Vancomycin Use Pattern and Therapeutic Drug Monitoring in Adult Patients
Article Sidebar
Main Article Content
Abstract
Patients should receive an optimal dose when commencing vancomycin therapy to ensure the rapid achievement of a therapeutic drug level, and then the measured drug level will be used to determine the vancomycin dose for individuals. However, the common initial dose for this drug for adults in Thailand is 1g intravenous every 12 hours and this may not make the blood concentration reach therapeutic range. Objective To study the pattern of vancomycin use in terms of loading dose and maintenance dose as well as to study the plasma drug concentration, pharmacokinetic parameters and correlation between vancomycin dosing and trough concentration. Methods An observational analytic study was conducted in adult patients with stable renal function for at least 72 hours before commencing intravenous vancomycin. The recommended loading dose for vancomycin is 20-35 mg/kg and the recommended maintenance dose is 15-20 mg/kg with the interval adjusted according to renal function. The therapeutic range of vancomycin in blood is 10-20 mg/L. Results A total of 90 patients were recruited into the study. Thirty-seven patients (42.1%) received a loading dose of vancomycin during initiation of therapy and all patients received a maintenance dose. For the 37 patients who received a loading dose of vancomycin, the loading and maintenance doses complied with recommendations in 28 patients (75.7%). Overall, maintenance doses complied with recommendations in 41 patients (45.6%). Vancomycin concentrations were found to be in the therapeutic range for 39 patients (43.3%). This was higher in patients who received the recommended maintenance dose, with 21 patients (51.2%) showing vancomycin concentrations in the therapeutic range. Augmented renal clearance (ARC) was observed in 21 patients (23.3%). Patients with ARC that received the recommended loading dose were four times more likely to have sub therapeutic levels of vancomycin compared to those with mild-impaired or normal renal function (RR = 4.0, 95%CI 0.11 - 0.42, P < 0.05). In addition, ARC patients who received the recommended maintenance dose of vancomycin were 5 times more likely to have drug levels under the therapeutic range compared to others (RR = 5.07, 95%CI 1.98 - 12.95, P < 0.05). Conclusion Providing an optimal initial dose of vancomycin is a key factor to achieving therapeutic levels of vancomycin in patients with normal renal function, mild renal impairment and augmented renal clearance.
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
In the case that some parts are used by others The author must Confirm that obtaining permission to use some of the original authors. And must attach evidence That the permission has been included
References
Aljutayli A, Marsot A, Nekka F. An update on population pharmacokinetic analyses of vancomycin, part I: in adults. Clin Pharmacokinet 2020 Jun; 59(6): 671-698.
American Pharmacists Association. Drug information handbook: a clinically relevant resource for all healthcare professionals. 28th ed. Alphen aan den Rijn: Wolters Kluwer; 2019.
Bauer LA. Applied Clinical Pharmacokinetics. New York: McGraw-Hill; 2001.
Bland CM and Sutton S. Estimating Renal Function. Sutton S, editor. McGraw Hill’s NAPLEX® Review Guide [Online] 2020 [cited 2021 May 19]. Available from: https://accesspharmacy.mhmedical.com/content.aspx? bookid=3025§ionid=254093345
Bilbao-Meseguer I, Rodriguez-Gascon A, Barrasa H, Isla A, Solinis MA. Augmented renal clearance in critically Ill patients: A systematic review. Clin Pharmacokinet 2018 Sep; 57(9): 1107-1121.
Clinical and Laboratory Standards Institute. M100-ED31:2021 Performance Standards for Antimicrobial Susceptibility Testing, 31st ed. [online] Mar 2021 [cited 2021 Apr 1]. Available from: http://em100.edaptivedocs.net/ GetDoc.aspx?doc=CLSI%20M100%20ED31:2021&xormat=SPDF&src=BB
Chu Y, Luo Y, Ji S, Jiang M, Zhou B. Population pharmacokinetics of vancomycin in Chinese patients with augmented renal clearance. J Infect Public Health 2020 Jan; 13(1): 68-74.
Garrelts JC, Godley PJ, Horton MW, Karboski JA. Accuracy of Bayesian, Sawchuk-Zaske, and nomogram dosing methods for vancomycin. Clin Pharm 1987 Oct; 6(10): 795-799.
Gilbert DN, Chambers HF, Saag MS, Pavia AT, editors. The Sanford guide to antimicrobial therapy 2020. 50th ed. Sperryville: Antimicrobial Therapy; 2020.
He J, Yang ZT, Qian X, Zhao B, Mao EQ, Chen EZ, et al. A higher dose of vancomycin is needed in critically ill patients with augmented renal clearance. Transl Androl Urol 2020 Oct; 9(5): 2166-2171.
Jumah MTB, Vasoo S, Menon SR, De PP, Neely M, Teng CB. Pharmacokinetic/Pharmacodynamic determinants of vancomycin efficacy in Enterococcal Bacteremia. Antimicrob Agents Chemother 2018 Feb 23; 62(3): e01602-1617.
Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int 2020 Oct; 98(4S): S1-S115.
Laboratory medicine Srinagarind Hospital. Percentage of susceptible organisms isolated from all specimens [Online] 2020 [cited 2021 May 19]. Available from: http://202.28.95.4/mdlab/mdclinicallab/ Antibiogram%202020.pdf
Li J, Udy AA, Kirkpatrick CM, Lipman J, Roberts JA. Improving vancomycin prescription in critical illness through a drug use evaluation process: a weight-based dosing intervention study. Int J Antimicrob Agents 2012 Jan; 39(1): 69-72.
Neely MN, Kato L, Youn G, Kraler L, Bayard D, Guilder MV, et al. Prospective trial on the use of trough concentration versus area under the curve to determine therapeutic vancomycin dosing. Antimicrob Agents Chemother 2018 Jan 25; 62(2): e02042-2117.
Riccobono DE, Monteagudo-Chu MO. Vancomycin. Cohen H, editor. Casebook in Clinical Pharmacokinetics and Drug Dosing [Online] 2015 [cited 2021 May 19]. Available from: https://accesspharmacy.mhmedical.com/ content.aspx?bookid=1514§ionid=88805949
Rybak M, Lomaestro B, Rotschafer JC, Moellering RJ, Craig W, Billeter M, et al. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2009 Jan 1; 66(1): 82–98.
Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2020 May 19; 77(11): 835-864.
Sakoulas G, Gold HS, Cohen RA, Venkataraman L, Moellering RC, Eliopoulos GM. Effects of prolonged vancomycin administration on methicillin-resistant Staphylococcus aureus (MRSA) in a patient with recurrent bacteraemia. J Antimicrob Chemother 2006 Apr; 57(4): 699-704.
Truong J, Levkovich BJ, Padiglione AA. Simple approach to improving vancomycin dosing in intensive care: a standardised loading dose results in earlier therapeutic levels. Intern Med J 2012 Jan; 42(1): 23-29.