Attainment of therapeutic vancomycin level within the first 24 h: Authors' response

Object. Staphylococcal ventriculitis may be a complication in temporary external ventricular drains (EVDs). The limited penetration of vancomycin into the cerebrospinal fluid (CSF) is well known; the pharmacodynamics and efficacy of systemically compared with intraventricularly administered vancomycin is examined in this prospective study. Methods. Ten patients in whom EVDs were implanted to treat intracranial hemorrhage and who were suffering from drain-associated ventriculitis were randomized into two treatment groups. Five of these patients (median age 47 years) were treated with 2 g/day vancomycin administered intravenously (four infusions/day, Group 1), and the other five (median age 49 years) received 10 mg vancomycin intraventricularly once daily (Group 2). Vancomycin levels were measured in serum and CSF six times a day. The maximum vancomycin level in CSF was 1.73 ± 0.4 µg/ml in Group 1 and 565.58 ± 168.71 µg/ml 1 hour after vancomycin application in Group 2 (mean ± standard deviation). Vancomycin levels above the recommended trough level of 5 µg/ml in CSF were never reached in Group 1, whereas in Group 2 they were below the trough level (3.74 ± 0.66 µg/ml) only at 21 hours after intraventricular vancomycin application. The vancomycin level in the serum was constant within therapeutic levels in Group 1, whereas in Group 2 in most instances vancomycin was almost below a measurable concentration. In both groups bacteriologically and laboratory-confirmed CSF clearance could be obtained. Conclusions. Intraventricular vancomycin application is a safe and efficacious treatment modality in drain-associated ventriculitis, with much higher vancomycin levels being achieved in the ventricular CSF than by intravenous administration.

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Assessment of Empiric Vancomycin Regimen in the Neonatal Intensive Care Unit

The Canadian Journal of Hospital Pharmacy ◽

10.4212/cjhp.v72i3.2901 ◽

2019 ◽

Vol 72 (3) ◽

Cited By ~ 1

Author(s):

Ruthdol Ywaya ◽

Brandi Newby

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Neonatal Intensive Care Unit ◽

