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RUIZ J, GARCÍA-ROBLES A, MARQUÉS MR, COMPANY MJ, SOLANA A, POVEDA JL. Influence of pharmacokinetic/pharmacodynamic ratio on vancomycin treatment response in pediatric patients with Staphylococcus aureus bacteremia. Minerva Pediatr (Torino) 2022; 74:525-529. [DOI: 10.23736/s2724-5276.18.04978-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Sridharan K, Abbasi MY, Mulubwa M. Population Pharmacokinetics and Dose Optimization of Vancomycin in Critically Ill Children. Eur J Drug Metab Pharmacokinet 2021; 46:539-546. [PMID: 34156647 DOI: 10.1007/s13318-021-00695-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Critically ill children may exhibit varied vancomycin pharmacokinetic parameters mainly due to altered protein binding, extracellular volume, and renal elimination. The objective of this study was to assess the pharmacokinetics of vancomycin in critically ill children and determine the optimum dose regimen. METHODS This was a cross-sectional study of critically ill children admitted to a pediatric intensive care unit. They received vancomycin dose of 15 mg/kg every 8 h for mild infections or every 6 h if infection was moderate or severe. A nonlinear mixed-effects modeling approach was applied in estimating pharmacokinetic parameters using Monolix 2019R2®. We performed Monte Carlo simulations to assess and optimize the dosing regimen using Simulx®. We used the ratio of the area under the concentration-time curve up to 24 h to minimum inhibitory concentration (AUC0-24/MIC) ≥ 400 as the pharmacokinetic-pharmacodynamic target. RESULTS Fifty-eight critically ill children with 145 concentrations were included in the present study. A one-compartment pharmacokinetic model with linear elimination described the concentration-time profile well. The estimated median (95% confidence intervals) volume of distribution (Vd) was 13.3 (10.8-16.5) l and clearance (CL) was 1.23 (1.03-1.45) l/h. Creatinine clearance significantly affected the CL of vancomycin. Monte Carlo simulations revealed that a dose of either 15 mg/kg 6 hourly or 20 mg/kg 8 hourly was likely to result into most critically ill children attaining the vancomycin lead pharmacokinetic-pharmacodynamic target. CONCLUSION We established pharmacokinetic parameters of vancomycin for critically ill children. We also observed that the current dosing regimen practiced in the intensive care unit was inadequate for achieving the pharmacokinetic-pharmacodynamic target. We recommend vancomycin dose escalation in critically ill pediatric patients from 15 mg/kg 8 hourly (current dosing regimen) to either 6 hourly or 20 mg/kg 8 hourly with intense therapeutic drug monitoring for adverse effects.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain.
| | - Mohammad Yaseen Abbasi
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Mwila Mulubwa
- Drug Discovery and Development Centre (H3D), Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
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Salem M, Khalil A, Mohamed A, Elmasoudi A. Evaluation of vancomycin initial trough levels in children: A 1-year retrospective study. SAGE Open Med 2020; 8:2050312120951058. [PMID: 32922785 PMCID: PMC7453445 DOI: 10.1177/2050312120951058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/24/2020] [Indexed: 11/17/2022] Open
Abstract
Background and objectives Achieving vancomycin therapeutic levels is essential for antibacterial success and resistance prevention. Multiple studies have shown that most of the children fail to reach therapeutic trough levels (10-20 µg/mL). This study aims to determine the frequency of achieving therapeutic vancomycin initial trough levels in children, evaluate the effect of age on that achievement and the mean initial trough levels, and the frequency of supratherapeutic levels. Methods Children aged 1 month to 12 years who received three or more vancomycin doses 15 mg/kg every 6 h while admitted at our hospital from February 2016 to January 2017, and had a level before the fourth dose were included. Cases with high baseline serum creatinine, acute kidney injury, and congenital heart disease were excluded. Results Out of 75 included cases, one third, 28/75 (37.3%), achieved goal. The lowest frequency was 6/28 (21.4%) of the 2-5 years group, which were statistically less likely to achieve, and had significantly lower mean initial trough than the 1-23 months group (P = 0.026 and 0.013, respectively). Mean initial trough levels were 10.1, 7.3, and 8.2 µg/mL in the 1-23 months, 2-5 years, and 6-12 years groups, respectively (P = 0.014). No supratherapeutic levels were observed. Conclusion Vancomycin dose of 60 mg/kg/day is insufficient to attain target levels for most of the children. Children aged 2-5 years are the least likely to achieve and have the lowest mean levels. More intensified doses are warranted to be studied prospectively to identify the most effective empiric dose for children.
