Why vancomycin trough

Trough levels correlate better with efficacy than peak levels, with target trough levels of As with any assay employing mouse antibodies, the possibility exists for interference by human antimouse antibodies HAMA in the sample, which could cause falsely lowered results.

Am J Health Syst Pharm. Mayo Clinic. Updated July 29, Skip to main content. Register Sign In. The primary end point was the development of nephrotoxicity, which was defined as an increase in serum creatinine by either 0. Patients who had a documented isolated increase in serum creatinine that resolved upon recheck within 24 hours were not classified as experiencing nephrotoxicity.

In patients who developed nephrotoxicity, mean troughs, maximum troughs, duration of vancomycin treatment, and receipt of concomitant nephrotoxins were ascertained using data collected only before nephrotoxicity onset. Bivariate and multivariate models were subsequently constructed in order to determine risk factors for nephrotoxicity, using either mean or maximum trough achieved prior to nephrotoxicity for each patient.

Association of clinical variables with nephrotoxicity was assessed using bivariate logistic regression with subsequent multivariable logistic regression. Age, sex, race, comorbidities, and indication for vancomycin use were similar between the 2 groups. Overall, nephrotoxicity was noted in 31 patients 8.

The median time to onset of nephrotoxicity was 7 days, with a median peak serum creatinine of 1. Osteomyelitis, urinary tract infection, endocarditis, meningitis, otomastoiditis, empiric therapy. Results of bivariate and multivariate analysis of clinical factors potentially associated with nephrotoxicity are displayed in Table 2. Among the 31 patients experiencing nephrotoxicity, the mean maximum vancomycin trough prior to nephrotoxicity onset was The duration of vancomycin therapy was also not significantly associated with nephrotoxicity, both when evaluated as a continuous variable and when prolonged courses 14 days were compared to short courses between 5 and 14 days of therapy.

The only factor significantly associated with nephrotoxicity in either bivariate or multivariate analysis was receipt of intravenous contrast dye OR 3. Of the 31 patients with nephrotoxicity, 20 Thus, overall reversibility of nephrotoxicity either prior to, or within, 72 hours of vancomycin discontinuation was Only 1 persistently nephrotoxic patient required dialysis: a critically ill patient with multiorgan failure for whom care was withdrawn within 4 days of vancomycin discontinuation.

Over the past 5 years, many institutions have adopted higher dosing guidelines for vancomycin, based on pharmacokinetic concerns related to its performance in the treatment of invasive staphylococcal disease. The data on nephrotoxicity at these higher troughs are limited. Previous studies that address the relationship between higher vancomycin troughs and nephrotoxicity suffer from small sample size 29 , 33 ; do not address reversibility of nephrotoxicity 9 , 26 , , 33 ; may not account for the temporal relationship between the development of nephrotoxicity and high trough levels, 9 , or examine patient populations at relatively high 27 or low 30 risk for renal injury apart from receipt of vancomycin.

A recent expert consensus statement identified these factors as limiting the strength of evidence for a direct causal relationship between elevated vancomycin troughs and nephrotoxicity.

In particular, we chose to focus on nephrotoxicity occurring after at least 5 days of vancomycin therapy in order to reduce confounding by other possible sources of renal injury that may have affected the decision to initially prescribe vancomycin, an approach advocated by a recent review. The research cited in published reviews demonstrates that studies published in journals have a tendency to report larger effect sizes than studies published in grey literature [ 63 , 64 ].

Based on pooled adjusted OR, high vancomycin trough level is the variable that was identified as the independent factor associated with risk of nephrotoxicity in MRSA infections. However, we need to acknowledge that this conclusion does not take into account vancomycin MIC data, which were not available for analysis in this study.

Since adjustment of funnel plot asymmetry using the trim and fill method yielded significant change in pooled OR for clinical success, association between high vancomycin trough levels and both risk for adverse events and improvement in clinical outcomes in patients with MRSA infection requires further study.

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