Vancomycin Trough Levels Research Articles

Evaluation of a modified vancomycin nomogram for obese adults.

The purpose of this study was to compare therapeutic vancomycin trough levels in obese adults when using an original nomogram (phase I) versus a modified nomogram (phase II). This study compared a vancomycin nomogram with a modified vancomycin nomogram for obese adults over 100kg. The primary endpoint compared the percentage of sub-therapeutic, therapeutic, and supra-therapeutic vancomycin trough concentrations between the nomograms. Patients were included if they were at least 18years of age, had a total body weight of 100-299kg, and had an initial vancomycin trough level collected. Patients were excluded if they had end-stage renal disease or were on continuous renal replacement therapy. Therapeutic trough levels occurred in 85 out of 171 patients (50%) in phase I and 98 out of 149 patients (66%) in phase II. The incidence of both sub-therapeutic and supra-therapeutic troughs was less in phase II (p = 0.013). In the subgroup of adults aged 18 to 49 with a normalized creatinine clearance of greater than 90mL/min, there was a trend in more therapeutic levels with the modified nomogram and less chance of sub-therapeutic levels (p = 0.088). In the subgroup of adults with a normalized creatinine clearance of 60-90mL/min, there was significant improvement in therapeutic levels and a decrease in supra-therapeutic levels without increasing the percent of sub-therapeutic levels (p = 0.001). The modified vancomycin nomogram at Cone Health showed significant improvement in therapeutic trough concentrations while reducing the rates of under and over dosing obese adults. The Cone Health-modified vancomycin nomogram could be a useful tool for initial dosing of vancomycin in the obese population.

Attention to age: similar dosing regimens lead to different vancomycin levels among older and younger patients.

little is known on the clinical implications of vancomycin trough levels among older patients. to evaluate the association between vancomycin levels and outcomes among older versus younger patients. retrospective study. patients aged 18-64 and ≥65years treated with vancomycin for documented methicillin resistant Staphylococcus aureus (MRSA) infections. we compared the effectiveness and toxicity of vancomycin according to trough levels in older versus younger patients. Subgroup analysis of patients with glomerular filtration rate (GFR) > 60ml/min/1.73m2 was performed. we included 181 patients aged ≥65years and 104 younger patients. Mean age in the older group was 76.9 ± 8years versus 50.9 ± 12.4 in the younger group. Vancomycin trough levels and 24-hours area under the curve to minimal inhibitory concentrations (AUC/MIC) were significantly higher in older patients who were also significantly more likely to achieve trough levels of ≥15mg/l within 4days, (98/181 (54.1%) vs. 38/104 (36.5%) in younger patients, P = 0.004). Results were similar among patients with GFR > 60. Thirty-day mortality was significantly higher in older (74/181, 40.9% vs. 13/104, 12.5%, respectively, P < 0.001). There was no association between vancomycin trough levels and mortality among older patients. No significant differences were demonstrated in clinical or microbiological success or nephrotoxicity. applying uniform dosing recommendations across age groups among adults with MRSA infections results in higher vancomycin levels and AUC/MIC in older versus younger patients. Yet, mortality rates remain higher among older adults. Prospective studies are needed to define the optimal approach for using this drug in older patients.

1430. The Hidden Costs of Vancomycin Use During the Treatment of Staphylococcus aureus Bacteremia Concurrent with Acute Hematogenous Osteomyelitis

