Vancomycin Dosing and Monitoring in the Treatment of Cystic Fibrosis: Results of a National Practice Survey

Abstract

OBJECTIVES Vancomycin is commonly used in patients with cystic fibrosis (CF) to treat acute pulmonary exacerbations, but few guidelines exist to help dose and monitor patients. The objective of this study was to assess vancomycin use and monitoring strategies at Cystic Fibrosis Foundation (CFF)-accredited centers in hopes of developing and implementing vancomycin dosing and monitoring standards. METHODS An anonymous national cross-sectional survey of pharmacists affiliated with CFF-accredited pediatric and/or adult centers was performed by using Surveymonkey.com. The survey consisted of 3 sections: (1) CF Center Demographic Information (10 questions); 2) vancomycin use in pediatric CF patients (31 questions); and 3) vancomycin use in adult CF patients (29 questions); it was administered from March 9, 2015, to April 13, 2015. RESULTS The survey was completed by 31/69 (45%) pharmacists and 28 (90.3%) reported using vancomycin in the pediatric population. The most common initial starting dose for pediatric patients was 15 mg/kg/dose (57.1%) and every 6 hours was the most common dosing frequency (67.9%). The most common monitoring strategy was collection of a trough concentration (92.9%) with 57.7% of pharmacist targeting a range of 15 to 20 mg/L. The most common initial starting vancomycin dose in adults with CF was 15 mg/kg/dose (61.5%), and initial frequency of every 8 hours (73.1%). The most common monitoring strategy was a trough concentration (96.2%) with 83.3% of pharmacists reporting a goal trough range of 15 to 20 mg/L. CONCLUSIONS The most common vancomycin dosing reported was 15 to 20 mg/kg/dose every 6 hours (pediatric) and 15 to 20 mg/kg/dose every 8 to 12 hours (adults). Serum concentrations measured to meet monitoring parameters of trough concentrations of 15 to 20 mg/L, or area under the curve to minimum inhibitory concentration ratio > 400, were the same in both pediatric and adult patients.

Retrospective review of vancomycin monitoring via trough only versus two‐point estimated area under the curve in pediatric and adult patients with cystic fibrosis

“…Because of their frequent need for IV antibiotics, the potential use of concomitant nephrotoxic medications, and longer duration of antibiotic therapy, patients with CF are at higher risk of nephrotoxicity related to vancomycin 10 . In a 2017 national survey of Cystic Fibrosis Foundation Centers, 93% of pharmacists reported using serum trough to monitor vancomycin 11 . For this reason, little data is available in this patient population for monitoring vancomycin using two concentrations to estimate AUC.…”

“…10 In a 2017 national survey of Cystic Fibrosis Foundation Centers, 93% of pharmacists reported using serum trough to monitor vancomycin. 11 For this reason, little data is available in this patient population for monitoring vancomycin using two concentrations to estimate AUC. Until October 2018, UKHC utilized trough monitoring for vancomycin therapies.…”

Earlier Targeted Vancomycin Troughs Concentration with Loading Dose: A Retrospective Study

“…After 3-5 doses or at least 24 hours of continuous infusion (in order to reach steady state), the serum vancomycin level is routinely determined (therapeutic drug monitoring, TDM). The target levels are a trough concentration of 10-15 mg/L or 15-20 mg/L [3,5] . Some studies reported that the trough concentration of vancomycin should be maintained at 20 mg/L or higher to reach a target value of the AUC/MIC ratio of 400 or higher [4] .…”

Consenso chileno para la atención integral de niños y adultos con fibrosis quística

“…los aminoglucósidos pueden producir ototoxicidad, por lo que se debe realizar una evaluación auditiva (ver manifestaciones otorrinolaringológicas). 109 Fármaco que depende tanto del tiempo como de la concentración para ejercer su efecto bactericida. Se recomienda medir niveles peak y valle con el fin de aproximarse a un valor de área bajo la curva sobre la CIM, el cual, debe ser mayor a 400 µg/ml.…”