Vancomycin therapeutic drug monitoring

Freeman CD, Quintiliani R, Nightingale CH. Vancomycin therapeutic drug monitoring is it necessary Ann Pharmacother 1993 27(5) 594-8. 

Welty TE, Copa AK, Impact of vancomycin therapeutic drug monitoring on patient care, Ann of Pharmacother, 1994,28 1335-39. 

Pharmacokinetics of vancomycin Renal transport of vancomycin Epidemiology of vancomycin nephrotoxicity Risk factors for nephrotoxicity Therapeutic drug monitoring of vancomycin Prevention of vancomycin nephrotoxicity Alternative gram positive antibiotics References ... 

Due to the risks of serious adverse events such as nephrotoxicity and ototoxicity observed when systemic vancomycin was first used, therapeutic drug monitoring programs (TDM) for vancomycin were developed. To amehorate the risk of toxicity, clinicians have historically targeted a peak vancomycin serum concentration of 30 to 40 mg/L and a trough serum concentration of 5 to 10 mg/L. However, there is a notable lack of... 

Ceftriaxone and vancomycin are the agents of choice to treat presumed pneumococcal meningitis empirically until the susceptibility is known. Penicillin may be used for drug-susceptible isolates with MICs of 0.06 mg/L or less, but for intermediate isolates, ceftriaxone is used, and for highly drug resistant isolates, a combination of ceftriaxone and vancomycin should be used. Vancomycin should not be used as monotherapy. In especially severe cases, therapeutic drug monitoring of the CSF and possibly even direct antibiotic instillation may be necessary. 

Vancomycin exhibits predictable pharmacokinetic properties and its clinical use has been guided by the pharmacokinetic monitoring of serum levels to determine the dose and frequency of administration. Pharmacokinetic monitoring of vancomycin, however, has become increasingly controversial given the improved safety of this antibiotic and the lack of data to support what are considered the therapeutic and toxic serum levels. Historically, the most severe toxicities of vancomycin were ototoxicity and nephrotoxicity. The incidence of nephrotoxicity has declined since its introduction possibly due to the availability of purer forms of the antibiotic. Ototoxicity has always been a rare adverse event of vancomycin, but it has been observed with excessively high concentrations of the drug in plasma [170-172]. The purpose of this section is to describe the nephrotoxicity associated with the clinical use of vancomycin. 

Serum drug concentrations should be monitored for drugs with narrow therapeutic indices and ehminated largely by the kidney (e.g., aminoglycosides and vancomycin) to optimize therapy in pediatric patients with renal dysfunction. For drugs with wide therapeutic ranges (e.g., penicillins and cephalosporins), dosage adjustment may be necessary only in moderate to severe renal failure. 

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