Evaluation of Continuous Infusion Vancomycin Administration in a Critically Ill Trauma Population

Abstract

Vancomycin is a first-line antibiotic for empiric treatment of gram-positive infections in the trauma intensive care unit. When dosed intermittently, difficulties arise from trough collection and drug monitoring. The objective of this study was to evaluate time to goal vancomycin levels comparing a continuous infusion protocol when compared to standard intermittent infusion dosing. This was a retrospective cohort of patients admitted to the trauma intensive care unit between July 2011 and July 2015 receiving vancomycin for at least 48 hours. In this cohort of 150 patients, continuous infusion vancomycin had a decreased time to goal vancomycin level (2.5 vs 3.8 days, P ≤ .05) with a higher incidence of target attainment (60% vs 40%, P ≤ .05). This reflected in a decrease in average number of blood samples per patient (1 vs 3, P ≤ .05) and shorter duration of therapy (3.8 vs 6.8 days, P ≤ .05). Patients receiving continuous infusion vancomycin also experienced less nephrotoxicity (21% vs 43%, P ≤ .05). Patients in the intermittent infusion group had more missed levels and doses, with only 1 in every 3 patients receiving all intended doses on time. Vancomycin continuous infusion resulted in a decrease in time to goal therapeutic vancomycin levels, number of blood samples required, and therapy duration. Larger trials are needed to validate these outcomes in broad patient groups and to validate the clinical implication and potential cost savings of these results.

Clinical Practice Guidelines for Therapeutic Drug Monitoring of Vancomycin in the Framework of Model-Informed Precision Dosing: A Consensus Review by the Japanese Society of Chemotherapy and the Japanese Society of Therapeutic Drug Monitoring

“…Because no comparative study on efficacy and safety between continuous and intermittent infusion therapy based on AUC-guided dosing is available, vancomycin continuous infusion is not currently recommended [ 175 , 176 , 177 , 178 , 179 , 180 , 181 , 182 , 183 ] (III-B).…”

“…Bissell et al reported that the continuously infused vancomycin had a shorter time to target achievement with a higher incidence of target attainment than intermittently infused vancomycin in critically ill patients, which resulted in a lower average number of blood samples per patient and shorter duration of therapy [ 181 ]. A recent meta-analysis of RCTs and observational studies for critically ill adult patients reported by Flannery et al demonstrated that continuous infusion was associated with a lower AKI risk (OR = 0.47, 95% CI = 0.34–0.65) and a higher PK target attainment rate (OR = 2.63, 95% CI = 1.52–4.57) than intermittent infusion [ 176 ].…”

Development and Validation of a Risk Prediction Model of Vancomycin‐Associated Nephrotoxicity in Elderly Patients: A Pilot Study

“…Patients' clinical parameters were extracted mainly based on previous studies. 3,6,7,9,[12][13][14][15][16][17][18][19][20][21][22][23]26,27…”

“…6,12 With the aging of our society, VANT in elderly patients is worthy of more attention. 12 Previous studies indicate that age, 7 mechanical ventilation, 12 intensive care unit (ICU) admittance, 13 vancomycin trough concentration, 9,14-17 dose, 15 length of therapy, 9,17 infusion method (continuous or intermittent infusions), 18,19 cirrhosis, 14 hypertension, 20 hyperuricemia, 12 shock, 6 heart failure, 6 concomitant medications, vasopressor drugs, 16,17 aminoglycosides, 9,21 contrast agents, 22,23 piperacillin/tazobactam (PTZ), 24,25 furosemide, 3,11 amphotericin B, 26 and the Acute Physiology and Chronic Health Evaluation II (APACHE-II) 21,27 are risk factors associated with VANT. However, only two studies reported VANT risk factors in elderly patients.…”

Pharmacokinetic/Pharmacodynamic Target Attainment of Vancomycin, at Three Reported Infusion Modes, for Methicillin-Resistant Staphylococcus aureus (MRSA) Bloodstream Infections in Critically Ill Patients: Focus on Novel Infusion Mode

“…In critically ill patients, more current studies on vancomycin II vs. CI have focused mainly on the comparison in terms of the efficacy and safety of vancomycin ( Vuagnat et al., 2004 ; Hutschala et al., 2009 ; Akers et al., 2012 ; Saugel et al., 2013 ; Schmelzer et al., 2013 ; Hanrahan et al., 2014 ; Tafelski et al., 2015 ; Bissell et al., 2020 ). However, comparative studies on the outcomes of vancomycin II vs. CI against MRSA isolates with a specific MIC are still scarce.…”