Analiza zdravljenja s parenteralnim vankomicinom na Kliniki za infekcijske bolezni in vročinska stanja Univerzitetnega kliničnega centra Ljubljana v letih 2018 in 2019

Bohte, Iva (author), Kerec Kos, Mojca (mentor), Nadrah, Kristina (comentor)

Vankomicin je glikopeptidni antibiotik, ki se parenteralno uporablja pri zdravljenju resnejših okužb s po Gramu pozitivnimi bakterijami. Razvrščen je na seznam rezervnih antibiotikov, zaradi ozkega terapevtskega okna pa zahteva redno spremljanje serumskih koncentracij vankomicina in ohranjanje le-teh znotraj terapevtskega območja. Previsoke koncentracije so problematične s strani nefrotoksičnosti, prenizke pa lahko vodijo do razvoja bakterijske odpornosti in neučinkovitega zdravljenja. Z retrospektivno raziskavo smo analizirali parenteralno uporabo vankomicina na Kliniki za infekcijske bolezni in vročinska stanja, UKC Ljubljana, v letih 2018 in 2019. V raziskavo smo vključili polnoletne bolnike iz oddelka za odrasle in enote intenzivne terapije. Pri terapijah smo analizirali ustreznost začetnega odmerjanja vankomicina in izvajanja terapevtskega spremljanja serumskih koncentracij glede na interna priporočila klinike. Preverili smo tudi razvoj akutne ledvične okvare med zdravljenjem z vankomicinom ter vpliv potencialnih dejavnikov tveganja za njen pojav. V raziskavo smo vključili 148 bolnikov (povprečna starost 65,8 let, 52 % moških), ki so skupno imeli 176 terapij z vankomicinom. Vodilni indikaciji za vankomicin sta bili sepsa in bakterijska pljučnica. Zdravljenje so na obeh oddelkih začeli najpogosteje s standardnim režimom odmerjanja vankomicina 1000 mg/12 h. Ledvična funkcija bolnika je bila pri izbiri začetnega odmernega režima upoštevana pri skupno 67,9 % terapij. Polnilni odmerek so uporabili pri 17,3 % terapij, pogosteje v enoti intenzivne terapije in prevladoval je odmerek 2000 mg. Spremljanje terapevtskih koncentracij vankomicina so izvajali pri 158 terapijah, pri večini od njih so z meritvami koncentracij vankomicina začeli še pred stacionarnim stanjem. Terapevtsko območje vankomicina (10–15 μmol/L) je bilo pri vseh meritvah doseženo pri manj kot 20 % obravnavanih terapijah. Med neustreznimi izmerjenimi minimalnimi koncentracijami vankomicina v serumu so prevladovale vrednosti nad 15 μmol/L. Akutna ledvična okvara se je med zdravljenjem razvila v 14,0 % deležu, na njen pojav je med opazovanimi dejavniki značilno vplivala le prisotnost vsaj ene izmerjene koncentracije vankomicina nad terapevtskim območjem. Glede na rezultate smo podali predloge možnih izboljšav pri sistemskem zdravljenju okužb z vankomicinom na Kliniki za infekcijske bolezni in vročinska stanja.

• Language: Slovenian
• Keywords: vankomicin, terapevtsko spremljanje koncentracij, prilagajanje odmerjanja, akutna ledvična okvara
• Work type: Master's thesis/paper
• Organization: FFA - Faculty of Pharmacy
• Year: 2020
• PID: 20.500.12556/RUL-117293
• Publication date in RUL: 04.07.2020

Secondary language

• Language: English
• Title: Analysis of parenteral vancomycin treatment in 2018 and 2019 at Department of Infectious Diseases, University Medical Centre Ljubljana

Abstract

Vancomycin is a glycopeptide antibiotic, used for parenteral treatment of severe Gram-positive bacterial infections. It is on the list of reserve antimicrobials. Due to the narrow therapeutic window, regular therapeutic drug monitoring of vancomycin and maintaining its serum concentrations within the therapeutic range is required. Too high concentrations are problematic because of the nephrotoxicity; on the other hand, too low concentrations can lead to development of bacterial resistance and ineffective therapy. In the retrospective study, we analysed parenteral vancomycin treatment at Department of Infectious Diseases, University Medical Centre Ljubljana in 2018 and 2019. Adults from non-intensive care unit and from intensive care unit were included. We evaluated the adequacy of vancomycin initial dosing and therapeutic drug monitoring according to the clinic´s internal recommendations. We also checked the development of acute kidney failure during the vancomycin therapy and the impact of potential risk factors on its occurrence. The research included 148 patients (average age 65.8 years, 52 % men) with a total of 176 vancomycin therapies. Sepsis and bacterial pneumonia were the main indications for vancomycin treatment. Treatment was most often started with the standard dosing regimen of 1000 mg/12 h. In 67.9 % of therapies, initial dose of vancomycin was adjusted according to patient´s renal function. Loading dose was used in 17.3 % of therapies, mostly 2000 mg dose and more often at intensive care unit. Therapeutic vancomycin concentrations were monitored in 158 therapies, the first concentration was mostly measured before steady state was reached. All measurements reached the therapeutic concentration range of vancomycin (10–15 μmol/L) in less than 20 % of therapies. Measured trough concentrations higher than 15 μmol/L prevailed among inappropriate trough concentrations. Acute kidney failure developed in 14.0 % of the therapies. Among potential risk factors, only the presence of at least one therapeutic serum concentration of vancomycin above the therapeutic range was significantly associated with its occurrence. According to these results, we have suggested some possible improvements in systemic vancomycin treatment at Department of Infectious Diseases.

• Keywords: vancomycin, therapeutic drug monitoring, dosing adjustment, acute kidney failure