A Study To Optimize Vancomycin Regimen In Critical Patients

Background In recent years,serious Gram-positive cocci infections,especially methicillin-resistant Staphylococcus aureus(MRSA),the treatment of enterococcal infection is still a serious problem facing clinicians.Vancomycin is a glycopeptide antibiotic,approved by the FDA in 1958 for clinical use,which has a strong bactericidal activity against Gram-positive bacteria.At present,vancomycin is still the first-line clinical treatment against Gram-positive cocci infection,especially MRSA infection,which can improve the cure rate and reduce the mortality of patients,and is recommended by several guidelines.Vancomycin serum steady-state trough concentration is the most accurate and practical evaluation of drug efficacy predictors.However,due to the narrow therapeutic window of vancomycin and individual differences in pharmacokinetics in clinical practice,routine empirical use of vancomycin in patients with severe infections is often difficult to achieve the ideal concentration of blood serum,which may lead to treatment failure or serious adverse reactions.How to use vancomycin for severe infections more scientifically,rationally,safely,effectively and individually has become a problem that needs to be solved clinically.Based on the above background,we designed a retrospective and prospective two-part study designed to provide theoretical basis for further optimization of clinical vancomycin dosing regimen.First Part:Retrospective StudyObjectives To analyze the application of vancomycin in 107 patients in the Department of Critical Care Medicine in our hospital and analyze its distribution and qualify rate of the concentration of vancomycin in order to provide a theoretical reference for the rational application of vancomycin.MethodsThe data of patients who treated with vancomycin in the ICU of our hospital from January 2015 to May 2016 were retrospectively analyze.Using 15-20 ?g/ml as the target blood trough concentration,the distribution of blood trough concentrationa and qualify rate was analyzed.At the same time,the patients were divided into two groups,the first standard monitoring which the first blood trough concentration monitoring time for the fourth or fifth dose 30 minutes before administration and the first non-standard monitoring in which the time for the first monitoring of trough concentrations was 30 min prior to the administration of the fifth dose,and the influence of each group's first load dose on the concentration of blood trough concentration was analyzed respectively.Results 1.107 cases,a total of 230 serum trough concentration of vancomycin were enrolled in this study,and 52 patients(22.61%)reached the targeting serum though concentration(15-20?g/ml).2.The first standardized monitoring vancomycin blood trough concentration in patients with 59 cases,of which 7 patients reached the targeting serum though concentration,accounting for 11.86% of the total population.In the first standardized monitoring data,the target valley concentration of the load dose group was higher than that of the non-load dose subgroup(15.8% vs 4.8%),there was no significant difference between the two subgroups(P=0.505).The first non-standardized monitoring vancomycin blood trough concentration in patients with 48 cases,17 of whom achieved the target trough concentration of 35.4%.The target trough concentration of the load dose group was higher than that of the non-load dose subgroup(44% vs 26.1%),there was no significant difference between the two subgroups(P = 0.062).Conclusion 1.The empirical use of vancomycin,the target blood trough concentration is low.2.The first dose of vancomycin given to the loading dose did not increase the risk of excessively high plasma trough concentrations and may increase the target trough concentrations rate.Second Part:Prospective StudyObjectives To evaluate the effect of individualized regimen based on the use of vancomycin calculator on the qualify rate of the concentration of vancomycin.Methods The patients with severe infection during June 2016 to January 2017 admitted to our hospital ICU were collected as the experimental group,vancomycin individualized regimen was based on vancomycin calculator.The serum vancomycin concentration was determined 30 minutes before the fifth dose.The variation of drug valley concentration and the renal function before and after medication were analyzed.In accordance with the principle of benefit,the control group was not established at the same time.The medical records of patients undergraduated application of vancomycin and serum valley concentration was recorded at the same time during January 2015 to May 2016 were reviewed.The patients who were determinated the serum valley concentration 30 minutes before the fouth or fifth doses were selected as the previous group,the difference of the concentration of blood medicine valley between the two groups was compared.Results 1.The experimental group included 67 patients.The range of concentration of vancomycin of 20(29.85%)cases was 15-20?g/ml.The previous group included 56 patients,the range of concentration of vancomycin of 7(12.5%)cases was 15-20?g/ml,with significant statistical difference between the two groups(P = 0.028).2.There was no statistically significant difference in endogenous creatinine clearance before and after treatment with vancomycin in the experimental group(P>0.05).Conclusion Vancomycin calculator can develop individualized drug regimen and improve qualify rate of the trough concentration of vancomycin of patients with severe infection.It has no effect on renal function in patients with early treatment and is convenient for clinical use.