Vancomycin levels are frequently subtherapeutic in critically ill patients: a prospective observational study

Bakke, V; Sporsem, H.; Lippe, E von der; Nordøy, Ingvild; Lao, Yvonne Elisabeth; Nyrerød, Hans Christian; Sandvik, Leiv; Hårvig, K. R.; Bugge, J. F.; Helset, E.

doi:10.1111/aas.12897

Cited by 61 publications

(81 citation statements)

References 22 publications

(33 reference statements)

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“…These variations in pharmacokinetic parameters reflect the underlying illnesses of the patients. In particular, trauma patients have consistently been found to have augmented renal clearance of vancomycin . While data on vancomycin dosing and TDM in critically ill children are sparse, in the neonatal intensive care setting it has been shown that only 25–51% of trough concentrations are within target range with empiric dosing, despite both these studies targeting lower trough concentrations of 5–15 mg/L .…”

Section: Discussionmentioning

confidence: 99%

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: Discussionmentioning

confidence: 99%

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

show abstract

“…The need for clearer guidelines regarding vancomycin dosing and TDM for patient subpopulations has been recently reported …”

Section: Therapeutic Drug Monitoringmentioning

confidence: 99%

“…Significant challenges in vancomycin use in critically ill patients have been recently identified . There is wide variability in reported practices for antibiotic dosing and monitoring.…”

Section: Therapeutic Drug Monitoringmentioning

confidence: 99%

“…Long duration of fasting and massive diarrhea have been associated with elevations in serum vancomycin concentrations, which suggest that TDM might be necessary during enteral vancomycin administration in critically ill patients . Less than 40% of these patients attained therapeutic trough serum concentrations during the first 3 days of therapy . Patients with augmented renal clearance presented lower serum Ctroughs despite receiving higher maintenance doses and several loading doses .…”

Section: Therapeutic Drug Monitoringmentioning

confidence: 99%

“…Less than 40% of these patients attained therapeutic trough serum concentrations during the first 3 days of therapy . Patients with augmented renal clearance presented lower serum Ctroughs despite receiving higher maintenance doses and several loading doses . Subjects requiring intensive care unit support are significantly more likely to have higher vancomycin 24‐hour area under the concentration versus time curve (AUC24) and AUC than those who do not need intensive care unit support.…”

Section: Therapeutic Drug Monitoringmentioning

confidence: 99%

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Vancomycin therapeutic drug monitoring and population pharmacokinetic models in special patient subpopulations

Monteiro

Hahn

Gonçalves

et al. 2018

Pharmacology Res & Perspec

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Vancomycin is a fundamental antibiotic in the management of severe Gram‐positive infections. Inappropriate vancomycin dosing is associated with therapeutic failure, bacterial resistance and toxicity. Therapeutic drug monitoring (TDM) is acknowledged as an important part of the vancomycin therapy management, at least in specific patient subpopulations, but implementation in clinical practice has been difficult because there are no consensus and agglutinator documents. The aims of the present work are to present an overview of the current knowledge on vancomycin TDM and population pharmacokinetic (PPK) models relevant to specific patient subpopulations. Based on three published international guidelines (American, Japanese and Chinese) on vancomycin TDM and a bibliographic review on available PPK models for vancomycin in distinct subpopulations, an analysis of evidence was carried out and the current knowledge on this topic was summarized. The results of this work can be useful to redirect research efforts to address the detected knowledge gaps. Currently, TDM of vancomycin presents a moderate level of evidence and practical recommendations with great robustness in neonates, pediatric and patients with renal impairment. However, it is important to investigate in other subpopulations known to present altered vancomycin pharmacokinetics (eg neurosurgical, oncological and cystic fibrosis patients), where evidence is still unsufficient.

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Assessing the impact of an electronic therapeutic drug monitoring record in the management of vancomycin through pharmacist intervention: a single‐centre study

Ong

Oates

Banakh

2023

Pharmacy Practice and Res

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Background A gap in vancomycin therapeutic drug monitoring (TDM) electronic documentation, management, and related clinical pharmacist activities was identified by our clinical pharmacy team. In response, an electronic TDM (eTDM) template was planned, designed, and implemented by the pharmacy department team in collaboration with the electronic medical records team (EMR) and documentation committee. Aim To assess the impact of an electronic therapeutic drug monitoring (eTDM) template to measure the impact of adherence to vancomycin guidelines. Guideline adherence indicators include the number of vancomycin levels within the therapeutic range and the number of appropriate concentrations taken. Method An interventional, single‐centre study of vancomycin therapy in adult patients was performed from 2019–2021. Data were extracted from the electronic medical records and TDM paper‐based forms completed by clinical pharmacists. The number of concentrations within the therapeutic range and the number of appropriately taken levels were analysed by the chi‐square test. This study received an exemption from the Peninsula Health Human Research Ethics Commitee (QA/60523/PH‐2019/197291). Results There was a total of 198 concentrations collected in the ‘before’ period and 125 concentrations collected in the ‘after’ period. The number of concentrations in therapeutic range increased from 34.8% to 43.2% (p = 0.132), not statistically significant. The number of concentrations taken appropriately increased from 33.8% to 55.2% (p < 0.001). The proportion of patients with pharmacist involvement increased from 43.0% to 57.0% (p = 0.868). Conclusion The study shows that implementation of an electronic vancomycin monitoring template improved the proportion of appropriate levels taken and is the preferred method of documentation by clinical pharmacists. Future projects may benefit from analysing the cost associated with unnecessary vancomycin serum levels ordered or inclusion of pharmacists in the TDM of other narrow therapeutic medications.

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Vancomycin levels are frequently subtherapeutic in critically ill patients: a prospective observational study

Cited by 61 publications

References 22 publications

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

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

Vancomycin therapeutic drug monitoring and population pharmacokinetic models in special patient subpopulations

Assessing the impact of an electronic therapeutic drug monitoring record in the management of vancomycin through pharmacist intervention: a single‐centre study

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