81, ppFEV 1 79%, ppFEF 25-75 77%, as compared to her best PFTs in the past year of ppFVC 110, ppFEV 1 105, and ppFEF 25-75 100. Since presenting to our CF center one and a half years prior, the patient has had three bronchoscopy cultures and 12 sputum cultures obtained. Of these, two bronchoscopies were positive for MRSA only, and the third grew MRSA and mold. Of the sputum cultures, eight grew only MRSA, and another (the first obtained at our center) grew Pseudomonas in addition to MRSA.Given this history of infection primarily with MRSA, prior to admission she was treated with a 3 week course of tedizolid directed against MRSA as her typical respiratory pathogen. On week prior to admission oral minocycline was added to her antibiotic regimen. She underwent bronchoscopy upon admission to determine if there were any other pathogens present that could account for her failure to respond to tedizolid, but cultures only grew 800 000 CFU/mL of MRSA. The patient has multiple allergies and reactions to medications that complicated antibiotic management, including significant hives with both minocycline and ceftaroline, independent of one another; facial swelling with aztreonam; paresthesias with linezolid during two treatment courses; and significant red man syndrome with intermittent dosing of vancomycin.Her most recent culture susceptibilities indicated sensitivity to ceftaroline, doxycycline, linezolid, and vancomycin (with a MIC of 2 mcg/mL) and resistance to clindamycin and sulfam...

show abstract

Evaluation of a pediatric continuous-infusion vancomycin therapy guideline

Abstract: Conversion from IIV to CIV therapy in selected pediatric patients appeared to be safe and well tolerated, with few adverse effects noted. Using the institutional CIV dosing guideline, goal plateau SVC values were attained in most patients within 24-48 hours.

Cited by 20 publications

References 27 publications

Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

Towards Rational Dosing Algorithms for Vancomycin in Neonates and Infants Based on Population Pharmacokinetic Modeling

Continuous vancomycin in a pediatric cystic fibrosis patient

Contact Info

Product

Resources

About