Cindy Luo1, Trana Hussaini2, Katie Lacaria3, Janice Yeung4, Tim T Y Lau5, Raewyn C Broady6. 1. BSc(Pharm), ACPR, is a Clinical Pharmacist at Vancouver General Hospital and a Clinical Instructor in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia. 2. BSc(Pharm), ACPR, PharmD, is a Pharmacotherapeutic Specialist, Solid Organ Transplantation, Vancouver General Hospital, and a Clinical Instructor, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia. 3. BSc, BSc(Pharm), ACPR, is a Clinical Pharmacist, Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital, and a Clinical Instructor, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia. 4. BSc(Pharm), ACPR, PharmD, is Coordinator, Lower Mainland Pharmacy Services Pharmacy Practice Residency Program; a Pharmacotherapeutic Specialist, Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital; and a Clinical Assistant Professor, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia. 5. PharmD, ACPR, FCSHP, is a Pharmacotherapeutic Specialist, Infectious Diseases and Antimicrobial Stewardship, Vancouver General Hospital, and is also a Clinical Professor, Faculty of Pharmaceutical Sciences, and an Associate Member, Division of Infectious Diseases, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia. 6. MBChB, FRACP, is Director, Ambulatory Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital, and Clinical Associate Professor, Division of Hematology, The University of British Columbia, Vancouver, British Columbia.
Abstract
BACKGROUND: The Leukemia/Bone Marrow Transplant Program of British Columbia manages patients with high-risk febrile neutropenia and those with non-neutropenic immunocompromised states in an outpatient clinic setting. Because the program treats outpatients only, once-daily administration of IV antibiotics is desirable. A high-dose, once-daily vancomycin nomogram was developed and implemented as part of the antibiotic treatment regimen. OBJECTIVE: To determine if therapeutic vancomycin trough levels could be achieved with a high-dose, once-daily regimen in this outpatient setting. METHODS: A prospective, single-centre, observational cohort study was conducted over a 7-month period. Outpatients in the Leukemia/Bone Marrow Transplant Program were started on IV vancomycin with the high-dose, once-daily vancomycin nomogram, and outcomes were assessed. RESULTS: Of 48 outpatients treated over the 7-month period, 10 (21%) had therapeutic vancomycin trough concentrations (i.e., greater than 10 mg/L). Thirty-five (90%) of the 39 patients with suspected clinical infection experienced clinical cure, and 6 (67%) of the 9 patients with documented microbiological infection experienced microbiological cure. Thirty (62%) of the 48 patients experienced symptoms of "red man syndrome", and 7 (15%) experienced some degree of nephrotoxicity. Two of 3 patients with laboratory-reported minimum inhibitory concentration (MIC) for identified pathogens had a calculated area under the curve to MIC ratio greater than or equal to 400. CONCLUSION: The high-dose, once-daily vancomycin nomogram was effective in attaining trough levels greater than 10 mg/L in only 21% of patients in this study. A substantial number of adverse drug reactions were observed. Given these results, high-dose, once-daily vancomycin is no longer recommended for outpatient therapy.
BACKGROUND: The Leukemia/Bone Marrow Transplant Program of British Columbia manages patients with high-risk febrile neutropenia and those with non-neutropenic immunocompromised states in an outpatient clinic setting. Because the program treats outpatients only, once-daily administration of IV antibiotics is desirable. A high-dose, once-daily vancomycin nomogram was developed and implemented as part of the antibiotic treatment regimen. OBJECTIVE: To determine if therapeutic vancomycin trough levels could be achieved with a high-dose, once-daily regimen in this outpatient setting. METHODS: A prospective, single-centre, observational cohort study was conducted over a 7-month period. Outpatients in the Leukemia/Bone Marrow Transplant Program were started on IV vancomycin with the high-dose, once-daily vancomycin nomogram, and outcomes were assessed. RESULTS: Of 48 outpatients treated over the 7-month period, 10 (21%) had therapeutic vancomycin trough concentrations (i.e., greater than 10 mg/L). Thirty-five (90%) of the 39 patients with suspected clinical infection experienced clinical cure, and 6 (67%) of the 9 patients with documented microbiological infection experienced microbiological cure. Thirty (62%) of the 48 patients experienced symptoms of "red man syndrome", and 7 (15%) experienced some degree of nephrotoxicity. Two of 3 patients with laboratory-reported minimum inhibitory concentration (MIC) for identified pathogens had a calculated area under the curve to MIC ratio greater than or equal to 400. CONCLUSION: The high-dose, once-daily vancomycin nomogram was effective in attaining trough levels greater than 10 mg/L in only 21% of patients in this study. A substantial number of adverse drug reactions were observed. Given these results, high-dose, once-daily vancomycin is no longer recommended for outpatient therapy.
Entities:
Keywords:
febrile neutropenia; nomogram; once-daily vancomycin; therapeutic drug monitoring
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