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Why is vancomycin blood concentration monitoring necessary
Vancomycin is a widely used glycopeptide antibacterial agent in clinical practice. It is primarily employed as a first-line therapy for Gram-positive coccus infections, particularly those caused by methicillin-resistant Staphylococcus aureus (MRSA). However, vancomycin has a narrow therapeutic window and significant pharmacokinetic variability among individuals. Its efficacy is easily influenced by factors such as age, body weight, hepatic and renal function, and the presence of severe infection. Its therapeutic efficacy is closely correlated with trough plasma concentrations. Both subtherapeutic and therapeutic concentrations of the drug may impair its efficacy, induce resistance, and increase the risk of adverse reactions such as ototoxicity and nephrotoxicity [2]. Therefore, therapeutic drug monitoring (TDM) is essential during clinical use to adjust dosing regimens based on the results of monitoring. This ensures that therapeutic concentrations remain within the safe and effective range, thereby guaranteeing the safety and efficacy of the medication while minimizing the emergence of resistant bacteria. Vancomycin TDM is therefore recommended for clinical use.
The following individuals are recommended for vancomycin therapeutic drug monitoring (TDM)
1. Therapeutic drug monitoring (TDM) of vancomycin is recommended for patients in intensive care units, obese patients, patients with burns, patients receiving nephrotoxic medications and patients with renal impairment.
2. TDM is also recommended for neonates, paediatric patients, and patients undergoing renal replacement therapy (RRT).
3. Vancomycin TDM is recommended for patients with unstable renal function (expert opinion). This refers to a significant deterioration or improvement in renal function during treatment, such as an increase in serum creatinine exceeding 3 mg/dL (26.5 μmol/L) within 48 hours.
4. Vancomycin TDM is recommended for elderly patients (over 65 years old). (Low-quality evidence. Renal function declines with age, so elderly patients should undergo renal function assessment prior to vancomycin prescription.
5. TDM is also recommended for patients with moderate to severe heart failure, adults with a low BMI (BMI <18.5 kg/m²) and patients with hyperdynamic renal function (e.g. those with traumatic brain injury, burns, neutropenia with fever or who are critically ill).
Timing for Vancomycin Therapeutic Drug Monitoring (TDM)
Initiate Test
Retest
a. Patients with normal renal function: Conduct the first test on Day 3 of treatment (48 hours after the first dose).
b. Patients with impaired renal function: Conduct the first test on Day 4 of treatment (72 hours after the first dose).
a. After dosage adjustment: If the drug dosage is modified following the initial TDM, re-test vancomycin TDM after 4-5 subsequent doses.
b. High-risk patients: For intensive care unit (ICU) patients, patients receiving vasopressor therapy, patients undergoing renal replacement therapy (RRT), and patients with severe methicillin-resistant Staphylococcus aureus (MRSA) infections, perform vancomycin TDM weekly
Target range for vancomycin concentration in the valley
Population
Target Range of Steady-State Trough Concentration
Adult patients (common infection)
10~15μg/mL
Adult patients (severe MRSA infection)
10~20μg/mL
Neonatal/paediatric patients
5~15μg/mL
Haemodialysis patients
Peritoneal dialysis patients
12~25μg/mL
Chinese Vancomycin Therapeutic Drug Monitoring Guidelines Recommendation: Vancomycin should primarily monitor trough plasma concentrations.
Case 1
Cases of vancomycin-induced liver injury (DILI) in children: Two pediatric patients at the Second Affiliated Hospital of Xi'an Medical University developed DILI following vancomycin administration. Both children exhibited varying degrees of liver impairment after vancomycin therapy, with gradual recovery upon discontinuation. This liver damage may be associated with vancomycin-induced direct hepatotoxicity or oxidative stress. Recommendations for pediatric intravenous vancomycin administration include adhering to the dosage recommended in the package insert or guidelines, monitoring liver function parameters and measuring vancomycin blood concentrations. If DILI occurs, discontinue, or reduce the dosage promptly and provide symptomatic treatment as necessary.
Case 2
Vancomycin Therapeutic Peak Concentration Monitoring in Preterm Infants: Results from the monitoring of vancomycin trough concentrations in 89 preterm infants at Ningbo University Affiliated Women and Children's Hospital suggest that it is crucial to maintain vancomycin within the optimal therapeutic trough concentration range. Achieving therapeutic concentrations as early as possible significantly improves outcomes for preterm infants. Clinicians are advised to develop individualized antimicrobial dosing strategies for preterm infants, taking into account the patient's physiological and pathological status, with particular attention to corrected gestational age and pre-treatment serum creatinine levels. Dosage and frequency should be determined through a comprehensive evaluation. Following attainment of steady-state concentrations, therapeutic drug monitoring should be conducted. Once the target trough concentration has been achieved, the dosing regimen should be optimized to enhance clinical efficacy while preventing bacterial resistance and drug toxicity.
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