BackgroundCurrent guidelines recommend the use of parenteral vancomycin for children with acute hematogenous osteomyelitis and concurrent Staphylococcus aureus bacteremia (SAB) due to Methicillin-Resistant Staphylococcus aureus (MRSA), despite vancomycin’s slow bactericidal activity. This study explores the hidden costs of this approach.MethodsChildren with AHO and concurrent SAB, treated from 2009 to 2018, who had received vancomycin at some point during their treatment course were studied. Data collected included antibiotic susceptibilities; duration of bacteremia, blood culture results, duration of vancomycin; number of dose/interval changes; vancomycin trough and creatinine levels; rate of achieving target trough; use of other nephrotoxic agents; occurrence of acute kidney injury (AKI); and length of stay.Results130 children diagnosed with AHO and concurrent SAB received vancomycin. Isolates were CR MSSA (3 or 2.3%), CR MRSA (5 or 3.8%), CS MSSA (35 or 26.9%), and CS MRSA (87 or 66.9%). Mean LOS was 14.6 days. 1,312 blood cultures were obtained (503 positive cultures and 809 negative cultures). Bacteremia persisted an average of 3.6 days. Target trough level (15–20 µg/mL) was achieved in 65 children (50%) within an average of 3.4 days of initial dosing. Attempts to reach therapeutic levels were abandoned in 32 children (24.6%) as MSSA was isolated before the trough. There were 319 vancomycin dose and/or interval changes, 1,192 serum creatinine levels, and 689 vancomycin trough levels obtained. Fourteen children (10.8%) experienced AKI. Additional nephrotoxicity exposure included: NSAIDs (127), IV contrast (100), loop diuretics (37), and aminoglycosides (11).ConclusionThis study exposes and quantifies a substantial amount of resources devoted to dosing adjustments and serum level monitoring for vancomycin use in children with AHO and concurrent SAB. The cost differential in comparison to that of newer antibiotic alternatives is undermined by the effort to attain therapeutic target levels, resolve bacteremia, and address episodic AKI. If vancomycin is utilized, a deliberate approach should be taken to minimize risk of toxicity, including AUC/MIC ratio calculation, as opposed to therapeutic level monitoring, and avoid the concurrent use of other nephrotoxic agents. Disclosures All authors: No reported disclosures.

1572. Evaluation of Vancomycin Levels Following Weight-Based Pre-operative and Re-warming Vancomycin Dosing in Cardiac Surgery

BackgroundWeight-based dosing of vancomycin in the pre-operative setting is standard practice at our institution based on the 2013 Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. Our antimicrobial subcommittee recommended a weight-based dosing (15 mg/kg/dose) approach to negate the need for a subsequent vancomycin dose during rewarming in cases requiring cardiopulmonary bypass (CPB). However, after discussion with all perioperative stakeholders, administration of vancomycin 1 g intravenously for all patients on CPB at rewarming continued. The aim of this study was to determine whether subsequent rewarming vancomycin doses contributed to the development of postoperative acute kidney injury (AKI).MethodsThis was a prospective cohort study of all cardiac surgery patients undergoing surgery from April 16, 2018 through April 27, 2018 for the development of AKI as defined by RIFLE criteria. Institutional guidelines recommend vancomycin as perioperative prophylaxis in all cardiac surgery cases with a preoperative 15 mg/kg dose, a 1 g rewarming dose, and nomogram-based post-operative dosing. Vancomycin troughs were obtained prior to the first post-operative dose in the intensive care unit. Serum creatinine was recorded on the post-op day (POD) 0, POD 1, and POD 7.ResultsData were collected on 54 patients over a 2-week period. The median age was 64 years of age, with 41 (76%) male patients. Seven patients (13%) had a prior diagnosis of chronic kidney disease (CKD). Post-op AKI developed in 8 patients (15%) by POD 7; two of which had CKD at baseline. All patients received appropriate preoperative and postoperative dosing. Forty-nine (91%) patients had trough levels obtained, with the median trough 7.6 μg/mL (range 2 – 15.9 μg/mL) prior to the first nomogram-based post-operative vancomycin dose. Higher rates of AKI were associated with a longer duration of CPB rather than vancomycin levels obtained.ConclusionThe current practice of redosing 1 g vancomycin at rewarming did not appear to contribute higher rates of AKI. In addition, all vancomycin trough levels reviewed were less than 20 μg/mL. Levels observed in this study are lower than previously described in the literature to cause nephrotoxicity. Further evaluation of vancomycin use in this setting is warrantedDisclosures All authors: No reported disclosures.