Neonatal Intensive Care ◽

Culture Result ◽

Dosing Regimen ◽

Clinical Resolution ◽

Negative Culture ◽

Trough Levels ◽

Vancomycin Level

ABSTRACT Background: Vancomycin is used to treat serious gram-positive infections in neonates. Currently, there is no consensus on the preferred empiric dosing regimen or target trough vancomycin levels for neonates. The current Fraser Health empiric dosing regimen, implemented in 2010, was designed to achieve target trough levels of 5 to 15 mg/L. Objectives: To determine the percentage of neonates receiving vancomycin in whom target trough levels of 5 to 15 mg/L were achieved, to identify the times to negative culture result and clinical resolution, and to determine the incidence of nephrotoxicity. Methods: A chart review was completed for patients who had received vancomycin in the neonatal intensive care unit of either Surrey Memorial Hospital or Royal Columbian Hospital from June 2012 to May 2017 and for whom at least 1 interpretable vancomycin level was available. Results: A total of 87 vancomycin encounters (in 78 neonates) were identified in which the drug had been given according to the Fraser Health empiric dosing regimen. Target trough vancomycin level (5 to 15 mg/L) was achieved in 75% of these encounters. The mean times to negative culture result and clinical resolution were 5 and 6 days, respectively. There was no statistically significant correlation between vancomycin level and time to clinical resolution (rs = 0.366, p = 0.072). Among cases in which the trough vancomycin level exceeded 15 mg/L, the incidence of nephrotoxicity was 22% (4/18). Conclusions: The current Fraser Health empiric dosing regimen for vancomycin achieved target trough levels of the drug for most neonates in this study. Targeting trough levels less than 15 mg/L when appropriate to the infection type may limit nephrotoxicity associated with vancomycin in neonates. Further studies are needed to evaluate the clinical significance of various vancomycin levels.RÉSUMÉ Contexte : La vancomycine est utilisée dans le traitement d’infections graves à bactéries à Gram positif chez le nouveau-né. Il n’y a pour l’instant pas de consensus quant à la posologie empirique ou aux concentrations minimales visées de vancomycine à privilégier chez le nouveau-né. La posologie empirique actuelle de la Fraser Health, instaurée en 2010, visait des concentrations minimales de 5 à 15 mg/L. Objectifs : Déterminer le pourcentage de nouveau-nés ayant reçu les concentrations minimales visées de 5 à 15 mg/L de vancomycine, établir le temps nécessaire à l’obtention d’un résultat de culture négatif et celui nécessaire à la disparition clinique des symptômes et déterminer l’incidence de la néphrotoxicité.Méthodes : Les investigateurs ont analysé des dossiers de patients ayant reçu de la vancomycine pendant leur séjour à l’unité de soins intensifs néonatals du Surrey Memorial Hospital ou du Royal Columbian Hospital entre juin 2012 et mai 2017, qui mentionnaient au moins une concentration de vancomycine interprétable. Résultats : Ils ont répertorié 87 traitements de vancomycine (chez 78 nouveau-nés) administrés selon la posologie empirique de la Fraser Health. Les concentrations minimales visées de 5 à 15 mg/L ont été atteintes dans 75 % de ces traitements. Le temps moyen nécessaire à l’obtention d’un résultat de culture négatif ou à la disparition clinique des symptômes était respectivement de cinq et de six jours. Aucune corrélation statistiquement significative entre les concentrations de vancomycine et le temps nécessaire à la disparition clinique des symptômes n’a été relevée (rs = 0,366, p = 0,072). Parmi les cas où les concentrations minimales de vancomycine dépassaient 15 mg/L, l’incidence de néphrotoxicité était de 22 % (4/18). Conclusions : La posologie empirique de vancomycine actuellement en place à la Fraser Health a permis d’atteindre les concentrations minimales visées de médicament pour la plupart des nouveau-nés de la présente étude. Cibler des concentrations minimales de moins de 15 mg/L lorsque cela est pertinent en fonction du type d’infection pourrait limiter le nombre de cas de néphrotoxicité associés à la vancomycine chez les nouveau-nés. De plus amples études sont nécessaires pour évaluer la portée clinique de différentes concentrations de vancomycine.

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Optimizing the correct timing of vancomycin level collection utilizing a vancomycin medication administration record (MAR) level order

International Journal of Medical Informatics ◽

10.1016/j.ijmedinf.2020.104249 ◽

2020 ◽

Vol 143 ◽

pp. 104249

Author(s):

Sunish Shah ◽

Ginger E. Rouse ◽

Dayna McManus ◽

Eric M. Tichy ◽

Laura DeVaux ◽

...

Keyword(s):

Medication Administration ◽

Level Order ◽

Vancomycin Level

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Vancomycin Penetration of a Brain Abscess: Case Report and Review of the Literature

Neurosurgery ◽

10.1227/00006123-198605000-00021 ◽

1986 ◽

Vol 18 (5) ◽

pp. 632-636 ◽

Cited By ~ 23

Author(s):

Robert M. Levy ◽

Philip H. Gutin ◽

David S. Baskin ◽

Vincent G. Pons

Keyword(s):

Radiation Therapy ◽

Brain Abscess ◽

Review Of The Literature ◽

Operative Removal ◽

Iodine 125 ◽

Serum Vancomycin ◽

The Brain ◽

Interstitial Radiation Therapy ◽

Vancomycin Level ◽

Interstitial Radiation

Abstract A 56-year-old man developed an abscess within a right parietal cystic anaplastic astrocytoma 3 days after removal of iodine-125 sources placed 9 days earlier for interstitial radiation therapy. After treatment with cephalosporin antibioties proved unsuccessful, the patient was treated with intravenous vancomycin and intermittent percutaneous drainage of the abscess. Vancomycin levels obtained from the brain abscess fluid, both before and during later operative removal of the abscess, were 15 and 18 μg/ml, respectively; the serum vancomycin level was 21 μg/ml. This is the first report of the excellent penetration of vancomycin into brain abscess fluid.

