Abstract
BackgroundVancomycin is a commonly used antibiotic in critically ill patients for various indications. Critical illness imposes pharmacokinetic-pharmacodynamics challenges, which makes optimizing vancomycin in this population cumbersome. Data are scarce on the clinical impact of time to therapeutic trough levels of vancomycin in critically ill patients. This study aims to evaluate the timing to achieve therapeutic trough level of vancomycin on 30-day mortality in critically ill patients.MethodA retrospective cohort study was conducted for all adult critically ill patients with confirmed Gram-positive infection who received IV vancomycin between January 1, 2017, and December 31, 2020. We compared early (< 48 h) versus late (≥ 48 h) attainment of vancomycin therapeutic trough levels. The primary outcome was the 30-day mortality in critically ill patients. Secondary outcomes were the development of resistant organisms, microorganisms eradication within 4–5 days of vancomycin initiation, acute kidney injury (AKI), and length of stay (LOS). Propensity score-matched (1:1 ratio) used based on patient’s age, serum creatinine, and albumin values at baseline.ResultsA total of 326 patients were included; 110 patients attained the therapeutic trough levels within 48 h of vancomycin initiation. Late achievement of the therapeutic trough levels was associated with higher 30-day mortality (HR: 2.54; 95% CI [1.24–5.22]; p = 0.01). Additionally, patients who achieved therapeutic trough levels of vancomycin late were more likely to develop AKI (OR = 2.59; 95% CI [1.01–6.65]; p = 0.04). Other outcomes were not statistically significant between the two groups.ConclusionEarly achievement of vancomycin therapeutic levels in patients with confirmed Gram-positive infection was associated with possible survival benefits.
Highlights
Vancomycin is a commonly used antibiotic in critically ill patients for various indications
The recent recommendation suggested that the area under the curve (AUC)guided vancomycin monitoring strategy should be utilized in patients with methicillin-resistant Staphylococcus aureus (MRSA) infections due to superiority in efficacy as well as nephrotoxicity data [7, 8]
Result section A total of 2338 critically ill patients were admitted to the intensive care units (ICUs) during the study period; 326 patients were eligible for inclusion
Summary
Vancomycin is a commonly used antibiotic in critically ill patients for various indications. Data are scarce on the clinical impact of time to therapeutic trough levels of vancomycin in critically ill patients. This study aims to evaluate the timing to achieve therapeutic trough level of vancomycin on 30-day mortality in critically ill patients. Vancomycin is still commonly used for suspected or confirmed Gram-positive infections in critically ill patients, despite having newer antimicrobial therapies with MRSA coverage [3,4,5,6,7,8]. Vancomycin dosing and monitoring in critically ill patients is still challenging, despite being in the market for over 60 years [6,7,8]. Due to the complexity of AUC-guided vancomycin monitoring in clinical practice, the vancomycin trough level remains the most common and practical method for monitoring vancomycin efficacy and safety [8]
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