Automating Vancomycin Monitoring to Improve Patient Safety

Intravenous vancomycin is a frequently used antibiotic and a common cause of medication-related harm because of its narrow therapeutic range. Improving monitoring of drug levels with automation in the electronic health record (EHR) may decrease this harm. After examining the existing state of vancomycin ordering, administration, and monitoring, an automated process was created in the EHR that, on initiation of a new vancomycin order, automatically ordered a vancomycin trough level 30 minutes before the fourth dose. In addition, a nursing alert was integrated into the bar coding medication administration process that, if no trough level had been drawn by the time of the administration of the fourth dose, prompted the nurse to draw a trough level. Data from a three-month, post-implementation period was compared to data from a preceding three-month period. The frequency of trough levels drawn between the third and fourth dose increased from 58.6% to 75.8% (p < 0.01). However, the percentage of trough levels drawn within one hour of the fourth dose remained unchanged, possibly because nursing staff waited for the result of the level prior to administering the next dose of vancomycin. A minority of patients in both groups had trough levels that were in range (difference between groups, p = 0.46). Automation of vancomycin monitoring was associated with improvement in the frequency of monitoring and only delayed medication dosing by six minutes. Because vancomycin is high risk, this type of process should be broadly implemented, and outcomes should be assessed to identify unexpected outcomes and necessary further refinements.

Vancomycin-associated nephrotoxicity in non-critically ill patients admitted in a Brazilian public hospital: A prospective cohort study.

IntroductionVancomycin is widely used to treat infections caused by Gram positive bacteria, mostly methicillin-resistant strains. Despite its therapeutic effectiveness, vancomycin is a nephrotoxic drug that has been associated with the occurrence of acute kidney injury (AKI). In this study, we sought to evaluate the variability of serum trough concentrations of vancomycin and to determine the incidence and risk factors of vancomycin-associated nephrotoxicity (VAN) in non-critically ill patients.MethodsThis was a prospective cohort including Brazilian public hospital inpatients from April 2017 to June 2018. The participants received intravenous vancomycin therapy for at least 48 hours for any suspected or confirmed infection by Gram positive bacteria. Demographic, clinical and laboratory data were collected. Information on vancomycin therapy and concomitant use of other nephrotoxic drugs were also recorded. Patients were followed up until discontinuation of vancomycin treatment or death, whatever occurred first. The primary outcome was the occurrence of AKI. We performed a Poisson regression to determine risk factors for AKI.ResultsOverall, 98 participants were included in the study. Median age was 55.9 (interquartile range [IQR] 40.6–66.8) years and 58 (59.2%) were men. Most of them showed subtherapeutic (<10mg/L) or supratherapeutic (>20mg/L) trough levels of vancomycin; 42.9% and 15.3%, respectively. A total of 19 (19.4%) patients developed AKI. Poisson regression showed that male sex (odds ratio [OR] 2.90; confidence interval [CI] 95% 1.28–6.53; p = 0.011), concomitant use of piperacillin-tazobactam (OR 4.66; CI 95% 2.26–9.58; p <0.001) and vancomycin trough levels above 20mg/mL (OR 4.21; CI 95% 1.57–11.278; p = 0.004) were independently associated with AKI.ConclusionsOur study showed that usual doses of vancomycin did not reach recommended therapeutic serum trough levels of vancomycin in non-critically ill patients. Besides that, nephrotoxicity was common in this population, being associated with male sex, concomitant use of piperacillin-tazobactam and supra-therapeutic trough serum levels of vancomycin.

The influencing factors achieving target vancomycin trough level in critically ill patients

Objective: To assess the rate achieving the target vancomycin trough level (VTL) and its influencing factors in critically ill patients. Methods: The retrospective observational study recruited adult patients treated with intravenous vancomycin in the intensive care unit (ICU) at Zhongda Hospital from January 2015 to December 2017. Serum VTL was tested at steady state. Patients' demographics, the sites of infection, microbial culture results, the severity of illness, laboratory data and vancomycin regimen were obtained at the baseline. The rate achieving target VTL (15-20 mg/L) was analyzed based on renal function. Linear regression was performed to determine the influencing factors of VTL. Results: A total of 85 patients were enrolled, among whom only 23.5% (20/85) achieved the target VTL. In patients with normal renal function, the achieving rate was only 11.4% (4/35), and 80.0% (28/35) was lower than the target trough level multiple linear regression analysis showed that procalcitonin (PCT), estimated glomerular filtration rate (eGFR) and acute physiology and chronic health disease classification system Ⅱ (APACHE Ⅱ) score were independent factors associated with VTL. Conclusion: Achieving target VTL in critically ill patients is not satisfactory. Further study to optimize the administration is needed to facilitate prompt attainment of target VTL.