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Rapid onset vancomycin-induced thrombocytopenia confirmed by vancomycin antibody test

BMJ Case Reports ◽

10.1136/bcr-2021-243027 ◽

2021 ◽

Vol 14 (7) ◽

pp. e243027

Author(s):

Thakul Rattanasuwan ◽

Yael Marks ◽

Jess Delaune ◽

Adonice P Khoury

Keyword(s):

Platelet Count ◽

Blood Count ◽

Complete Blood Count ◽

Clinical Symptoms ◽

Antibody Test ◽

Rapid Onset ◽

Antibody Testing ◽

Drug Dependent ◽

Related Reaction ◽

Vancomycin Level

We report a case of vancomycin-induced thrombocytopenia (VIT) with rapid onset after re-exposure to vancomycin. A 58-year-old man with cellulitis was initiated on vancomycin. Approximately 1 hour into the vancomycin infusion, the patient developed an infusion-related reaction. Vancomycin infusion was stopped. A complete blood count obtained 4 hours after discontinuation of the vancomycin infusion revealed a platelet count of 31 ×109/L. Investigations ruled out likely causes of thrombocytopenia. VIT was diagnosed based on clinical symptoms and confirmed with drug-dependent platelet antibody testing. Without complications, platelet counts recovered within 7 days after discontinuation of vancomycin. No correlation between vancomycin level and VIT was observed.

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Effects of therapeutic drug monitoring criteria in a computerized prescriber-order-entry system on the appropriateness of vancomycin level orders

American Journal of Health-System Pharmacy ◽

10.2146/ajhp090661 ◽

2011 ◽

Vol 68 (4) ◽

pp. 347-352 ◽

Cited By ~ 24

Author(s):

Kristi A. Traugott ◽

Pamela R. Maxwell ◽

Kay Green ◽

Christopher Frei ◽

James S. Lewis

Keyword(s):

Therapeutic Drug Monitoring ◽

Drug Monitoring ◽

Therapeutic Drug ◽

Order Entry ◽

Computerized Prescriber Order Entry ◽

Vancomycin Level

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Novel approach to vancomycin level monitoring: Impact of a multidisciplinary monitoring system on timing of vancomycin levels

American Journal of Health-System Pharmacy ◽

10.2146/ajhp160760 ◽

2018 ◽

Vol 75 (3) ◽

pp. 121-126 ◽

Cited By ~ 6

Author(s):

Vincent Peyko ◽

Michelle Friedman-Jakubovics

Keyword(s):

Monitoring System ◽

Novel Approach ◽

Level Monitoring ◽

Vancomycin Level

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Vancomycin Intermittent Dosing versus Continuous Infusion for Treatment of Ventilator-associated Pneumonia in Trauma Patients

The American Surgeon ◽

10.1177/000313481307901123 ◽

2013 ◽

Vol 79 (11) ◽

pp. 1185-1190 ◽

Cited By ~ 7

Author(s):

Thomas M. Schmelzer ◽

A. Britton Christmas ◽

H. James Norton ◽

B. Todd Heniford ◽

Ronald F. Sing

Keyword(s):

