Abstract
BackgroundThis systematic review and meta-analysis explored the relationship between vancomycin (VCM) monitoring strategies and VCM effectiveness and safety.MethodsWe conducted our analysis using the MEDLINE, Web of Sciences, and Cochrane Register of Controlled Trials electronic databases searched on August 9, 2020. We calculated odds ratios (ORs) and 95% confidence intervals (CIs).ResultsAdult patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia with VCM trough concentrations ≥15 μg/mL had significantly lower treatment failure rates (OR 0.63, 95% CI 0.47–0.85). The incidence of acute kidney injury (AKI) increased with increased trough concentrations and was significantly higher for trough concentrations ≥20 μg/mL compared to those at 15–20 μg/mL (OR 2.39, 95% CI 1.78–3.20). Analysis of the target area under the curve/minimum inhibitory concentration ratios (AUC/MIC) showed significantly lower treatment failure rates for high AUC/MIC (cut-off 400 ± 15%) (OR 0.28, 95% CI 0.18–0.45). The safety analysis revealed that high AUC value (cut-off 600 ± 15%) significantly increased the risk of AKI (OR 2.10, 95% CI 1.13–3.89). Our meta-analysis of differences in monitoring strategies included four studies. The incidence of AKI tended to be lower in AUC-guided monitoring than in trough-guided monitoring (OR 0.54, 95% CI 0.28–1.01); however, it was not significant in the analysis of mortality.ConclusionsWe identified VCM trough concentrations and AUC values that correlated with effectiveness and safety. Furthermore, compared to trough-guided monitoring, AUC-guided monitoring showed potential for decreasing nephrotoxicity.
Highlights
This systematic review and meta-analysis explored the relationship between vancomycin (VCM) monitoring strategies and VCM effectiveness and safety
A recent meta-analysis revealed that compared to low area under the curve/minimum inhibitor concentration ratios (AUC/Minimum inhibitor concentration (MIC)), high Area under the curve (AUC)/MIC ratios were associated with significantly lower mortality and treatment failure rates [3]
Search results In database searching for VCM target trough concentrations evaluation, we obtained 3293 articles to be screened (Fig. 1a)
Summary
This systematic review and meta-analysis explored the relationship between vancomycin (VCM) monitoring strategies and VCM effectiveness and safety. The practice guidelines for TDM of VCM recommended an AUC/MIC ratio of ≥400 to predict the clinical efficacy of VCM against MRSA (MIC ≤1 μg/mL) [4, 5]. The target AUC/MIC value, which is an indicator of effectiveness in MRSA infection therapy, is still controversial. In real-world clinical situations, trough concentrations are used as alternate indicators of AUC values, and in practice, target trough concentrations between 10 and 20 μg/mL are recommended to achieve an AUC/MIC ratio of ≥400 at MIC values of 0.5 and 1 μg/mL. Tongsai et al performed a meta-analysis to clarify the relationship between trough concentrations and effectiveness. They reported that no significant differences in mortality and treatment success rate between trough concentrations of ≥15 and < 15 μg/mL [8]. A reanalysis of the relationship between trough concentrations and effectiveness is needed
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