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Affiliation(s)
- Muhammad Salem
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Khalil
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Asmaa Mohamed
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Elmasoudi
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
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Dolan E, Hellinga R, London M, Ryan K, Dehority W. Effect of Vancomycin Loading Doses on the Attainment of Target Trough Concentrations in Hospitalized Children. J Pediatr Pharmacol Ther 2020; 25:423-430. [PMID: 32641912 DOI: 10.5863/1551-6776-25.5.423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Subtherapeutic vancomycin trough concentrations are common in children and may be associated with suboptimal therapeutic response. Our objective was to determine if vancomycin loading doses safely increase the frequency of target trough attainment in hospitalized children. METHODS Patients (≥6 months and <18-years-old) who received a vancomycin loading dose between February 1, 2018, and January 30, 2019, were retrospectively enrolled. These patients were compared to a convenience cohort of patients hospitalized between January 1, 2015, and December 31, 2015, who received vancomycin without a loading dose. Target trough concentrations were defined as >15 mg/dL for invasive infections and >10 mg/dL for non-invasive infections. RESULTS A total of 151 patients were enrolled, with 77 in the control arm and 74 in the loading dose arm. There was no significant difference in the frequency of comorbidities or need for intensive care unit admission between the two arms. Those receiving a vancomycin loading dose were older (mean age 9.1 vs 5.2 years, p < 0.0001). Patients given a loading dose achieved higher mean initial trough values (13.0 mg/dL vs 9.2 mg/dL, p < 0.0001), were more likely to have an initial trough at or above target (37.0% vs 10.4%, p = 0.0001), were more likely to reach target trough values at any point during therapy (52.1% vs 32.9%, p = 0.0081), and attained a target trough concentration more quickly (mean 41.1 hours vs 58.8 hours, p = 0.0118). There were no significant differences in the frequency of serum creatinine elevation or oliguria at the end of therapy. CONCLUSIONS Vancomycin loading doses may improve the ability to safely obtain target trough values in hospitalized children.
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Chow TCH, Li JYS, Wong JCL, Poon FMH, Lam HS, Lam TTN, Lee CP, Ewig CLY, Cheung YT. Vancomycin Prescribing Practices and Therapeutic Drug Monitoring for Critically Ill Neonatal and Pediatric Patients: A Survey of Physicians and Pharmacists in Hong Kong. Front Pediatr 2020; 8:538298. [PMID: 33330263 PMCID: PMC7734090 DOI: 10.3389/fped.2020.538298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/04/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Deviations from the optimal vancomycin dosing may occur in the neonatal and pediatric population due to inconsistencies in the recommended dosing algorithms. This study aims to collect the expert opinions of clinicians who practice in the neonatal or pediatric intensive care units (NICU/PICUs) of 12 major medical centers in Hong Kong. Methods: This was a multicenter, cross-sectional study. Eligible physicians and pharmacists completed a structured questionnaire to identify the challenges they encountered when selecting the initial intermittent vancomycin dosing. They also answered questions concerning therapeutic monitoring services (TDM) for vancomycin, including the targeted trough levels for empirical vancomycin regimens administered for complicated and uncomplicated infections. Results: A total of 23 physicians and 43 pharmacists completed the survey. The top clinical parameters reported as most important for determining the initial vancomycin dosing were renal function (90.9%), post-menstrual/postnatal age (81.8%), body weight (66.7%), and suspected/documented pathogen (53.0%). Respondents reported challenges such as difficulties in determining the optimal initial dose for a targeted level (53.0%), inconsistencies between dosing references (43.9%) and a lack of clear hospital guidelines (27.3%). Half of the pharmacists (48.8%) reported that they had helped to interpret the TDM results and recommend vancomycin dose adjustments in >75% of cases. For methicillin-resistant Staphylococcus aureus infection, physicians, and pharmacists reported target trough levels of ~10-15 and 15-20 mg/L, respectively. For suspected moderate/uncomplicated Gram-positive infections physicians tended to prefer a lower trough range of 5-10 mg/L, while pharmacists preferred a range of 10-15 mg/L. Conclusions: Our results demonstrate that clinicians used varying vancomycin dosing guidelines in their practices. The multidisciplinary TDM service in Hong Kong can be improved further by establishing a standardized dosing guideline and implementing a well-structured, evidence-based service protocol. Future work includes conducting drug utilization studies to evaluate real-world antimicrobial usage patterns and the impact on tangible clinical outcomes, and developing pharmacokinetic-guided dose calculator for antimicrobials in critically ill neonates and pediatric patients.
