Molina Kyle C, Hall Scott T, Barletta Jeffrey F, Mangram Alicia J, Dzandu James K, Huang Vanthida
Department of Pharmacy, Scripps Mercy Hospital, San Diego, California.
Department of Pharmacy, HonorHealth John C. Lincoln Medical Center, Phoenix, Arizona.
Surg Infect (Larchmt). 2020 Feb;21(1):43-47. doi: 10.1089/sur.2019.026. Epub 2019 Jul 23.
The Augmented Renal Clearance in Trauma Intensive Care (ARCTIC) scoring system is a validated system to predict augmented renal clearance in trauma patients. This study examined the ability of the ARCTIC score to identify patients at risk for subtherapeutic vancomycin trough concentrations relative to estimated creatinine clearance (eCrCl) alone. Trauma patients admitted to the intensive care unit from September 2012 to December 2017 who received vancomycin and had a vancomycin trough concentration recorded were included. Patients were excluded if their serum creatinine concentration was >1.3 mg/dL, if they had received vancomycin doses <30 mg/kg per day, an improperly timed trough concentration measurement, or renal replacement therapy. The primary endpoint was an initial subtherapeutic vancomycin trough concentration (<10 mg/L). Classification and regression tree (CART) analysis was used to identify thresholds for the ARCTIC score and other continuous data where subtherapeutic troughs were more common. A step-wise logistic regression analysis was performed to control for confounders for subtherapeutic troughs whereby inclusion of ARCTIC was modeled sequentially after eCrCl. A total of 119 patients with a mean age of 42 ± 17 years and eCrCl 142 ± 39 mL/min met the inclusion criteria. The mean daily vancomycin dose was 44 ± 9 mg/kg, and the incidence of subtherapeutic trough concentration was 46%. The CART analysis identified two variables creating three groups where subtherapeutic trough concentrations differed: eCrCl >105 mL/min and ARCTIC score ≥7, eCrCl >105 mL/min and ARCTIC score <7, and eCrCl ≤105 mL/min. The base logistic regression model identified eCrCl >105 mL/min and pelvic fracture as risk factors for subtherapeutic trough values. The final model included the addition of ARCTIC score ≥7, which improved the model significantly (p = 0.009). Predictors of subtherapeutic trough concentrations were (odds ratio [95% confidence interval]): eCrCl >105 mL/min (6.5 [1.66-25.07]), ARCTIC score ≥7 (3.26 [1.31-8.09]), and pelvic fracture (4.36 [1.27-14.93]). The ARCTIC score is useful when applied in conjunction with eCrCl. Patients with a eCrCl >105 mL/min and an ARCTIC score ≥7 may require a more aggressive dosing strategy.
创伤重症监护中的增强肾清除率（ARCTIC）评分系统是一个经过验证的用于预测创伤患者增强肾清除率的系统。本研究考察了ARCTIC评分相对于单独的估计肌酐清除率（eCrCl）来识别万古霉素谷浓度低于治疗水平风险患者的能力。纳入了2012年9月至2017年12月入住重症监护病房、接受万古霉素治疗且有记录的万古霉素谷浓度的创伤患者。如果患者血清肌酐浓度>1.3mg/dL、接受的万古霉素剂量<30mg/kg/天、谷浓度测量时间不当或接受了肾脏替代治疗，则将其排除。主要终点是初始万古霉素谷浓度低于治疗水平（<10mg/L）。使用分类与回归树（CART）分析来确定ARCTIC评分及其他连续数据中谷浓度低于治疗水平更为常见的阈值。进行逐步逻辑回归分析以控制谷浓度低于治疗水平的混杂因素，其中在eCrCl之后依次纳入ARCTIC进行建模。共有119例平均年龄为42±17岁、eCrCl为142±39mL/min的患者符合纳入标准。万古霉素平均每日剂量为44±9mg/kg，谷浓度低于治疗水平的发生率为46%。CART分析确定了两个变量，形成了三组谷浓度低于治疗水平存在差异的情况：eCrCl>105mL/min且ARCTIC评分≥7、eCrCl>105mL/min且ARCTIC评分<7以及eCrCl≤105mL/min。基础逻辑回归模型确定eCrCl>105mL/min和骨盆骨折是谷浓度低于治疗水平的危险因素。最终模型纳入了ARCTIC评分≥7，这显著改善了模型（p=0.009）。谷浓度低于治疗水平的预测因素为（比值比[95%置信区间]）：eCrCl>105mL/min（6.5[1.66 - 25.07]）、ARCTIC评分≥7（3.26[1.31 - 8.09]）以及骨盆骨折（4.36[1.27 - 14.93]）。当与eCrCl联合应用时，ARCTIC评分很有用。eCrCl>105mL/min且ARCTIC评分≥7的患者可能需要更积极的给药策略。
