优化耐甲氧西林金黄色葡萄球菌菌血症患者使用万古霉素治疗药物监测的结果：谷浓度还是曲线下面积？

Optimizing outcomes using vancomycin therapeutic drug monitoring in patients with MRSA bacteremia: trough concentrations or area under the curve?

机构信息

HonorHealth John C. Lincoln Medical Center, Department of Pharmacy Services, Phoenix, AZ, USA.

Midwestern University College of Pharmacy, Department of Pharmacy Practice, Glendale, AZ, USA.

出版信息

Diagn Microbiol Infect Dis. 2021 Oct;101(2):115442. doi: 10.1016/j.diagmicrobio.2021.115442. Epub 2021 May 28.

DOI:10.1016/j.diagmicrobio.2021.115442

PMID:34192639

Abstract

BACKGROUND

Vancomycin therapeutic drug monitoring is routinely performed but the specific measure used in practice is variable.

OBJECTIVE

To evaluate the relationship between the first measured vancomycin trough, area-under-the-curve (AUC), and failure in patients with MRSA bacteremia.

METHODS

This retrospective, cohort study included adult non-neutropenic patients with MRSA bacteremia who received vancomycin. The primary outcome was treatment failure. Initial trough and AUC values were compared between the failure and success groups. Classification and regression tree analysis was used to identify thresholds associated with failure. Multivariate analysis was performed to control for identified confounders.

RESULTS

There were 89 patients. Failure occurred in 23 (26%). Trough and AUC values associated with failure were < 10.6 mg/L (39% vs. 13%; P = 0.006) and AUC < 410mgh/L (40% vs. 17%; P = 0.014). Both remained significant after controlling covariates (trough < 10.6 mg/L, OR [95% CI] = 4.91 [1.6-15]; AUC<410mgh/L, OR [95% CI] = 3.13 [1.14-8.62]). Only AUC was predictive of nephrotoxicity.

CONCLUSION

Failure was more common with troughs < 10.6 mg/L or AUC < 410 mg*h/L. Supratherapeutic AUCs, but not trough, were associated with nephrotoxicity.

摘要

背景

万古霉素治疗药物监测通常是常规进行的，但在实践中使用的具体测量方法是可变的。

目的

评估万古霉素谷浓度、曲线下面积（AUC）与耐甲氧西林金黄色葡萄球菌（MRSA）菌血症患者治疗失败之间的关系。

方法

本回顾性队列研究纳入了接受万古霉素治疗的成人非中性粒细胞减少性 MRSA 菌血症患者。主要结局为治疗失败。比较失败组和成功组的初始谷浓度和 AUC 值。采用分类回归树分析确定与失败相关的阈值。进行多变量分析以控制已确定的混杂因素。

结果

共纳入 89 例患者。23 例（26%）发生治疗失败。与失败相关的谷浓度和 AUC 值分别为 <10.6mg/L（39%比 13%；P=0.006）和 AUC<410mgh/L（40%比 17%；P=0.014）。在控制混杂因素后，这两个因素仍然具有统计学意义（谷浓度 <10.6mg/L，比值比[95%置信区间]为 4.91[1.6-15]；AUC<410mgh/L，比值比[95%置信区间]为 3.13[1.14-8.62]）。只有 AUC 与肾毒性相关。