Oral vancomycin in staphylococcal septicaemia of bowel origin in neonates

Does oral vancomycin use necessitate therapeutic drug monitoring?

PURPOSE

Oral vancomycin use has generally increased as a consequence of the need to treat and/or prevent Clostridium (Clostridiodes) difficile-associated disease (CDAD). This review examines the cumulative scientific evidence that guides therapeutic monitoring of oral vancomycin therapy.

METHODS

The existing publications were reviewed from the time of the drug's inception to July 2019. This review utilized access as available in PubMed, EMBASE, CINAHL Plus, and the Cochrane Library.

RESULTS

Case reports and small patient series have documented anecdotal-associated elevations in serum levels. Correlation of absorbed vancomycin with subsequent toxicity is difficult to determine, but serum levels approaching those obtained after parenteral administration have raised concern. Prolonged usage and total dosing over 500 mg/day among adult age ranges have been associated with accumulation. In addition, risk factors for vancomycin accumulation systemically after oral dosing include renal compromise, combined oral and other enteral therapy, severe CDAD, other intercurrent bowel inflammation, polypharmacy, and increased patient complexity/morbidity.

CONCLUSION

Until systemic toxicity from oral vancomycin absorption is better understood, individual considerations should be made for therapeutic serum monitoring during oral vancomycin treatment. Therapeutic drug monitoring is suggested for several high-risk situations in which high blood levels may be anticipated.

Infection rates in surgical neonates and infants receiving parenteral nutrition: a five-year prospective study

We performed a prospective, observational, cohort study on 208 surgical neonates and infants between 1992 and 1997. Surveillance cultures of the oropharynx and rectum were obtained at the start of parenteral nutrition and thereafter twice weekly. Blood cultures were taken on clinical indication only. Microbial translocation was diagnosed when the micro-organisms in the blood were not distinguishable from those carried in the oropharynx and/or rectum. Liver function was monitored weekly and when septicaemia was suspected. The incidence of septicaemia was 15%. The predominant micro-organisms (86%) were the low-level pathogens, coagulase-negative staphylococci and enterococci. Potential pathogens, including aerobic Gram-negative bacilli, were responsible for the remainder. Microbial translocation was responsible for 84% of septicaemic episodes in 76% of patients. The potential pathogens caused septicaemia significantly later than coagulase-negative staphylococci, at a time when liver function was significantly more impaired. In neonates and infants receiving parenteral nutrition, septicaemia is mainly a gut-derived phenomenon and requires novel strategies for prevention.