Evaluation of vancomycin initial trough levels in children: a one-year retrospective study

Purpose: Achieving vancomycin therapeutic levels is essential for antibacterial success and resistance prevention. Multiple pediatric studies have shown that most of the children fail to reach therapeutic vancomycin trough levels (10-20 mcg/mL) while receiving the conventional doses. The objective is to determine the frequency of achieving therapeutic vancomycin initial trough levels in children receiving an empiric dose of 15 mg/kg/dose every 6 hours. Secondary objectives are to evaluate the effect of age on both that achievement and the mean initial trough levels, and to …

Correlation between serum vancomycin trough level and therapeutic response in septic patients during augmented renal clearance phase

Background: Vancomycin is a glycopeptide antibiotic that was extensively used for treatment of gram positive infections. Therapeutic drug monitoring (TDM) is recommended to optimize efficacy and safety of vancomycin. Data regarding TDM of vancomycin are scant in septic patients especially during augmented renal clearance (ARC) phase. Methods: In this observational study, 39 patients with diagnosis of sepsis that were in ARC phase were evaluated. The breakpoint for serum trough level of vancomycin was considered as 15 mg/l. The patients were stratified in two groups based on the measured serum trough levels (&lt; 15 mg/l versus ≥15 mg/l). Results: Clinical response and microbiological clearance were compared between the groups. In terms of clinical response, there was no significant difference between the groups (P = 0.677). Also, the microbiological clearance was not different between the groups (P= 1.00). Conclusion: Septic patients during ARC phase had comparable clinical and microbial responses regardless of serum trough levels of vancomycin.

Assessment of Empiric Vancomycin Regimen in the Neonatal Intensive Care Unit

Vancomycin is used to treat serious gram-positive infections in neonates. Currently, there is no consensus on the preferred empiric dosing regimen or target trough vancomycin levels for neonates. The current Fraser Health empiric dosing regimen, implemented in 2010, was designed to achieve target trough levels of 5 to 15 mg/L. To determine the percentage of neonates receiving vancomycin in whom target trough levels of 5 to 15 mg/L were achieved, to identify the times to negative culture result and clinical resolution, and to determine the incidence of nephrotoxicity. A chart review was completed for patients who had received vancomycin in the neonatal intensive care unit of either Surrey Memorial Hospital or Royal Columbian Hospital from June 2012 to May 2017 and for whom at least 1 interpretable vancomycin level was available. A total of 87 vancomycin encounters (in 78 neonates) were identified in which the drug had been given according to the Fraser Health empiric dosing regimen. Target trough vancomycin level (5 to 15 mg/L) was achieved in 75% of these encounters. The mean times to negative culture result and clinical resolution were 5 and 6 days, respectively. There was no statistically significant correlation between vancomycin level and time to clinical resolution (rs = 0.366, p = 0.072). Among cases in which the trough vancomycin level exceeded 15 mg/L, the incidence of nephrotoxicity was 22% (4/18). The current Fraser Health empiric dosing regimen for vancomycin achieved target trough levels of the drug for most neonates in this study. Targeting trough levels less than 15 mg/L when appropriate to the infection type may limit nephrotoxicity associated with vancomycin in neonates. Further studies are needed to evaluate the clinical significance of various vancomycin levels.

