Vancomycin trough level and loading dose

Tuon, Felipe Francisco; R, Romero; Gasparetto, Juliano; Cieslinski, Juliette

doi:10.2147/idr.s184897

Cited by 16 publications

(14 citation statements)

References 8 publications

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“…Similar results were observed by Obara et al in 83 Brazilian critically-ill patients [13]. Finally, another retrospective study also including 164 critically-ill patients, conducted by Tuon et al in two Brazilian hospitals have reported that only 13.4% of patients achieved target levels [22]. Considering that most previous studies have been focused on critically ill patients, we believe our study contributes to expand the knowledge on vancomycin use in non-critically ill patients.…”

Section: Discussionsupporting

confidence: 87%

Vancomycin-associated nephrotoxicity in non-critically ill patients admitted in a Brazilian public hospital: A prospective cohort study

et al. 2019

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Introduction Vancomycin is widely used to treat infections caused by Gram positive bacteria, mostly methicillin-resistant strains. Despite its therapeutic effectiveness, vancomycin is a nephrotoxic drug that has been associated with the occurrence of acute kidney injury (AKI). In this study, we sought to evaluate the variability of serum trough concentrations of vancomycin and to determine the incidence and risk factors of vancomycin-associated nephrotoxicity (VAN) in non-critically ill patients. Methods This was a prospective cohort including Brazilian public hospital inpatients from April 2017 to June 2018. The participants received intravenous vancomycin therapy for at least 48 hours for any suspected or confirmed infection by Gram positive bacteria. Demographic, clinical and laboratory data were collected. Information on vancomycin therapy and concomitant use of other nephrotoxic drugs were also recorded. Patients were followed up until discontinuation of vancomycin treatment or death, whatever occurred first. The primary outcome was the occurrence of AKI. We performed a Poisson regression to determine risk factors for AKI. Results Overall, 98 participants were included in the study. Median age was 55.9 (interquartile range [IQR] 40.6–66.8) years and 58 (59.2%) were men. Most of them showed subtherapeutic (<10mg/L) or supratherapeutic (>20mg/L) trough levels of vancomycin; 42.9% and 15.3%, respectively. A total of 19 (19.4%) patients developed AKI. Poisson regression showed that male sex (odds ratio [OR] 2.90; confidence interval [CI] 95% 1.28–6.53; p = 0.011), concomitant use of piperacillin-tazobactam (OR 4.66; CI 95% 2.26–9.58; p <0.001) and vancomycin trough levels above 20mg/mL (OR 4.21; CI 95% 1.57–11.278; p = 0.004) were independently associated with AKI. Conclusions Our study showed that usual doses of vancomycin did not reach recommended therapeutic serum trough levels of vancomycin in non-critically ill patients. Besides that, nephrotoxicity was common in this population, being associated with male sex, concomitant use of piperacillin-tazobactam and supra-therapeutic trough serum levels of vancomycin.

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Section: Discussionsupporting

confidence: 87%

Vancomycin-associated nephrotoxicity in non-critically ill patients admitted in a Brazilian public hospital: A prospective cohort study

et al. 2019

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“…AKI was less frequent in patients who received OS. This could be attributed to several factors such as infection severity, aminoglycoside exposure, and cumulative dose of cephalosporin and vancomycin [21–23]. Oral drugs currently used in this study (quinolones and beta-lactams) are considerably less nephrotoxic than IV options (vancomycin and aminoglycosides).…”

Section: Discussionmentioning

confidence: 99%

Intravenous-to-oral antibiotic switch therapy: a cross-sectional study in critical care units

et al. 2019

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Background This study aimed to evaluate the oral switch (OS) stewardship intervention in the intensive care unit (ICU). Methods This was a retrospective study with a convenience sample in two Brazilian ICUs from different hospitals in patients with sepsis receiving antibiotic therapy. The stewardship intervention included OS in patients diagnosed with sepsis when clinical stability was achieved. The primary outcome was overall mortality. Other variables evaluated were as follows: cost of antimicrobial treatment, daily costs of intensive care, acute kidney injury, and length of stay. Results There was no difference in mortality between the OS and non-OS groups ( p = 0.06). Length of stay in the ICU ( p = 0.029) was shorter and acute kidney injury incidence ( p = 0.032) and costs of antimicrobial therapy ( p < 0.001) were lower in the OS group. Conclusion OS stewardship programs in the ICU may be considered a safe strategy. Switch therapy reduced the cost and shortened the length of stay in ICUs. Electronic supplementary material The online version of this article (10.1186/s12879-019-4280-0) contains supplementary material, which is available to authorized users.

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“…Most of their study patients also had a high CL cr (mean 93 mL/min). However, in a study including patients with deteriorated renal function, a loading dose resulted in a higher concentration at steady state [16,17]. In patients with deteriorated renal function, not only a loading dose but also a maintenance dose had a significant impact on the C min .…”

Section: Discussionmentioning

confidence: 94%

Vancomycin loading dose is associated with increased early clinical responses without attainment of initial target trough concentration at a steady state in patients with normal renal function

Takesue

Nakajima

Ichiki

et al. 2019

Preprint

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Background Vancomycin therapeutic guidelines suggest a loading dose of 25–30 mg/kg for seriously ill patients. However, high-quality data to guide the use of loading dose are lacking. Evaluate whether a loading dose 1) achieves a target trough concentration (Cmin) at steady state and 2) improves early clinical responses. Methods Patients with an estimated glomerular filtration rate ≥90 mL/min/1.73 m2 were included. A loading dose of 25 mg/kg vancomycin followed by 15 mg/kg twice daily was compared with traditional dosing. A Cmin sample was obtained before the fifth dose. An early clinical response 48–72 h after the start of therapy and clinical success at end of therapy (EOT) was evaluated in patients with methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant coagulase-negative Staphylococci, or Enterococcus faecium. Results There was no significant difference in Cmin between the regimen with and without a loading dose (median: 10.4 µg/mL and 10.2 µg/mL, P=0.538). Proportions of patients achieving 10–20 µg/mL and 15–20 µg/mL were 56.9% and 5.6%, respectively, in patients with a loading dose. Although there was no significant difference in success rate at EOT between groups, loading dose was associated with increased early clinical responses for all infections [adjusted odds ratio (OR): 4.829, 95% confidence interval (CI): 1.441–16.188] and MRSA infections (OR: 10.851, 95% CI: 1.701–69.233). Increased adverse events were not observed with the loading dose. Study limitations included no Cmin measurements within 24 hours, and the inclusion of less critically ill patients. Conclusions Although the loading dose did not achieve optimal Cmin at steady state, a higher early clinical response was obtained compared with traditional dosing.

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Vancomycin trough level and loading dose

Cited by 16 publications

References 8 publications

Vancomycin-associated nephrotoxicity in non-critically ill patients admitted in a Brazilian public hospital: A prospective cohort study

Vancomycin-associated nephrotoxicity in non-critically ill patients admitted in a Brazilian public hospital: A prospective cohort study

Intravenous-to-oral antibiotic switch therapy: a cross-sectional study in critical care units

Vancomycin loading dose is associated with increased early clinical responses without attainment of initial target trough concentration at a steady state in patients with normal renal function

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