Vancomycin use, dosing and serum trough concentrations in the pediatric population: a retrospective institutional review

Rajon, Kevin; Vaillancourt, Régis; Varughese, Nisha; Villarreal, Gilda

doi:10.18549/pharmpract.2017.02.887

Cited by 11 publications

(10 citation statements)

References 14 publications

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“…In our study, there was a similar proportion of children with supratherapeutic vancomycin concentrations compared to previously published paediatric data from outside the PICU setting. These studies reported that between 2.2 and 6.3% of patients had initial concentrations exceeding 20 mg/L Accordingly, the overall rate of nephrotoxicity seen in our study (8%) is comparable with previously reported rates of 9–14% in the paediatric population . All vancomycin‐associated renal impairment that occurred in our cohort of children was mild and self‐limiting, as was also seen in other paediatric studies …”

Section: Discussionsupporting

confidence: 91%

Vancomycin is commonly under‐dosed in critically ill children and neonates

Sosnin

Curtis

Cranswick

et al. 2019

Brit J Clinical Pharma

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Aims Vancomycin is frequently used in critically ill children in whom the drug pharmacokinetics are significantly altered as a result of changes in renal clearance and volume of distribution. Therapeutic drug monitoring (TDM) is recommended to achieve vancomycin trough concentrations between 10 and 20 mg/L. In this study we reviewed vancomycin dosing, TDM and treatment outcomes in paediatric and neonatal intensive care unit patients. Methods We reviewed the medical records of all patients receiving intravenous vancomycin in a tertiary paediatric and neonatal intensive care unit over a 10‐month period. Demographic, vancomycin dosing, TDM and drug‐related adverse effects data were collected. Results In total, 115 children received 126 courses of vancomycin and had at least 1 TDM blood sample taken at steady state. In only 38/126 (30%) courses was the target concentration (10–20 mg/L) achieved at the initial steady state trough sample. Of the 88 courses that had initial trough concentrations outside the target range, the dose was adjusted in only 49 (56%). Overall, minimum doses of 30 mg/kg/day in neonates with a corrected gestational age of <35 weeks, and 50 mg/kg/day in older children, were required to achieve target vancomycin concentrations. Vancomycin‐attributable nephrotoxicity occurred in 10/126 (8%) courses and there were no episodes of red man syndrome. Conclusion In critically ill children, individualised dosing is needed. In the absence of Bayesian model‐based dosing, in children with normal renal function, empiric vancomycin doses of at least 30 mg/kg/day in neonates of <35 weeks corrected gestational age, and 50 mg/kg/day in older children, should be considered. Optimisation of TDM practices through the development of protocols, ideally built into electronic medical records, should be considered.

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Section: Discussionsupporting

confidence: 91%

Vancomycin is commonly under‐dosed in critically ill children and neonates

Sosnin

Curtis

Cranswick

et al. 2019

Brit J Clinical Pharma

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“…Glycopeptides are concentration‐dependent antimicrobials with time dependence and with efficacy described by area under the concentration–time curve (AUC)/minimum inhibitory concentration (MIC) . The AUC/MIC ratio describes the ratio of the AUC of the unbound drug, which signifies exposure, to the MIC, which is the lowest concentration of an antimicrobial that will inhibit the visible growth of a microorganism …”

Section: Introductionmentioning

confidence: 99%

Vancomycin therapeutic drug monitoring in paediatrics

Patel

Lucas

Ryan

et al. 2019

J Paediatrics Child Health

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Aim: Vancomycin guidelines for therapeutic drug monitoring (TDM) aim to maximise efficacy while minimising toxicity and resistance. Vancomycin is effective against Staphylococcus aureus when it achieves area under the concentration-time curve (AUC)/minimum inhibitory concentration (MIC) > 400. Studies in children have shown that target trough concentrations poorly correlate to AUC/MIC > 400; however, they are used in practice for clinical convenience. This review in paediatric inpatients aims to audit performance against TDM guidelines and consider what changes are needed to optimise vancomycin monitoring. Methods: Vancomycin prescriptions in patients younger than 18 years old were collected over a 15-month period. Primary outcome measures were vancomycin initial dose (mg/kg/day) and the timing and result of first trough concentration (mg/L). Secondary outcome measures were the numbers achieving recommended targets and whether appropriate dose adjustments were made in response to TDM. Results: A total of 133 courses reached the time when TDM should occur. Average patient age was 6.5 years, and the average initial dose was 52.55 mg/kg/day (range 19.05-86.54 mg/kg). Only 25% of courses (n = 34) had a trough concentration measured at the recommended time. The mean trough concentration was 11.6 mg/L (range < 2.0-39.7). Of 40 patients with a low trough concentration, 50% continued without dose adjustment. Conclusion: As shown in the literature, there is a poor correlation between the vancomycin dose given and the trough concentration achieved. Given that recommendations for trough concentration monitoring are designed to simplify the process yet are poorly adhered to, a strategic plan to address these issues is needed.

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“…One study reported a comparatively larger percentage of achieving vancomycin initial trough 10-20 µg/mL, 50% of 74 children with complicated infections. 18 Rajon et al 23 reported that out of 52 children, nine cases (17.3%) reached the initial target. Recently, Maloni et al 24 reported only 22%-23% of children in the PICU who received 51 mg/kg/day or above attained 10-20 µg/mL.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of vancomycin initial trough levels in children: A 1-year retrospective study

et al. 2020

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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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Vancomycin use, dosing and serum trough concentrations in the pediatric population: a retrospective institutional review

Cited by 11 publications

References 14 publications

Vancomycin is commonly under‐dosed in critically ill children and neonates

Vancomycin is commonly under‐dosed in critically ill children and neonates

Vancomycin therapeutic drug monitoring in paediatrics

Evaluation of vancomycin initial trough levels in children: A 1-year retrospective study

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