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

Vancomycin is one of the commonly used anti-microbial drugs in intensive care units (ICUs). Guidelines recommend maintaining therapeutic trough levels of vancomycin (10-20mg/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 inchildren admitted in the ICU who were administered vancomycin. We carried out a chart review of children admitted in the paediatric ICU unit of a tertiary care hospital over a period of 3years. 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. 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 (10-20mg/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 20mg/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. 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.

The association of vancomycin trough levels with outcomes among patients with methicillin-resistant Staphylococcus aureus (MRSA) infections: Retrospective cohort study.

IntroductionCurrent guidelines recommend maintaining vancomycin trough concentrations between 15–20 mg/L for serious methicillin resistant staphylococcus aureus (MRSA) infections. This recommendation is based on limited evidence.MethodsA retrospective study including patients with vancomycin susceptible MRSA infections (MIC< = 2 mg/L), treated with vancomycin. We compared outcomes among patients attaining high (> = 15mg/L) vs low (<15mg/L) trough vancomycin levels. We used a propensity score to matching patients achieving low and high levels and conducted an adjusted analysis in the propensity score (PS)-matched cohort using regression analysis. Primary outcome was 30-day all-cause mortality.ResultsAmong 285 patients included, there were no significant differences between patients achieving high and low vancomycin levels in mortality (46/131, 35.1% vs 41/154, 26.6%), clinical success, microbiological success, or nephrotoxicity. Similarly, in the PS-matched cohort (n = 162), there was no significant difference in mortality between patients with high and low vancomycin levels (24/53, 45.3% vs 57/109, 52.3%, respectively), adjusted odds ratio for mortality with high levels 0.63 (95% confidence interval 0.28–1.43). In both cohorts, patients with pneumonia achieving high levels had significantly higher clinical and microbiological success (PS-matched cohort: clinical success: 16/32, 50.0% vs 5/27, 18.5%, p = 0.012; microbiological success: 19/32, 59.4% vs 7/27, 25.9%, p = 0.010), without significant differences in mortality.ConclusionsWe found no association between vancomycin levels > = 15 mg/L and clinical outcomes in patients with MRSA infections. In patients with MRSA pneumonia, vancomycin levels > = 15 mg/L were associated with higher clinical success rates. Further larger cohort studies are needed to define optimal vancomycin levels according to the site of infection.

The Effect of Hypoalbuminemia on the Therapeutic Concentration and Dosage of Vancomycin in Critically Ill Septic Patients in Low-Resource Countries.

Purpose:To determine whether severe hypoalbuminemia (<25 mg/L) has a significant effect on serum levels of vancomycin and whether it can effect vancomycin dosage regimen and the loading dose administration.Material and Methods:Prospective, cohort, and a single-center study included 61 patients whose vancomycin serum levels were measured in steady state. Vancomycin trough levels (C min) that were in the range 15 to 20 µg/mL were considered therapeutic and trough levels higher than 15 µg/mL were considered potentially nephrotoxic.Results:In the group of patients with severe hypoalbuminemia, C min was significantly higher compared to the those with nonsevere hypoalbuminemia (>25 mg/L; 23.04 [19.14] vs 13.28 [11.28], P = .01). In the group of patients who received the vancomycin loading dose of 2 g, C min was significantly higher in patients with severe hypoalbuminemia compared to the patients with nonsevere hypoalbuminemia (34.52 [25.93] vs 15.37 [10.48], P = .04).Conclusion:In critically ill septic patients with severe hypoalbuminemia, there is a high probability that the loading dose of vancomycin is not necessary since it is associated with potentially toxic vancomycin C min, while in the patients with nonsevere hypoalbuminemia the loading dose may be necessary to achieving therapeutic C min.

