Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.
Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.
PLoS One. 2019 Apr 4;14(4):e0214309. doi: 10.1371/journal.pone.0214309. eCollection 2019.
Current guidelines recommend maintaining vancomycin trough concentrations between 15-20 mg/L for serious methicillin resistant staphylococcus aureus (MRSA) infections. This recommendation is based on limited evidence.
A retrospective study including patients with vancomycin susceptible MRSA infections (MIC< = 2 mg/L), treated with vancomycin. We compared outcomes among patients attaining high (> = 15mg/L) vs low (<15mg/L) trough vancomycin levels. We used a propensity score to matching patients achieving low and high levels and conducted an adjusted analysis in the propensity score (PS)-matched cohort using regression analysis. Primary outcome was 30-day all-cause mortality.
Among 285 patients included, there were no significant differences between patients achieving high and low vancomycin levels in mortality (46/131, 35.1% vs 41/154, 26.6%), clinical success, microbiological success, or nephrotoxicity. Similarly, in the PS-matched cohort (n = 162), there was no significant difference in mortality between patients with high and low vancomycin levels (24/53, 45.3% vs 57/109, 52.3%, respectively), adjusted odds ratio for mortality with high levels 0.63 (95% confidence interval 0.28-1.43). In both cohorts, patients with pneumonia achieving high levels had significantly higher clinical and microbiological success (PS-matched cohort: clinical success: 16/32, 50.0% vs 5/27, 18.5%, p = 0.012; microbiological success: 19/32, 59.4% vs 7/27, 25.9%, p = 0.010), without significant differences in mortality.
We found no association between vancomycin levels > = 15 mg/L and clinical outcomes in patients with MRSA infections. In patients with MRSA pneumonia, vancomycin levels > = 15 mg/L were associated with higher clinical success rates. Further larger cohort studies are needed to define optimal vancomycin levels according to the site of infection.
目前的指南建议维持万古霉素谷浓度在 15-20mg/L 之间，用于治疗严重耐甲氧西林金黄色葡萄球菌（MRSA）感染。这一建议是基于有限的证据。
这是一项回顾性研究，纳入了万古霉素敏感的 MRSA 感染（MIC< = 2mg/L）患者，接受了万古霉素治疗。我们比较了达到高（> = 15mg/L）和低（<15mg/L）万古霉素谷浓度的患者的结局。我们使用倾向评分匹配患者，在倾向评分（PS）匹配的队列中使用回归分析进行调整分析。主要结局是 30 天全因死亡率。
在 285 名患者中，达到高和低万古霉素水平的患者在死亡率（46/131，35.1% vs 41/154，26.6%）、临床成功率、微生物学成功率或肾毒性方面无显著差异。同样，在 PS 匹配的队列（n=162）中，高和低万古霉素水平的患者死亡率也无显著差异（24/53，45.3% vs 57/109，52.3%），高水平的死亡率调整优势比为 0.63（95%置信区间为 0.28-1.43）。在两个队列中，肺炎患者达到高水平时，临床和微生物学成功率显著更高（PS 匹配队列：临床成功率：16/32，50.0% vs 5/27，18.5%，p=0.012；微生物学成功率：19/32，59.4% vs 7/27，25.9%，p=0.010），但死亡率无显著差异。
我们发现 MRSA 感染患者的万古霉素水平> = 15mg/L 与临床结局之间没有关联。在 MRSA 肺炎患者中，万古霉素水平> = 15mg/L 与更高的临床成功率相关。需要进一步开展更大规模的队列研究，根据感染部位确定最佳的万古霉素水平。
