Vancomycin Use in a Paediatric Intensive Care Unit of a Tertiary Care Hospital

Abstract

Background Vancomycin is one of the commonly used anti-microbial drugs in intensive care units (ICUs). Guidelines recommend maintaining therapeutic trough levels of vancomycin (10-20 mg/L). The success of achieving the recommended therapeutic concentration of vancomycin is influenced by several factors, and this is even more complex in children, particularly those admitted in the ICU. Hence, we carried out the present study in children admitted in the ICU who were administered vancomycin. Methods We carried out a chart review of children admitted in the paediatric ICU unit of a tertiary care hospital over a period of 3 years. Information on their demographic factors, diagnoses, duration of hospital stay, vancomycin treatment (dose, frequency and time of administration) and concomitant drugs, and vancomycin trough levels were retrieved. Descriptive statistics were used for representing the demographic factors, and multivariable logistic regression analyses were carried out to assess the determining factors. Results One-hundred and two children were identified, of whom 13 had renal dysfunction. Two-hundred and fifty-two vancomycin trough levels were available, of which only 25% were observed in the recommended range (10-20 mg/L) amongst patients without any renal dysfunction and 22% amongst patients with renal dysfunction. Vancomycin was administered intravenously at an average [standard deviation (SD)] dose (mg/dose) of 13 (3.9) mostly either thrice or four times daily. Even in patients receiving vancomycin as a definitive therapy, only 40.9% achieved the recommended trough levels. Lower trough levels were associated with an increased risk of mortality. Nearly 4% of the levels were above 20 mg/L (toxic range). Seven children were suspected to have acute kidney injury (AKI) during the course of therapy where the cumulative vancomycin dose and mortality rate was higher. Only one serum vancomycin level during augmented renal clearance was observed in the recommended range. All the patients received at least one concomitant drug that either had nephrotoxic potential or predominant renal elimination, and use of a greater number of such drugs was associated with an increased risk of AKI. Conclusion The current vancomycin dosing strategy is ineffective in achieving therapeutic trough levels in children admitted to the ICU. Sub-therapeutic vancomycin trough levels significantly increase the risk of mortality.

Scoping review of augmented renal clearance in critically ill pediatric patients

“…Review of titles and abstracts led to the retrieval of 215 potentially relevant full‐text citations. After full‐text review, 25 citations met the criteria for inclusion 16–41 . The most common reason for exclusion was non‐pediatric population studies (190 citations), followed by lack of ARC data (24 citations).…”

“…Table 1 summarizes the characteristics of the studies included based upon their primary objective 16–41 . The first articles related to ARC in pediatrics were published in 2015 and were pharmacokinetic objective studies 20,36 .…”

“…In 2019, the first articles were published that evaluated general information related to ARC in pediatric patients 16,28,34 . Most of the published work (84%) has described the impact of ARC on pharmacokinetic/pharmacodynamic alterations in antimicrobial agents 18–22,24–27,29–33,35–41 . The 25 citations, representing a total of 2102 patients, were published across 22 different journals, with only two journals having more than one published article related to ARC: Pediatric Nephrology and Antimicrobial Agents and Chemotherapy .…”

Early Life Antibiotics Influence In Vivo and In Vitro Mouse Intestinal Epithelium Maturation and Functioning

“… 11 , 15 , 16 , 17 , 18 Upon onset of systemic or gastrointestinal infections with gram-positive bacteria, especially in the case of Staphylococcus aureus and Clostridium difficile , vancomycin is administered. 5 , 8 , 11 , 19 , 20 , 21 , 22 The combined use of the earlier-mentioned ABs is also common. 8 , 11 , 17 , 20 , 21 , 22 Although ABs have a crucial and beneficial role in treating bacterial infections, they also have several short- and long-term detrimental effects.…”

“… 5 , 8 , 11 , 19 , 20 , 21 , 22 The combined use of the earlier-mentioned ABs is also common. 8 , 11 , 17 , 20 , 21 , 22 Although ABs have a crucial and beneficial role in treating bacterial infections, they also have several short- and long-term detrimental effects. Use of ABs in early life is associated with necrotizing enterocolitis (NEC), 23 , 24 , 25 infantile colics, 26 , 27 and eczema.…”