Vancomycin-Associated Acute Kidney Injury in Critically Ill Adolescent and Young Adult Patients

Background: Risk factors for the development of vancomycin-associated acute kidney injury (AKI) have been evaluated in both pediatric and adult populations; however, no previous studies exist evaluating this in the critically ill adolescent and young adult patients. Objective: Identify the incidence of AKI and examine risk factors for the development of AKI in critically ill adolescents and young adults on vancomycin. Methods: This retrospective review evaluated the incidence of AKI in patients 15 to 25 years of age who received vancomycin, while admitted to an intensive care unit. Acute kidney injury in this population was defined as an increase in serum creatinine by 0.5 mg/dL or 50% from baseline. Patients who developed AKI were evaluated for specific risk factors compared to those who did not develop AKI. Results: A total of 50 patients (20 developed AKI) were included in the study. There was no difference in vancomycin daily dose or duration of vancomycin therapy. Maximum vancomycin trough (31.15 mg/dL vs 12.5 mg/dL, P = .006), percentage of patients with concurrent nephrotoxic medication (95% vs 60%, P = .012) and concurrent vasopressor (55% vs 23%, P = .029) were higher in those who developed AKI. Percentage of patients who underwent a procedure while on vancomycin (35% vs 6.7%, P = .021) was also higher within the AKI group. Conclusions: Vancomycin-associated AKI occurred in 40% of critically ill adolescent and young adult patients. These patients may be more likely to develop vancomycin-associated AKI if they had undergone a procedure, as well as in the presence of high vancomycin trough levels, concurrent nephrotoxic agents, and concurrent vasopressor therapy.

Low Serum Trough Concentrations and High Vancomycin Minimum Inhibitory Concentration in Methicillin-Sensitive Staphylococcus aureus From Hemodialysis Patients in Brazil.

The empiric antimicrobial therapy for bacteremia of long-term hemodialysis (HD) outpatients is currently based on the combination of vancomycin and gentamicin because of the high frequency of isolated Staphylococcus species. The vancomycin trough level range from 15 to 20 mcg/mL is expected for therapeutic success against methicillin-resistant Staphylococcus aureus with vancomycin minimum inhibitory concentration (MIC) ≥1.0 mcg/mL. Despite the availability of clinical practice guidelines for vancomycin therapeutic drug monitoring, these target serum concentrations are not reached in many patients. In this study, the authors investigated the vancomycin trough levels in 20 HD patients with S. aureus bacteremia and the antimicrobial susceptibility pattern of 45 S. aureus strains isolated from 45 HD patients. The vancomycin serum concentration was determined by chemiluminescent assay. The MIC was determined by broth microdilution method. None of the HD patients included in this study had vancomycin trough concentrations within the therapeutic range. Also, the vancomycin MIC for most methicillin-sensitive S. aureus isolated from bacteremia was ≥1.0 mcg/mL. The therapeutic range of vancomycin was not achieved, and vancomycin MIC was surprisingly high in methicillin-sensitive S. aureus.

Are Blacks at Higher Risk for Vancomycin-Related Acute Kidney Injury?

Background: Black individuals have a higher lifetime risk of acute kidney injury (AKI) and chronic kidney disease than whites. Vancomycin has a potential for nephrotoxicity. The objective of this study was to determine whether the incidence of AKI among patients being treated with vancomycin differs by race. Methods: Retrospective study of adult (3 ≥18 years) inpatients who were on vancomycin for 348 hours between January 2012 and December 2014. Data on demographics, comorbid conditions, clinical characteristics, vancomycin dose, duration, and nephrotoxic drugs were collected. Patients with a creatinine clearance <30 mL/min or undergoing dialysis were excluded. Results: We identified 1130 patients during the study period; 48.1% (544) were black. The overall incidence of AKI was 8.2% (10.1% blacks, 6.5% whites; P = .03). Independent predictors of AKI included black race (P = .011); higher Charlson score (P = .006); higher body mass index (BMI; P = .002); higher vancomycin trough level (P < .0001); and sepsis/systemic inflammatory response syndrome (<.0001), pneumonia (P = .001) or gastrointestinal/genitourinary (P = .025) as the source of infection. Conclusion: The incidence of vancomycin-related AKI was higher in blacks, independent of other risk factors. Based on our study, vancomycin trough levels and renal function need to be closely monitored in blacks.

