From the College of Pharmacy (R.D.V., S.N.), College of Medicine (O.T., A.C., A.C., R.K.), Oklahoma University HSC; and OU Medical Center (B.W.), Oklahoma City, Oklahoma.
J Trauma Acute Care Surg. 2019 Nov;87(5):1164-1171. doi: 10.1097/TA.0000000000002492.
Current guidelines from the Infectious Diseases Society of America and the American Society of Health-System Pharmacists recommend vancomycin troughs of 15 mg/L to 20 mg/L for serious methicillin-resistant Staphylococcus aureus infections. The pharmacokinetics of vancomycin are altered in critically ill patients, leading to inadequate serum levels. Rates of initial therapeutic vancomycin troughs have ranged from 17.6% to 33% using intermittent infusions (i.e., 15-20 mg/L) and approximately 60% using continuous infusions (i.e., 15-25 mg/L) in critically ill trauma patients (1-4). We hypothesized that our dosing protocol would achieve higher rates of initial therapeutic troughs compared with previously published reports due to more aggressive loading doses than those seen in previously published reports.
This was a retrospective study of all critically ill trauma patients admitted to a Level I trauma intensive care unit over a 39-month period who had a suspected serious infection, who were treated with empiric vancomycin per the "pharmacy to dose" protocol, and who had an appropriately drawn steady state trough level. The primary outcome was the rate of initial therapeutic troughs, which was defined as 14.5 mg/L to 20.5 mg/L.
One hundred ninety-seven patients were screened. Seventy patients met inclusion criteria. The study cohort had a median age of 47.5 years and a median Injury Severity Score of 28. Augmented renal clearances were observed, with a median creatinine clearance of 159.1 mL/min and a median Augmented Renal Clearance in Trauma Intensive Care (ARCTIC) score of 7. The median vancomycin loading dose was 24.6 mg/kg with an initial maintenance dose of 17.71 mg/kg. An every eight hour dosing interval was initiated on 47.14% of the patients, and 45.71% of the patients were initially started on an every 12 hour dosing interval. Only 15.71% of the study patients achieved an initial therapeutic trough; 42.86% were less than 10 mg/L, and 8.57% were greater than 20.5 mg/L. Acute kidney injury occurred in 10% based on the Infectious Diseases Society of America/American Society of Health-System Pharmacists vancomycin guidelines and in 11.4% based on the Acute Kidney Injury Network criteria.
Our incidence of initial therapeutic troughs was slightly below previously reported studies. Based on our results, which are consistent with previous literature, it would appear that our guideline-adherent protocol of intermittent vancomycin is insufficient to achieve troughs of 15 mg/L to 20 mg/L.
Therapeutic, level III.
目前，传染病学会和美国卫生系统药师协会的指南建议严重耐甲氧西林金黄色葡萄球菌感染的万古霉素谷浓度为 15 毫克/升至 20 毫克/升。重症患者的万古霉素药代动力学发生改变，导致血清水平不足。在重症创伤患者中，间歇性输注（即 15-20 毫克/升）初始治疗万古霉素谷浓度的比例为 17.6%至 33%，而连续输注（即 15-25 毫克/升）的比例约为 60%（1-4）。我们假设，由于我们的负荷剂量比以前发表的报告中看到的更积极，因此我们的给药方案会比以前发表的报告中更高地达到初始治疗谷浓度。
这是一项对在 39 个月期间入住一级创伤重症监护病房的所有疑似严重感染的重症创伤患者的回顾性研究，他们根据“药房到剂量”方案接受经验性万古霉素治疗，并进行了适当的稳态谷浓度检测。主要结局是初始治疗谷浓度的比例，定义为 14.5 毫克/升至 20.5 毫克/升。
筛选了 197 名患者。70 名患者符合纳入标准。研究队列的中位年龄为 47.5 岁，损伤严重程度评分中位数为 28。观察到增强的肾清除率，中位肌酐清除率为 159.1 毫升/分钟，中位创伤重症监护增强肾清除率（ARCTIC）评分为 7。万古霉素负荷剂量中位数为 24.6 毫克/千克，初始维持剂量为 17.71 毫克/千克。47.14%的患者开始每 8 小时给药一次，45.71%的患者开始每 12 小时给药一次。只有 15.71%的研究患者达到初始治疗谷浓度；42.86%的患者谷浓度小于 10 毫克/升，8.57%的患者谷浓度大于 20.5 毫克/升。根据传染病学会/美国卫生系统药师协会万古霉素指南，10%的患者发生急性肾损伤，根据急性肾损伤网络标准，11.4%的患者发生急性肾损伤。
我们初始治疗谷浓度的发生率略低于先前的报告研究。根据我们的结果，与之前的文献一致，我们的间歇性万古霉素治疗指南一致的方案似乎不足以达到 15 毫克/升至 20 毫克/升的谷浓度。
治疗性，III 级。
