Ann Lab Med.  2014 Jan;34(1):1-6. 10.3343/alm.2014.34.1.1.

Assessment of Therapeutic Drug Monitoring of Vancomycin in Elderly Patients According to New Guidelines

• Oh SJ
• Hong KS
• Lee EJ
• Choi HJ
• Kong KA
• Lee M
• Chung WS

• KMID: 1781352
• DOI: http://doi.org/10.3343/alm.2014.34.1.1

Abstract

BACKGROUND
Concerns regarding increasing microbial resistance to vancomycin have resulted in recommendations for a higher trough serum vancomycin concentration. This study aimed to assess the dosage guidelines targeting vancomycin trough concentrations of 15-20 mg/L.
METHODS
About 216 adult patients (age, >60 yr) were treated with intravenous vancomycin. The patients were divided into 2 groups according to their target vancomycin trough concentrations: the previous guideline group (n=108) treated with targeted vancomycin trough concentrations of 5-15 mg/L from Jan 2009 through April 2011 and the new guideline group (n=108) treated with targeted concentrations of 15-20 mg/L from November 2011 through July 2012.
RESULTS
The 2 groups were not significantly different with respect to age, weight, initial serum creatinine, initial creatinine clearance, predictive trough levels, doses, serum drug concentrations, and area under the curve/minimal inhibitory concentrations. Regarding the proportions of vancomycin trough concentrations, the target range was achieved in 50% in the previous guideline group and in 16% in the new guideline group. In the previous and new guideline groups, the trough concentrations of 10-20 mg/dL were observed in 32.4% and 52.8% patients, respectively, and those of <10 mg/L were observed in 45.4% and 29.6%, respectively.
CONCLUSIONS
Compared to the previous guideline group, the new guideline group showed higher proportions in the therapeutic range of 10-20 mg/L and lower proportions in trough concentrations <10 mg/L. The strictly managed vancomycin therapeutic drug monitoring in the new guideline group was assessed as more effective.

Keyword

Therapeutic drug monitoring; Vancomycin; Trough concentration

MeSH Terms

Aged
*Drug Monitoring
Female
Gram-Positive Bacterial Infections/drug therapy
Guidelines as Topic
Half-Life
Humans
Injections, Intravenous
Male
Middle Aged
Vancomycin/*blood/pharmacokinetics/therapeutic use
Vancomycin

Figure

• 

  Fig. 1 Number of patients and predicted vancomycin trough concentrations to show the target vancomycin trough concentrations comprised the target ranges according to different guidelines.

Reference

1. Song YG, Kim HK, Roe EK, Lee SY, Ahn BS, Kim JH, et al. Therapeutic Drug Monitoring of Vancomycin in Korean Patients. Infect Chemother. 2004; 36:311–318.

2. MacGowan AP. Pharmacodynamics, pharmacokinetics, and therapeutic drug monitoring of glycopeptides. Ther Drug Monit. 1998; 20:473–477. PMID: 9780121.

3. Kim DI, Im MS, Choi JH, Lee J, Choi EH, Lee HJ. Therapeutic monitoring of vancomycin according to initial dosing regimen in pediatric patients. Korean J Pediatr. 2010; 53:1000–1005. PMID: 21253314.

4. Moellering RC Jr. Vancomycin: a 50-yr reassessment. Clin Infect Dis. 2006; 42(Suppl 1):S3–S4. PMID: 16323117.

5. Kollef MH. Limitations of vancomycin in the management of resistant staphylococcal infections. Clin Infect Dis. 2007; 45(Suppl 3):S191–S195. PMID: 17712746.

6. Patanwala AE, Norris CJ, Nix DE, Kopp BJ, Erstad BL. Vancomycin dosing for pneumonia in critically ill trauma patients. J Trauma. 2009; 67:802–804. PMID: 19820588.

7. Moise-Broder PA, Forrest A, Birmingham MC, Schentag JJ. Pharmacodynamics of vancomycin and other antimicrobials in patients with Staphylococcus aureus lower respiratory tract infections. Clin Pharmacokinet. 2004; 43:925–942. PMID: 15509186.

8. Tobin CM, Darville JM, Thomson AH, Sweeney G, Wilson JF, MacGowan AP, et al. Vancomycin therapeutic drug monitoring: is there a consensus view? The results of a UK National External Quality Assessment Scheme (UK NEQAS) for Antibiotic Assays questionnaire. J Antimicrob Chemother. 2002; 50:713–718. PMID: 12407128.

9. Rybak M, Lomaestro B, Rotschafer JC, Moellering R Jr, Craig W, Billeter M, et al. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2009; 66:82–98. PMID: 19106348.

10. Eiland LS, English TM, Eiland EH 3rd. Assessment of vancomycin dosing and subsequent serum concentrations in pediatric patients. Ann Pharmacother. 2011; 45:582–589. PMID: 21521865.

11. Verhave JC, Fesler P, Ribstein J, du Cailar G, Mimran A. Estimation of renal function in subjects with normal serum creatinine levels: influence of age and body mass index. Am J Kidney Dis. 2005; 46:233–241. PMID: 16112041.

12. Patanwala AE, Norris CJ, Nix DE, Kopp BJ, Erstad BL. Vancomycin dosing for pneumonia in critically ill trauma patients. J Trauma. 2009; 67:802–804. PMID: 19820588.

13. Cunha BA. Vancomycin revisited: a reappraisal of clinical use. Crit Care Clin. 2008; 24:393–420. PMID: 18361953.

14. Joint Formulary Committee. British National Formulary. 56th ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain;2008.

15. del Mar Fernández de Gatta Garcia M, Revilla N, Calvo MV, Domínguez-Gil A, Sánchez Navarro A. Pharmacokinetic/pharmacodynamic analysis of vancomycin in ICU patients. Intensive Care Med. 2007; 33:279–285. PMID: 17165021.

16. Pea F, Porreca L, Baraldo M, Furlanut M. High vancomycin dosage regimens required by intensive care unit patients cotreated with drugs to improve haemodynamics following cardiac surgical procedures. J Antimicrob Chemother. 2000; 45:329–335. PMID: 10702552.

17. American Thoracic Society. Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005; 171:388–416. PMID: 15699079.

18. Sakoulas G, Gold HS, Cohen RA, Venkataraman L, Moellering RC, Eliopoulos GM. Effects of prolonged vancomycin administration on methicillin-resistant Staphylococcus aureus (MRSA) in a patient with recurrent bacteraemia. J Antimicrob Chemother. 2006; 57:699–704. PMID: 16464892.

19. Howden BP, Ward PB, Charles PG, Korman TM, Fuller A, du Cros P, et al. Treatment outcomes for serious infections caused by methicillin-resistant Staphylococcus aureus with reduced vancomycin susceptibility. Clin Infect Dis. 2004; 38:521–528. PMID: 14765345.