https://orcid.org/0000-0001-8755-752X
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Abstract
Background
To date, outcome data with a large sample size and data regarding the clinical outcomes of pharmacokinetic-guided (PK) dosing of vancomycin are limited.
Aim
We evaluated the pharmacokinetic and clinical outcomes of a PK-guided dosing advisory program, pharmacokinetic consultation service (PKCS), in vancomycin treatment.
Methods
We investigated vancomycin therapeutic drug monitoring (TDM) and PKCS use through a retrospective review of patients who had serum vancomycin trough concentration data from October 2017 to November 2018. Among these patients, we selected non-critically ill adult patients satisfying our selection criteria to evaluate the effect of PKCS. Target trough attainment rate, time to target attainment, vancomycin-induced nephrotoxicity (VIN), vancomycin treatment failure rate, and duration of vancomycin therapy were compared between patients whose dosing was adjusted according to PKCS (PKCS group), and those whose dose was adjusted at the discretion of the attending physician (non-PKCS group).
Results
A total of 280 patients met the selection criteria for the VIN analysis (PKCS, n=134; non-PKCS, n=146). The incidence of VIN was similar between the two groups (PKCS, n=5; non-PKCS, n=5); however, the target attainment rate was higher in the PKCS group (75% vs 60%, P = 0.012). The time to target attainment was similar between the two groups. Further exclusions yielded 112 patients for the clinical outcome evaluation (PKCS, n=51; non-PKCS, n=61). The treatment failure rate was similar, and the duration of vancomycin therapy was longer in the PKCS group (12 vs 8 days, P = 0.008).
Conclusion
In non-critically ill patients, an increase in target trough achieved by PKCS did not lead to decreased vancomycin treatment failures, shorter vancomycin treatment, or decreased nephrotoxicity in vancomycin treatment. Considering the excessive amount of effort currently put into vancomycin dosing and monitoring, more selective criteria for individualized pharmacokinetic-guided dosing needs to be applied.
Abbreviations
PK, pharmacokinetic; PKCS, pharmacokinetic consultation service; TDM, therapeutic drug monitoring; VIN, vancomycin-induced nephrotoxicity; MRSA, methicillin-resistant Staphylococcus aureus; MIC, minimum inhibitory concentration; AUC24/MICBMD, ratio of area under the curve over 24 hours to MIC determined by broth microdilution; PK/PD, pharmacokinetic/pharmacodynamics; GFR, glomerular filtration rate; CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; KIMS, kinetic interaction of microparticles in solution; IQR, interquartile range; BMI, body mass index; MRCNS, methicillin-resistant coagulase negative Staphylococcus; ACE inhibitor, Angiotensin-converting enzyme inhibitor; ARBs, Angiotensin II receptor blockers; OR, odds ratio; CrCl, creatinine clearance.
Ethical Approval
This study was performed with the approval of the Institutional Review Board of Samsung Medical Center (approval number: SMC 2017-12-038-004). Furthermore, this study was conducted in accordance with the Declaration of Helsinki.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Disclosure
The authors declare no conflicts of interest.