VANCOMYCIN DURATION OF TREATMENT
Question
How long should a patient receive intermittent intravenous vancomycin therapy? I have a
patient who has been receiving 1 g of vancomycin every 60 hours for 3.5 months. His
peak and trough are within normal limits. How much longer can he stay on this therapy?
The answer depends on a number of patient factors. Vancomycin is indicated for use in a
number of specified conditions, including infection due to beta-lactam-resistant gram-
positive organisms; documented urticarial or anaphylactic reaction to beta-lactam
antibiotics; and neutropenia with suspected catheter infection.[1] It is also indicated for
empiric use in cardiac surgery during MRSA infection cluster and for initial empiric
therapy in select cases, such as a recent hospital readmission.[1]
For most infections, 15 days of therapy or less is sufficient, and anything longer would be
considered inappropriate. In neutropenia, the appropriate duration of therapy is dictated
by defervescence and return of the neutrophil count, so therapy could span several weeks
in profound neutropenia.
For deep-seated infections such as bacterial endocarditis or osteomyelitis, 8 weeks is
considered the usual duration of therapy unless a justifiable exception exists, such as in
the case of a patient who has a removable focus of infection (eg, prosthesis) but is
inoperable.[2]
For all indications, the goal should be to determine the shortest acceptable duration of
therapy, as significant vancomycin resistance could develop, thus limiting its usefulness
in the given patient. This also could pose a public health threat, should the resistant
organism spread to others.[3] Thus, the answer to this question depends on all of these
factors.
Posted 10/13/2005
References
1. Singer MV, Haft R, Barlam T, Aronson M, Shafer A, Sands KE. Vancomycin
control measures at a tertiary-care hospital: impact and interventions on volume
and patterns of use. Infect Control Hosp Epidemiol. 1998;19:248-253.
2. Ena J, Dick RW, Jones RN, Wenzel RP. The epidemiology of intravenous
vancomycin usage in a university hospital. JAMA. 1993;269:598-602.
3. Turco TF, Melko GP, Williams JR. Vancomycin intermediate-resistant
Staphylococcus aureus. Ann Pharmacother. 1998;32:758-760.
VANCOMYCIN TROUGH LEVELS
Question
It is my understanding that the literature recommends no vancomycin trough levels unless
the patient falls within certain exclusion criteria (ie, changing renal function, CNS
infection, etc). Is this correct?
Correct. The primary goal of therapeutic drug monitoring and subsequent dosage
adjustment is to optimize serum drug concentrations for patients receiving agents with a
narrow therapeutic index. In light of the fact that the frequency of nephrotoxicity with
vancomycin is low,[1,2] coupled with the understanding that the efficacy of vancomycin, a
compound with concentration-independent pharmacodynamic characteristics, does not
correlate with serum concentrations, the need for vancomycin monitoring has been
questioned.
Many clinicians have abandoned the practice of routine pharmacokinetic monitoring as a
guide for vancomycin dosing[1-4] and instead advocate monitoring the vancomycin
serum concentrations in patients at risk for nephrotoxicity. Examples of such at-risk
patients include those receiving concomitant aminoglycoside antimicrobials; those with
changing renal function; those receiving higher than normal doses necessitated by
infections with resistant organisms; and those receiving dialysis with unconventional
high-flux filter membranes.[5,6]
Posted 10/20/2005
References
1. Edwards DJ, Pancorbo S. Routine monitoring of serum vancomycin concentration
levels: waiting for proof of its value. Clin Pharm. 1987;6:652-654.
2. Freeman CD, Quintiliani R, Nightingale CH. Vancomycin therapeutic drug
monitoring: is it necessary? Ann Pharmacother. 1993;27:594-598.
3. Cantu TG, Yamanaka-Yuen NA, Lietman PS. Serum vancomycin concentrations:
reappraisal of their clinical value. Clin Infect Dis. 1994;18:533-543.
4. Rodvold KA, Zokufa H, Rotschafer JC. Routine monitoring of serum vancomycin
concentrations: can waiting be justified? Clin Pharm. 1987;6:655-658.
5. Moellering RC Jr. Monitoring serum vancomycin levels: climbing the mountain
because it is there (editorial). Clin Infect Dis. 1994;18:544-546.
6. Pryka RD. Vancomycin serum concentration monitoring: a continued debate. Ann
Pharmacother. 1994;28:1397-1399.
