Methodological Study of Vancomycin Dosing in Elderly Patients Using Actual Serum Creatinine Versus Rounded Serum Creatinine

Young, Tramaine; Daniel, M J; Baumhover, Stephanie; Eidson, Duke; Green, Jane

doi:10.1007/s40268-017-0200-1

Cited by 10 publications

(13 citation statements)

References 23 publications

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“…The study results suggest that actual serum creatinine levels may more accurately predict vancomycin troughs than rounded serum creatinine values. (22) The results of this study produced similar results to our own, suggesting older patients with rounded low serum creatinine values did not achieve vancomycin trough levels as readily as patients with higher serum creatinine levels, nor is the up-rounded serum creatinine value indicative of true renal function. Bourguignon and colleagues evaluated the pharmacokinetics of patients over the age of 80 years on vancomycin and found that there can be large inter-individual variability of vancomycin pharmacokinetic parameters.…”

Section: Discussionsupporting

confidence: 83%

“…However, a discussion of appropriate vancomycin dosing in elderly patients was recently started with Young and colleagues. (22) Based on the data described above, limited national dosing guidelines, and the common practice of rounding serum creatinine to 1 mg/dl in elderly patients with serum creatinine levels of <1 mg/dl, more clinical data is needed to better understand the vancomycin utilization in the elderly population. The aim of this study was to evaluate vancomycin target trough attainment and the time to target trough attainment with vancomycin dosing per pharmacy in elderly patients, specifically in patients 75 years of age or older.…”

Section: Introductionmentioning

confidence: 99%

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Assessing Vancomycin Dosing Per Pharmacy in Elderly Patients Over the Age of 74 Years

Nguyen

Breen

Yamaki

et al. 2018

J Contemp Pharm Pract

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Vancomycin has a complex pharmacokinetic profile and carries potential risks for nephrotoxicity and ototoxicity. The pharmacokinetic profile in elderly patients significantly differs from that of younger patients. It is common practice in many institutions for pharmacists to intentionally round serum creatinine levels to 1 mg/dl in elderly patients with levels <1 mg/dl to avoid overestimating clearance and toxicities. This can potentially lead to underestimation of creatinine clearance, and subsequently lead to vancomycin under dosing. The aim of this study was to evaluate vancomycin target trough attainment and the time to trough attainment with vancomycin dosing per pharmacy in elderly patients. Methods In this retrospective study, patients 75 years and older who received vancomycin at our institution were evaluated. Subjects were included in the study if they were at least 75 years of age, received intravenous vancomycin therapy, and had a vancomycin trough drawn after the third dose. The study patients were divided into three serum creatinine groups; <0.8 mg/dl (LSCr), 0.8–0.9 mg/dl (MSCr), and ≥1 mg/dl (HSCr). Patients were excluded from the study if they did not meet inclusion criteria, had no trough levels drawn, or were <75 years of age. Results Two hundred and four patients 75 years or older were included in the study. The target trough attainment was highest in the HSCr group (n = 37, 80%), which was significantly higher than the LSCr (n=21, 31%; p<0.0001) and MSCr (n=42, 46%; p<0.0001) groups. The time to target trough goals (days, mean ± SD) differed between the three groups, with the LSCr group taking the longest duration: LSCr: 5.14 ± 2.5; MSCr: 3.74 ± 1.1; HSCr: 3.78 ± 1.6, p=0.005. Conclusion Adjustments need to be done to improve vancomycin dosing per pharmacy in patients 75 years of age and older. This study shows that LSCr patients (<0.8 mg/dl) had the lowest rates of target trough level attainment. Intentionally rounding serum creatinine to 1 mg/dl if values are less when estimating renal function in this older patient population may not be predictive of true renal function and can decrease the likelihood of target attainment or increase time to target attainment.

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Section: Discussionsupporting

confidence: 83%

Section: Introductionmentioning

confidence: 99%

Assessing Vancomycin Dosing Per Pharmacy in Elderly Patients Over the Age of 74 Years

Nguyen

Breen

Yamaki

et al. 2018

J Contemp Pharm Pract

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“…According to the results of a current systematic review [ 30 ], using urinary CrCL is the best diagnostic method for estimating drug dosing in augmented renal clearance (ARC). 24-hour urine collection is often difficult, and some limitations are reducing the accuracy of collecting urine within 24 hours [ 31 , 32 ]. In case of the critical condition of the ICU, requiring quick decision-making urine collection can be implemented by decreasing the time of urine collection.…”

Section: Discussionmentioning

confidence: 99%

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

Shahrami

Najmeddin

Ghaffari

et al. 2020

Critical Care Research and Practice

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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.

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“…By rounding SCr up to 0.8 mg/dL, we may have potentially underestimated CrCl and therefore inappropriately dose reduced certain drugs. Considering newer publications on this topic, we are in the process of updating our protocol by removing the rounding component 10,23‐25 . Patients for this study were identified from a report capturing the progress note template used for the protocol.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of a pharmacist‐driven renal dosing protocol at an academic medical center

Cheung

Cooper

et al. 2020

J Am Coll Clin Pharm

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Introduction: Kidney disease is a major worldwide public health problem. An increased risk for adverse drug events is associated with drug dosing errors in hospitalized patients with renal impairment. A pharmacist-driven renal protocol may improve dosing compliance by allowing pharmacists to monitor renal function and adjust drug doses as needed.Objectives: To evaluate the utilization and financial impact of a pharmacist-driven renal dosing protocol.Methods: This was a retrospective cohort study of patients admitted to an academic medical center from 1 April 2017 to 30 May 2017 who had drug(s) from the protocol dose adjusted by a pharmacist. Outcomes of interest included protocol use frequency, patient characteristics, type of dose adjustments, and when adjustments were made. Two subgroup analyses were performed to: (1) determine cost savings of the seven most adjusted drugs and (2) determine if any missed opportunities for dose adjustments for cefepime.Results: A total of 422 dosage adjustments, performed on 317 patients, were included. The mean age of the patients was 63 years with 51.2% female. The majority (62.8%) had no history of renal dysfunction, 22.4% had chronic kidney disease, 14.8% had end-stage renal disease, and 25.3% had acute kidney injury on admission.Most dose adjustments (73.5%) were dose decreases, while 24.4% were dose increases. The seven most commonly adjusted drugs contributed to a cost savings of approximately $3919.87 per duration of therapy which extrapolates to an annual cost savings of $23 519.22. Of all the cefepime orders reviewed over a 7-day period, 84% were dosed correctly, 9% needed dose adjustments that could have been made sooner, and 7% had incorrect dose based on renal function.Conclusion: This analysis demonstrates that implementation of a pharmacist-driven renal dose adjustment protocol was consistently utilized at our institution and resulted in cost savings.

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Methodological Study of Vancomycin Dosing in Elderly Patients Using Actual Serum Creatinine Versus Rounded Serum Creatinine

Cited by 10 publications

References 23 publications

Assessing Vancomycin Dosing Per Pharmacy in Elderly Patients Over the Age of 74 Years

Assessing Vancomycin Dosing Per Pharmacy in Elderly Patients Over the Age of 74 Years

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

Evaluation of a pharmacist‐driven renal dosing protocol at an academic medical center

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