Smith Darrell, Sanders James, Monogue Marguerite
Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
Pulm Med. 2025 May 28;2025:5683225. doi: 10.1155/pm/5683225. eCollection 2025.
Therapeutic drug monitoring (TDM) for vancomycin (VAN) in adult people with cystic fibrosis (pwCF) historically has utilized trough concentrations. Recent VAN TDM guidelines recommend area under the curve (AUC) monitoring to reduce the risk of acute kidney injury (AKI), despite limited evidence to support this practice in adult pwCF. This single-center, retrospective, observational cohort study included 143 adult pwCF admitted from July 1, 2017, to July 1, 2022, with an acute pulmonary exacerbation that received VAN for at least 72 h with available VAN plasma concentrations for TDM for AUC ( = 39) or trough monitoring ( = 104). Eligible patients with multiple hospital admissions during the study period were incorporated as separate encounters. The primary outcome was the incidence of AKI. Receipt of concurrent nephrotoxins was more common in the AUC cohort than in the trough cohort (97% vs. 81%, = 0.01), but the rate of AKI was similar (7.7% vs. 10.6%, = 0.76). AUC monitoring was associated with earlier achievement of TDM goal (median 0 days (IQR 0-2) vs. 2 days (IQR 0-4), < 0.01), lower total daily doses (34.8 mg/kg/day (IQR 27.6-49) vs. 57.5 mg/kg/day (IQR 43.9-68.6), < 0.01), and fewer regimen changes (median 1 change (IQR 0-2) vs. 2 changes (IQR 1-3), < 0.01). In patients with MRSA, pulmonary function recovery, readmission, and mortality were similar. In adult pwCF, the incidence of AKI was similar between AUC and trough monitoring cohorts; however, AUC monitoring achieved therapeutic targets sooner with fewer regimen modifications without significantly increasing the number of concentrations compared to trough monitoring.
历史上，针对成年囊性纤维化患者（pwCF）的万古霉素（VAN）治疗药物监测（TDM）一直采用谷浓度。近期的VAN TDM指南建议采用曲线下面积（AUC）监测以降低急性肾损伤（AKI）风险，尽管在成年pwCF中支持这种做法的证据有限。这项单中心、回顾性、观察性队列研究纳入了2017年7月1日至2022年7月1日期间收治的143例成年pwCF，这些患者因急性肺部加重接受VAN治疗至少72小时，且有可用于TDM的VAN血浆浓度以进行AUC（n = 39）或谷浓度监测（n = 104）。研究期间多次住院的符合条件患者被作为单独的病例纳入。主要结局是AKI的发生率。AUC队列中同时接受肾毒性药物的情况比谷浓度队列更常见（97%对81%，P = 0.01），但AKI发生率相似（7.7%对10.6%，P = 0.76）。AUC监测与更早达到TDM目标相关（中位数0天（四分位间距0 - 2）对2天（四分位间距0 - 4），P < 0.01），每日总剂量更低（34.8mg/kg/天（四分位间距27.6 - 49）对57.5mg/kg/天（四分位间距43.9 - 68.6），P < 0.01），且方案更改更少（中位数1次更改（四分位间距0 - 2）对2次更改（四分位间距1 - 3），P < 0.01）。在耐甲氧西林金黄色葡萄球菌（MRSA）患者中，肺功能恢复、再入院和死亡率相似。在成年pwCF中，AUC和谷浓度监测队列之间的AKI发生率相似；然而，与谷浓度监测相比，AUC监测能更快达到治疗目标，方案调整更少，且未显著增加监测浓度的数量。
