Assessment of vancomycin utilization in intensive care unit patients of a tertiary care hospital in the United Arab Emirates
Main Article Content
Keywords
Vancomycin, utilization, intensive care unit, monitoring, safety, efficacy
Abstract
Background: Adequate dosing and monitoring of vancomycin serum concentrations is necessary to maximize efficacy, minimize toxicity, and reduce the emergence of resistance. The aim of this study was to assess vancomycin dosing, administration and monitoring among adult and pediatric patients admitted to the intensive care unit. Methods: A retrospective, cohort study performed from October 2020 - October 2022 in a tertiary care hospital in the UAE. All patients received an IV vancomycin for a systemic bacterial infection. Results: Only 18.1% of the patients received loading doses. In 75.5% of the study population, vancomycin was started empirically. 55.4% of the patients had their trough levels measured, 61% of them had only 1 trough level measured, and the rest had more than 1 trough measured. Trough level was outside the target range in 50.6% of the patients. Obtaining the trough level before the 4th dose occurred in the majority (68.8%) of the patients. Nephrotoxicity occurred for 5.8% of the patients while receiving vancomycin. 61.2% of the patients did not have adequate renal function monitoring for patients who are on vancomycin. Total vancomycin appropriateness was achieved in only 16.7% of the patients which was mainly due to total trough inappropriateness. Conclusion: This study demonstrates a disparity in the proper utilization of vancomycin according to international guidelines within the included tertiary care hospital. It underscores the necessity for the development of dosing and monitoring protocols tailored to the utilization of vancomycin in these healthcare facilities.
References
2. Vital signs: Epidemiology and recent trends in Methicillin-resistant and in methicillin-susceptible Staphylococcus aureus bloodstream infections - united states. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/68/ wr/mm6809e1.htm. Published March 7, 2019. Accessed December 10, 2022.
3. Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA 1998; 279:593-8. https://doi.org/10.1001/jama.279.8.593
4. Vazin A, Mahi Birjand M, Darake M. Evaluation of vancomycin therapy in the adult icus of a teaching hospital in Southern Iran. Drug, Healthcare and Patient Safety. 2018;10:21-6. https://doi.org/10.2147/dhps.s149451
5. Rosini JM, Grovola MR, Levine BJ,et al. Prescribing habits of vancomycin in the Emergency Department: are we dosing appropriately.J Emerg Med. 2013;44(5):979-84. https://doi.org/10.1016/j.jemermed.2012.11.051
6. Ryback MJ.The pharmacokinetic and pharmacodynamics properties of vancomycin. Clin Infec Dis 2006;42(suppl):S35-9. https://doi.org/10.1086/491712
7. Rybak M,Lomaestro B , Rotschafer JC et al. Vancomycin Therapeutic Guidelines: A Summary of Consensus Recommendations from the Infectious Diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists.Clin Infect Dis 2009;49:325-7. https://doi.org/10.1086/600877
8. Liu C, Bayer A , Cosgrove SE, et al. Clinical practice guideline by the Infectious Disease Society of America for the treatment of methicillin- resistant staphylococcus aureus infections in adults and children. Clin Infect Dis 2011;52:e18-55. https://doi.org/10.1093/cid/ciq146
9. John C ROtshafer .Vancomycin and new agents for MRSA infections.
10. Ghasemiyeh P, Vazin A, Zand F, et al. Pharmacokinetic assessment of vancomycin in critically ill patients and nephrotoxicity
prediction using individualized pharmacokinetic parameters. Frontiers in Pharmacology. 2022;13:912202. https://doi.
org/10.3389/fphar.2022.912202
11. Van Hal SJ, Paterson DL, Lodise TP. Systematic review and meta-analysis of vancomycin-induced nephrotoxicity associated with
dosing schedules that maintain troughs between 15 and 20 milligrams per liter. Antimicrob Agents Chemother. 2013;57(2):734-
44. https://doi.org/10.1128/aac.01568-12
12. Jeffres MN, Isakow W, Doherty JA, et al. A retrospective analysis of possible renal toxicity associated with vancomycin in
patients with health care-associated methicillin-resistant Staphylococcus aureus pneumonia. Clin Ther. 2007;29(6):1107-15.
https://doi.org/10.1016/j.clinthera.2007.06.014
13. Sirard S, Abou Chakra CN, Langlois MF, Perron J, Carignan A, Valiquette L. Is Antimicrobial Dosing Adjustment Associated
with Better Outcomes in Patients with Severe Obesity and Bloodstream Infections? An Exploratory Study. Antibiotics (Basel).
2020;9(10):707. https://doi.org/10.3390/antibiotics9100707
14. Kollef MH Limitations of vancomycin in the management of resistant staphylococcal infections. Clin Infect Dis. 2007;45(3):S191-
5. https://doi.org/10.1086/519470
15. Malaeb DN, Fahs IM, Salameh P, Hallit S, Saad M, Bourji J, et al. Assessment of vancomycin utilization among Lebanese
hospitals. Saudi Med J. 2019;40(2):152-7. https://doi.org/10.15537/smj.2019.2.23872
16. Moise PA, Schentag JJ. Vancomycin treatment failures in Staphylococcus aureus lower respiratory tract infections. Int J
Antimicrob Agents. 2000;16(1):S31-4. https://doi.org/10.1016/s0924-8579(00)00303-4
17. Pacifici GM, Allegaert K. Clinical pharmacokinetics of vancomycin in the neonate: a review. Clinics (Sao Paulo). 2012;67(7):831-
7. https://doi.org/10.6061/clinics/2012(07)21
18. Blot S, Koulenti D, Akova M, Bassetti M, De Waele JJ, Dimopoulos G, et al. Does contemporary vancomycin dosing achieve
therapeutic targets in a heterogeneous clinical cohort of critically ill patients? Data from the multinational DALI study. Crit
Care. 2014;18(3):R99. https://doi.org/10.1186/cc13874
19. Sivagnanam S, Deleu D. Red man syndrome. Crit Care. 2003;7(2):119-20. https://doi.org/10.1186/cc1871
20. Bakke V, Sporsem H, Von der Lippe E, Nordøy I, Lao Y, Nyrerød HC et al. Vancomycin levels are frequently subtherapeutic in
critically ill patients: a prospective observational study. Acta Anaesthesiol Scand. 2017;61(6):627-35. https://doi.org/10.1111/
aas.12897
21. Islahudin F, Ong HY. Appropriate vancomycin use in a Malaysian tertiary hospital based on current HICPAC recommendations.
J Infect Dev Ctries. 2014;8(10):1267-71. https://doi.org/10.3855/jidc.4676
22. Kacířová I, Grundmann M. Terapeutické monitorování vankomycinu v rutinní klinické praxi [Therapeutic monitoring of
vancomycin in routine clinical practice]. Vnitr Lek. 2014;60(10):846-51.
23. Traugott KA, Maxwell PR, Green K, Frei C, Lewis JS 2nd. Effects of therapeutic drug monitoring criteria in a computerized
prescriber-order-entry system on the appropriateness of vancomycin level orders. Am J Health Syst Pharm. 2011;68(4):347-52.
https://doi.org/10.2146/ajhp090661
24. Arnaud FCS, Libório AB. Attributable nephrotoxicity of vancomycin in critically ill patients: a marginal structural model study. J
Antimicrob Chemother. 2020;75(4):1031‐7. https://doi.org/10.1093/jac/dkz520