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Affiliation(s)
| | | | | | | | - Hugh Simon Lam
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Teddy Tai-Ning Lam
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Department of Pharmacy, Prince of Wales Hospital, Hong Kong, China
| | - Chui Ping Lee
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Department of Pharmacy, Prince of Wales Hospital, Hong Kong, China
| | - Celeste Lom-Ying Ewig
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Department of Pharmacy, Prince of Wales Hospital, Hong Kong, China
| | - Yin Ting Cheung
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Sharma R, Hammerschlag MR. Treatment of Methicillin-Resistant Staphylococcus aureus (MRSA) Infections in Children: a Reappraisal of Vancomycin. Curr Infect Dis Rep 2019; 21:37. [PMID: 31486979 DOI: 10.1007/s11908-019-0695-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW In the last 50 years, vancomycin has been the agent of choice to treat infections due to methicillin-resistant Staphylococcus aureus (MRSA). However, vancomycin treatment failure is not uncommon, even when MRSA strains are fully susceptible to vancomycin. Treatment with vancomycin requires careful monitoring of drug levels as there is a potential for nephrotoxicity. Resistance to clindamycin is not infrequent, which also limits therapeutic options for treating infections due to MRSA in children. This paper reviews the current data on pharmacokinetics and pharmacodynamics and clinical efficacy of vancomycin in children. RECENT FINDINGS Resistance to vancomycin in MRSA (MIC >2 mg/L) is infrequent; there is increasing evidence in the literature that vancomycin maybe ineffective against increasing proportion of isolates with MICs between 1 and 2 mg/L. Recent studies and meta-analyses have demonstrated that strains with high vancomycin MICs are associated with poor outcomes especially in patients with bacteremia and deep tissue infections due to MRSA. This gradual increase in vancomycin MIC has been reported as MIC creep or vancomycin heteroresistance. Patients infected with MRSA isolates that exhibit MIC creep experience poorer clinical outcomes, including delayed treatment response, increased mortality, increase rate of relapse, and extended hospitalization. There are limited data to guide vancomycin dosing in children with MRSA. Although the vancomycin area under the curve AUC24/MIC ratio > 400 has been shown to predict clinical efficacy in adults, this relationship has not been documented very well for treatment outcomes in MRSA infections in children. Use of higher vancomycin dosages in attempts to achieve higher trough concentrations has been associated with increased nephrotoxicity. New recently approved antibiotics including ceftaroline, dalbavancin, and tedizolid offer a number of advantages over vancomycin to treat staphylococcal infections: improved antimicrobial activity, superior pharmacokinetics, pharmacodynamics, tolerability, and dosing, including once-daily and weekly regimens, and less need for monitoring drug levels.
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Affiliation(s)
- Roopali Sharma
- Department of Pharmacy Practice, Touro College of Pharmacy, New York, NY, USA. .,Department of Pharmacy, Downstate Medical Center, Brooklyn, NY, USA.
| | - Margaret R Hammerschlag
- Department of Pediatrics, Division of Infectious Diseases, State University of New York Downstate Medical Center, Brooklyn, NY, USA
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Describing vancomycin serum levels in pediatric intensive care unit (ICU) patients: are expected goals being met. BMC Pediatr 2019; 19:240. [PMID: 31319831 PMCID: PMC6639923 DOI: 10.1186/s12887-019-1602-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 06/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the pediatric population, infections by methicillin-resistant Staphylococcus aureus (MRSA) are associated with significant morbidity and hospital costs. Vancomycin is a glycopeptide antibiotic, widely used for the treatment of serious infections by Gram-positive microorganisms, especially MRSA. It is recommended to keep the serum level of vancomycin between 10 and 20 mg/L, that correlates with AUC/MIC > 400 in adults. This pharmacodynamic target is extrapolated to pediatric patients despite the lack of similar evidence. However, recent studies suggest that serum levels between 7 and 10 mg/L are predictive of reaching the pharmacodynamic target in this population. In spite of widespread use, ideal information about dosage for the pediatric population remains limited. METHODS A retrospective study was conducted in patients admitted to the Pediatric Intensive Care Unit during the period between January 01, 2008 to December 31, 2014. We investigated variables such as age, positive fluid balance and use of vasoactive drugs on the ability of these patients to achieve the proposed recommended serum level target and the vancomycin serum levels. RESULTS Our study showed that only 26% of children reached the 10-20 mg/L serum level whereas the 7-20 mg/L serum level was reached by 51% of patients. CONCLUSIONS We observed no evidence of a significant association between the inadequacy of serum level and age. The positive fluid balance also had no influence on the vancomycin serum level but patients using vasoactive drugs had a greater serum level adequacy than patients not using vasoactive drugs.