Elevated Vancomycin Trough Levels in a Tertiary Health System: Frequency, Risk Factors, and Prognosis

ObjectiveTo investigate the frequency of, risk factors for, and outcomes after elevated levels of vancomycin. Patients and MethodsWe identified hospitalizations among 21,285 individuals in which intravenous vancomycin was given between August 29, 2007, and October 10, 2014. We investigated frequency and risk factors for elevated vancomycin levels (trough levels >30 mg/L) as well as associations with subsequent acute kidney injury (AKI), length of stay, and in-hospital mortality. ResultsAmong the 21,285 patients, the mean age was 62.9 years, and 10,478 (49.2%) were female. Trough levels of vancomycin were checked in 7422 patients, and 755 elevated levels were detected. Compared with patients with trough levels checked but no elevated levels found, those with elevated levels had longer duration of vancomycin therapy (median, 6.0 days vs 3.4 days; P<.001) and slightly higher doses (mean, 1.72 g vs 1.58 g; P<.001). Patients with higher body mass index or lower estimated glomerular filtration rate had more elevated levels. In propensity-matched analyses, patients had higher risk of incident AKI after elevated levels compared with patients without elevated levels (hazard ratio, 1.55; 95% CI, 1.09-2.20; P=.02), as well as longer subsequent length of stay (relative risk, 1.14; 95% CI, 1.02-1.28; P=.03) but similar in-hospital mortality. ConclusionIn this study, elevated vancomycin levels were common, particularly in patients with higher body mass index and lower estimated glomerular filtration rate, and were associated with greater subsequent AKI and length of stay.

High sensitivity versus low level of vancomycin needs to be concern for another alternative anti- Staphylococcus aureus as the first- line antibiotic.

Background and aim: Vancomycin has been the first-line therapy for MRSA infection disease for many years. According to standard guidelines, the therapeutic vancomycin trough concentration should be above 10 mg/L and optimally between 15-20 mg/L. The aim of this study was to evaluate vancomycin trough level concentration in patients infected with MRSA.Methods: This cross- sectional study included a sample of 170 patients admitted to the ICU of Loghman hospital. We used a standard questionnaire, then applied appropriate statistical tests. All collected data had been analyzed and interpreted by IBM SPSS Statistics 19.0.Results: Among this study population, 71.8% was male. Just 20.8% of the patients can reach the therapeutic level trough even after changing the dose. It should be noted that a significant percentage of toxicity was observed after increasing the dose. Conclusions: Even though high sensitivity against vancomycin disc has been seen in antibiogram tests, sufficient efficiency has not been distinguished, in the sense that, just a few patients by low trough level concentration, reached to therapeutic level after the dose change. Based on some sources, because of the side effects and limited safe range of vancomycin, we should consider a new approach to the alternative antibiotics. (www.actabiomedica.it)

Prospective evaluation of vancomycin therapeutic usage and trough levels monitoring.

Vancomycin is the cornerstone of parenteral therapy for serious methicillin resistant Staphylococcus aureus infections. Optimal dosing of vancomycin is patient specific due to its narrow therapeutic window. The objective of this study is to evaluate the appropriate use of vancomycin focusing on the indication, dose, and therapeutic level monitoring. A prospective observational study was conducted in a tertiary care hospital over a 3- month period. A data collection form was used to gather information on 93 patients receiving vancomycin. Study outcomes were assessment of the appropriateness of vancomycin indication, dose, and therapeutic trough level. The use of vancomycin both empirically and after culture results was appropriate in 78.5 % of the patients. More than half of the patients (51.6 %) were given an inappropriate dose of vancomycin per actual body weight, creatinine clearance, and indication. Regarding therapeutic vancomycin monitoring, 69.0 % had inappropriate trough level monitoring. Only 15.7 % of the 166 measured troughs were within the target therapeutic level for the corresponding indication. This study demonstrates the high level of inappropriate use of vancomycin. This is mainly attributed to inappropriate dose and trough level monitoring. Interventions to improve vancomycin prescribing and monitoring practices are needed. The presence of an interdisciplinary team may improve the appropriate use of medications with a narrow therapeutic index such as vancomycin.

Vancomycin trough level and loading dose

Vancomycin trough level and loading dose