Injury Severity ◽

Randomized Study ◽

Total Body Weight ◽

Primary Outcome Measure ◽

Trauma Patients ◽

Ventilator Associated Pneumonia ◽

Treatment Groups ◽

Trauma Society ◽

Serum Vancomycin ◽

Vancomycin Level

Current guidelines for the empiric treatment of ventilator-associated pneumonia (VAP) recommend that vancomycin is dosed 15 mg/kg and administered twice daily for a target trough level of 15 to 20 mg/mL. This study compared conventional intermittent vancomycin infusion (IVI) with continuous vancomycin infusion (CVI). Our prospective, randomized study compared CVI with IVI in trauma patients with suspected VAP. The primary outcome measure was a serum vancomycin level within the target level 48 hours after initiation of therapy. Treatment groups were compared using standard statistical methods. The study included 73 patients, 36 IVI and 37 CVI. Eighteen patients were withdrawn from the study as a result of discontinuation of the drug before 48 hours or failure to draw levels at the appropriate time, resulting in 27 IVI and 28 CVI study patients. There were no differences between treatment groups in gender ( P = 0.97), Injury Severity Score ( P = 0.70), total body weight ( P = 0.36), or age ( P = 0.81). The mean serum vancomycin level for the IVI group was 8.9 ± 3.9 mg/mL, and the CVI level was 19.8 ± 6.13 mg/mL ( P < 0.0001). Two patients in the IVI group (7.4%) were in the therapeutic range compared with 16 (57.1%) in the CVI group ( P < 0.0001). Six patients in the CVI group (21.4%) and none of the IVI patients had supratherapeutic levels. Four patients developed renal insufficiency, three IVI (11.1%) and one CVI (3.6%) ( P = 0.36). The current American Trauma Society dosing recommendations for vancomycin for presumptive VAP treatment are inadequate. Continuous vancomycin infusion should be adopted as the standard dosing strategy.

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An Unusual Case of Ototoxicity with Use of Oral Vancomycin

Case Reports in Infectious Diseases ◽

10.1155/2018/2980913 ◽

2018 ◽

Vol 2018 ◽

pp. 1-3 ◽

Cited By ~ 2

Author(s):

Umut Gomceli ◽

Srija Vangala ◽

Cosmina Zeana ◽

Paul J. Kelly ◽

Manisha Singh

Keyword(s):

Renal Function ◽

Clostridium Difficile ◽

Normal Renal Function ◽

Systemic Absorption ◽

Temporal Association ◽

Oral Vancomycin ◽

Patient Reported ◽

Serum Vancomycin ◽

Detectable Serum ◽

Vancomycin Level

Introduction. Systemic absorption of oral vancomycin is poor due to the size of the molecule and its pharmacokinetics. It has an elimination half life of 5–11 hours in patients with normal renal function. We present a rare case of ototoxicity after oral vancomycin administration and detectable serum vancomycin levels 24 hours after cessation of vancomycin. Case Presentation. A 42-year-old woman with a history of hypertension, diabetes mellitus, and previously treated Clostridium difficile colitis presented with abdominal pain and diarrhea for two weeks. Clostridium difficile infection was confirmed by PCR, and at the time of diagnosis and initiation of therapy, the patient had normal renal function. Vancomycin was initiated at a dose of 125 mg po q6h. After the third dose of oral vancomycin, the patient reported new symptoms of lightheadedness, sensations of “buzzing” and whistling of bilateral ears, and decreased perception of hearing described as “clogged ears.” The patient reported to the emergency department the next day due to worsening of these symptoms, and vancomycin dosing was reduced to every 8 hours; however, the patient reported the auditory symptoms persisted. On day three, vancomycin was discontinued with gradual resolution of symptoms over the next 12 hours. On day four, a serum random vancomycin level obtained 24 hours after the last dose was detectable at 2 mcg/dl. Temporal association of the patient’s symptoms and improvement with cessation of therapy along with a detectable vancomycin level indicates systemic absorption of oral vancomycin with subsequent ototoxicity. Discussion. The potential for absorption of oral vancomycin is not well described and is attributed to compromised intestinal epithelium allowing for increased drug absorption. Few studies suggested that oral vancomycin may result in therapeutic or even potentially toxic levels of serum vancomycin in patients with impaired renal function. Ototoxicity may be a transient or permanent side effect of vancomycin therapy and is related to high serum levels. Symptoms usually resolve after decreasing the dose or cessation of vancomycin. No detectable serum vancomycin levels were found in 98% of the patients treated with oral vancomycin in a prospective study. The described case is unusual because despite normal renal function, the patient still developed ototoxicity, and systemic absorption of the drug was confirmed with a measurable vancomycin level approximately 24 hours after the drug was stopped. Additionally, the only other medication prescribed to the patient at the time of vancomycin administration was metformin at a dose of 500 mg po bid which has no known idiosyncratic interactions potentiating adverse side effects to vancomycin. This case reflects that some patients may be more susceptible to increased systemic absorption via the oral route, and the possibility for ototoxicity should be considered and discussed with patients while prescribing oral vancomycin.

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