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Song L, He CY, Yin NG, Liu F, Jia YT, Liu Y. A population pharmacokinetic model for individualised dosage regimens of vancomycin in Chinese neonates and young infants. Oncotarget 2017; 8:105211-105221. [PMID: 29285245 PMCID: PMC5739632 DOI: 10.18632/oncotarget.22114] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 09/23/2017] [Indexed: 12/31/2022] Open
Abstract
Population pharmacokinetic (PPK) modelling is an easy and impartment method for estimating drug concentration for use inindividualized therapy, especially for young patients and to help protect drug-induced diseases. The purpose of this study was to develop a PPK model for effective dosing of vancomycin in Chinese neonates and young infants. The PPK modelling tool Phoenix® NLME™ was use to assess demographic and routine clinical pharmacokinetic (PK) data retrospectively collected for patients admitted to Children's Hospital of Chongqing Medical University between 2011 and 2016. Data of patients admitted to the hospital between January and June of 2017 were used in validation study, and the final model was also preliminary validated in 2 cases in another hospital. A total of 421 serum samples from 316 patients were included in the initial PPK analysis. A two-compartment PPK model was developed, and exponential-error model was used to describe inter-individual variability of clearance. Residual variability was described by an additive model. The final PPK model was demonstrated as valid by internal and external model evaluation. Of note, the clearance and volume of vancomycin in Chinese neonates and young infants may be greater than in Caucasians. Herein, we describe the establishment of an accurate PPK model of vancomycin for Chinese neonates and young infants, which may be useful as a dosing algorithm for this particular paediatric population.
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Affiliation(s)
- Lin Song
- Department of Pharmacy, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Cui-Yao He
- Department of Pharmacy, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Nan-Ge Yin
- Department of Pharmacy, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Fang Liu
- Department of Pharmacy, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Yun-Tao Jia
- Department of Pharmacy, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Yao Liu
- Department of Pharmacy, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
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Lü Y, Shao M, Wang Y, Qian S, Wang M, Wang Y, Li X, Bao Y, Deng C, Yue C, Liu D, Liu N, Liu M, Huang Y, Chen Z, Hu Y. Zunyimycins B and C, New Chloroanthrabenzoxocinones Antibiotics against Methicillin-Resistant Staphylococcus aureus and Enterococci from Streptomyces sp. FJS31-2. Molecules 2017; 22:molecules22020251. [PMID: 28208722 PMCID: PMC6155704 DOI: 10.3390/molecules22020251] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/05/2017] [Accepted: 02/05/2017] [Indexed: 12/18/2022] Open
Abstract
This study performed an optimization of the fermentation conditions to activate the expression of the zunyimycin family biosynthesis genes of the zunyimycin-producing streptomycetes strain Streptomyces sp. FJS31-2. Bioassay-guided isolation and purification by varied chromatographic methods yielded two new compounds of the zunyimycin derivatives, namely, 31-2-7 and 31-2-8, accompanied with three known anthrabenzoxocinones family members of zunyimycin A, BE24566B, and chloroanthrabenzoxocinone. Their structures were elucidated by NMR, HRESIMS, IR, UV, and CD. Results showed that these two compounds were structurally similar to the previously reported compound zunyimycin A but differed in positions and number of chlorine atom substitution. The two novel compounds were called zunyimycins B and C. Antibacterial activity assay indicated that zunyimycin C showed a good inhibitory effect on the methicillin-resistant Staphylococcus aureus and Enterococci.
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Affiliation(s)
- Yuhong Lü
- Guizhou Key Laboratory of Microbial Resources & Drug Development, Zunyi Medical University, Zunyi 563003, Guizhou, China.
| | - Meiyun Shao
- Guizhou Key Laboratory of Microbial Resources & Drug Development, Zunyi Medical University, Zunyi 563003, Guizhou, China.
| | - Yinyin Wang
- Guizhou Key Laboratory of Microbial Resources & Drug Development, Zunyi Medical University, Zunyi 563003, Guizhou, China.
| | - Shengyan Qian
- Guizhou Key Laboratory of Microbial Resources & Drug Development, Zunyi Medical University, Zunyi 563003, Guizhou, China.
| | - Miao Wang
- Guizhou Key Laboratory of Microbial Resources & Drug Development, Zunyi Medical University, Zunyi 563003, Guizhou, China.
| | - Yingquan Wang
- Guizhou Key Laboratory of Microbial Resources & Drug Development, Zunyi Medical University, Zunyi 563003, Guizhou, China.
