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      Vancomycin in ICU Patients with Gram-Positive Infections: Initial Trough Levels and Mortality

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          Abstract

          Background

          Vancomycin is one of the most common therapeutic agents for treating gram-positive infections, particularly in critically ill patients. The aim of this study was to identify factors associated with initial therapeutic vancomycin trough levels and mortality in a tertiary-care intensive care unit (ICU).

          Methods

          This retrospective study evaluated 301 adult ICU patients admitted to King Abdulaziz Medical City in Riyadh between October 1, 2017 and December 31, 2018 with confirmed gram-positive infections and received intravenous vancomycin. Vancomycin trough levels of 15–20 mg/L for severe infections and 10–15 mg/L for less severe infections were considered therapeutic.

          Results

          The patients were relatively older with a mean age of 60 (SD ±20) years. Initial vancomycin trough levels were therapeutic in 168 (55.8%). Factors associated with initial therapeutic vancomycin trough levels were female gender (adjusted odds ratio [aOR]=2.575), older age (aOR=1.024), receiving a loading dose (aOR=2.445), having bacteremia (aOR=2.061), and high platelet count (aOR=1.003). On the other hand, the increase of estimated glomerular filtration rate (eGFR) (aOR=0.993) and albumin levels (aOR=0.944) were associated with lower odds of initial therapeutic vancomycin trough levels. Factors associated with higher mortality were female gender (adjusted hazard ratio [aHR]=2.630), increased body weight (aHR=1.021), cancer (aHR=3.451), and high APACHE II score (aHR=1.068).

          Conclusion

          The study identified several factors associated with achieving initial therapeutic vancomycin trough levels (i.e. older age, female gender, receiving a loading dose, bacteremia, high platelets count, low eGFR and albumin level). These factors should be considered in the dosing of vancomycin in critically ill patients with gram-positive infections.

          Most cited references31

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          Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.

          To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012".
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            Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children.

            Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system (CNS) infections. Recommendations are provided regarding vancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibility to vancomycin, and vancomycin treatment failures.
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              Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists.

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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                tcrm
                tcriskman
                Therapeutics and Clinical Risk Management
                Dove
                1176-6336
                1178-203X
                14 October 2020
                2020
                : 16
                : 979-987
                Affiliations
                [1 ]Pharmaceutical Care Department, Ministry of National Guard- Health Affairs , Riyadh, Saudi Arabia
                [2 ]Department of Epidemiology & Biostatistics, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences , Riyadh, Saudi Arabia
                [3 ]Henry M. Jackson Foundation for the Advancement of Military Medicine , Bethesda, MD, USA
                [4 ]King Abdullah International Medical Research Center, King Saud Bin-Abdulaziz University for Health Sciences , Riyadh, Saudi Arabia
                [5 ]Intensive Care Department, College of Medicine King Saud Bin Abdulaziz University for Health Sciences , Riyadh, Saudi Arabia
                Author notes
                Correspondence: Nadiyah Alshehri Department of Epidemiology & Biostatistics, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences , P.O. Box: 47323, Riyadh11552, Saudi Arabia Email alshehrina2@ngha.med.sa
                Author information
                http://orcid.org/0000-0002-1155-8021
                http://orcid.org/0000-0002-5547-2043
                http://orcid.org/0000-0002-3772-8949
                http://orcid.org/0000-0001-9787-6815
                Article
                266295
                10.2147/TCRM.S266295
                7569025
                815f3b3d-afba-4fc6-936d-fb7b28cb433b
                © 2020 Alshehri et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                : 18 June 2020
                : 06 September 2020
                Page count
                Figures: 3, Tables: 10, References: 32, Pages: 9
                Funding
                This research did not receive any funding.
                Categories
                Original Research

                Medicine
                vancomycin dosage,pharmacokinetics,renal function,serum trough levels,mortality
                Medicine
                vancomycin dosage, pharmacokinetics, renal function, serum trough levels, mortality

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