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

Abstract

Background: Vancomycin is used primarily for Gram-positive infections. Recommended dosage regimens and targeted therapeutic levels vary between institutions.

Objectives: This study aims to describe therapeutic levels according to initial vancomycin doses and patient’s age. A secondary objective was to evaluate appropriateness of vancomycin use in our hospital.

Methods: A retrospective chart review was conducted at the Children’s Hospital of Eastern Ontario. Patients included in this study were classified by age (neonates, infants, children and adolescents) and categorized into those who received vancomycin ≤5 and >5 days. Initial vancomycin dosing regimens and corresponding initial trough levels obtained were evaluated. Initial trough levels drawn in relation to the third, fourth, or fifth doses corresponding to the first course of therapy were analyzed. Acceptable trough levels ranged from 5-20 mg/L.

Results: One-hundred-and-sixty-four patients who received intravenous vancomycin in 2013 were included. Of the 229 courses of vancomycin, 190 (83%) were used 5 days or less (mean 4.9 days). Sixteen infants (88.9%) and 21 adolescents (100%), who received vancomycin empiric dosing of 60 mg/kg/day, had initial trough levels >5mg/L. However, in the children’s group 20 (37.7%) did not reach levels >5 mg/L. None of vancomycin minimum inhibitory concentration (MIC) values were >1mg/L for the four patients who had infections due to methicillin-resistant Staphylococcus aureus strains.

Conclusions: In our institution, initial empiric vancomycin dosing of 60 mg/kg/day resulted in levels ≥5mg/L in most infants and adolescents. It remains unclear why some children aged 1-12 years did not achieve these levels.

Downloads

Download data is not yet available.

Author Biography

Nisha Varughese, Children's Hospital of Eastern Ontario
Inpatient Pharmacy, Clinical Pediatric Pharmacist

References

1. Le J, Bradley JS, Murray W, Romanowski GL, Tran TT, Nguyen N, Cho S, Natale S, Bui I, Tran TM, Capparelli EV. Improved vancomycin dosing in children using area under the curve exposure. Pediatr Infect Dis J. 2013;32(4):e155-e163. doi: 10.1097/INF.0b013e318286378e

2. Rybak M, Lomaestro B, Rotschafer JC, Moellering R Jr, Craig W, Billeter M, Dalovisio JR, Levine DP. 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(1):82-98. doi: 10.2146/ajhp080434

3. Yeh YC, Yeh KM, Lin TY, Chiu SK, Yang YS, Wang YC, Lin JC. Impact of vancomycin MIC creep on patients with methicillin-resistant Staphylococcus aureus bacteremia. J Microbiol Immunol Infect. 2012;45(3):214-220. doi: 10.1016/j.jmii.2011.11.006

4. Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, J Rybak M, Talan DA, Chambers HF; Infectious Diseases Society of America. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18-e55. doi: 10.1093/cid/ciq146

5. Broome L, So TY. An evaluation of initial vancomycin dosing in infants, children and adolescents. Int J Pediatr. 2011;2011:470364. doi: 10.1155/2011/470364

6. Frymoyer A, Guglielmo BJ, Wilson SD,Scarpace SB, Benet LZ, Hersh Al. Impact of a hospital wide increase in empiric pediatric vancomycin dosing on initial trough concentrations. Pharmacotherapy. 2011;31(9):871-876. doi: 10.1592/phco.31.9.871

7. Eiland LS, English TM, Eiland EH 3rd. Assessment of vancomycin dosing and subsequent serum concentrations in pediatric patients. Ann Pharmacother. 2011;45(5):582-589. doi: 10.1345/aph.1P588

8. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2(1):1-138.

9. Schwartz GJ, Muñoz A, Schneider MF, Mak RH, Kaskel F, Warady BA, Furth SL.New equations to estimate GFR in children with CKD. J Am Soc Nephrol. 2009;20(3):629-637. doi: 10.1681/ASN.2008030287

10. Engle WA; American Academy of Pediatrics Committee on Fetus and Newborn. Age terminology during the perinatal period. Pediatrics. 2004;114(5):1362-1364. doi: 10.1542/peds.2004-1915

11. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook, 24th ed. Hudson, Ohio: Lexi-Com; 2015.

12. Benner KW, Worthington MA, Kimberlin DW, Hill K, Buckley K, Tofil NM. Correlation of Vancomycin dosing to serum concentrations in pediatric patients: A retrospective database review. J Pediatr Pharmacol Ther. 2009;14(2):86-93. doi: 10.5863/1551-6776-14.2.86

13. De Hoog M, Mouton JW, Van Den Anker, JN. Vancomycin: Pharmacokinetics and administration regimes in neonates. Clin Pharmacokinet. 2004;43(7):417-440. doi: 10.2165/00003088-200443070-00001

14. Frymoyer A, Hersh AL, Benet LZ, Guglielmo BJ. Current recommended dosing of vancomycin for children with invasive methicillin-resistant Staphylococcus aureus infections is inadequate. Pediatr Infect Dis J. 2009;28(5):398-402. doi: 10.1097/INF.0b013e3181906e40

15. Sinkeler FS, de Haan TR, Hodiamont CJ, Bijleveld YA, Pajkrt D, Mathôt RA. Inadequate Vancomycin therapy in term and preterm neonates: A retrospective analysis of trough serum concentrations in relation to MIC. BMC Pediatr. 2014;14:193. doi: 10.1186/1471-2431-14-193

16. Hidayat LK, Hsu DI, Quist R, Shriner KA, Wong-Beringer A. High-dose vancomycin therapy for methicillin-resistant Staphylo¬coccus aureus infections. Arch Intern Med. 2006 Oct 23;166(19):2138-2144. doi: 10.1001/archinte.166.19.2138

17. Buck ML. Vancomycin-associated nephrotoxicity and the use of higher trough concentrations in infants and children. Pediatric Pharmacotherapy. 2014;20(10). Available at: https://med.virginia.edu/pediatrics/wp-content/uploads/sites/237/2015/12/201410.pdf (accessed 15-Nov-2016).
Published
2017-06-30
How to Cite
RAJON, Kevin et al. Vancomycin use, dosing and serum trough concentrations in the pediatric population: a retrospective institutional review. Pharmacy Practice, [S.l.], v. 15, n. 2, p. 887, june 2017. ISSN 1886-3655. Available at: <https://www.pharmacypractice.org/journal/index.php/pp/article/view/887>. Date accessed: 17 dec. 2017.
Section
Original Research

Keywords

Vancomycin; Drug Monitoring; Pharmacy Service, Hospital; Infant; Adolescent; Inpatients; Pharmacokinetics; Clinical Audit; Canada