| | - Xiaoqian Li
- Guizhou Key Laboratory of Microbial Resources & Drug Development, Zunyi Medical University, Zunyi 563003, Guizhou, China.
| | - Yuxin Bao
- Guizhou Key Laboratory of Microbial Resources & Drug Development, Zunyi Medical University, Zunyi 563003, Guizhou, China.
| | - Chengmin Deng
- Zunyi Key Laboratory of Genetic Diagnosis & Targeted Drug Therapy, The First People's Hospital of Zunyi, Zunyi 563003, Guizhou, China.
| | - Changwu Yue
- Zunyi Key Laboratory of Genetic Diagnosis & Targeted Drug Therapy, The First People's Hospital of Zunyi, Zunyi 563003, Guizhou, China.
| | - Daishun Liu
- Zunyi Key Laboratory of Genetic Diagnosis & Targeted Drug Therapy, The First People's Hospital of Zunyi, Zunyi 563003, Guizhou, China.
| | - Ning Liu
- State Key Laboratory of Microbial Resources, Institute of Microbiology, Chinese Academy of Sciences, Beijing 100101, China.
| | - Minghao Liu
- State Key Laboratory of Microbial Resources, Institute of Microbiology, Chinese Academy of Sciences, Beijing 100101, China.
| | - Ying Huang
- State Key Laboratory of Microbial Resources, Institute of Microbiology, Chinese Academy of Sciences, Beijing 100101, China.
| | - Zehui Chen
- Department of Clinical Laboratory Medicine, Zunyi Medical University, Zunyi 563003, Guizhou, China.
| | - Yonglin Hu
- Department of Clinical Laboratory Medicine, Zunyi Medical University, Zunyi 563003, Guizhou, China.
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Buckel WR, Ghobrial S, Tamma PD, Milstone AM, Zhao Y, Hsu AJ. Risk Factors for Non-Therapeutic Initial Steady-State Vancomycin Trough Concentrations in Children and Adolescents Receiving High Empiric Doses of Intravenous Vancomycin. Paediatr Drugs 2017; 19:43-51. [PMID: 27873214 DOI: 10.1007/s40272-016-0202-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Achieving vancomycin troughs of 15-20 μg/mL remains challenging in children. Our objective was to identify risk factors associated with non-therapeutic initial vancomycin troughs in children. METHODS We conducted a retrospective cohort study of children who received intravenous vancomycin with at least one initial steady-state trough obtained. Patients who achieved therapeutic troughs (15-20 μg/mL in the 20-mg/kg/dose sub-cohort and 10-15 μg/mL in the 15-mg/kg/dose sub-cohort) were compared with those with subtherapeutic troughs (<15 and <10 μg/mL, respectively) and supratherapeutic troughs (>20 and >15 μg/mL, respectively) separately to determine risk factors associated with non-therapeutic troughs. RESULTS A total of 153 vancomycin courses in 140 patients met study eligibility criteria. Of 45 patients who received 20 mg/kg/dose of empiric vancomycin, 60, 16, and 24% were subtherapeutic, therapeutic, and supratherapeutic, respectively. Each 10-mL/min/1.73 m2 increase in initial creatinine clearance (CrCl) was associated with a 47% increase in the odds of an initial subtherapeutic trough (adjusted odds ratio [aOR] 1.47; 95% CI 0.98-2.22). Of 108 patients who received 15 mg/kg/dose of empiric vancomycin, 62, 19, and 19% were subtherapeutic, therapeutic, and supratherapeutic, respectively. Each 10-mL/min/1.73 m2 increase in initial CrCl was associated with an 18% increase in the odds of an initial subtherapeutic trough (aOR 1.18; 95% CI 1.02-1.37). CONCLUSION Achieving vancomycin troughs of 15-20 μg/mL for severe Gram-positive infections continues to be challenging in children, even at higher empiric doses of 20 mg/kg/dose IV every 6-8 h. Children with higher initial CrCls are particularly susceptible to subtherapeutic initial steady-state vancomycin troughs.
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Affiliation(s)
- Whitney R Buckel
- Department of Pharmacy, Intermountain Medical Center, Murray, UT, USA
| | - Shahira Ghobrial
- Division of Pediatric Pharmacy, Department of Pharmacy, The Johns Hopkins Hospital, 600 N. Wolfe Street, Carnegie 180, Baltimore, MD, 21287, USA
| | - Pranita D Tamma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yuan Zhao
- Division of Pediatric Infectious Diseases, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alice J Hsu
- Division of Pediatric Pharmacy, Department of Pharmacy, The Johns Hopkins Hospital, 600 N. Wolfe Street, Carnegie 180, Baltimore, MD, 21287, USA.
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