TY - JOUR
T1 - Cystatin C–Guided Vancomycin Dosing in Critically Ill Patients
T2 - A Quality Improvement Project
AU - Frazee, Erin
AU - Rule, Andrew D.
AU - Lieske, John C.
AU - Kashani, Kianoush B.
AU - Barreto, Jason N.
AU - Virk, Abinash
AU - Kuper, Philip J.
AU - Dierkhising, Ross A.
AU - Leung, Nelson
N1 - Publisher Copyright:
© 2017 National Kidney Foundation, Inc.
PY - 2017/5
Y1 - 2017/5
N2 - Background The aim of the study was to determine whether a vancomycin dosing algorithm based on estimated glomerular filtration rate from creatinine and cystatin C levels (eGFRcr-cys) improves target trough concentration achievement compared to an algorithm based on estimated creatinine clearance (eCLcr) in critically ill patients. Study Design This prospective quality improvement project evaluated intensive care unit (ICU) patients started on intravenous vancomycin using one of 2 different strategies. Dosing regimens were selected and implemented after an individualized goal trough range was established (10-15 or 15-20 mg/L). Steady-state goal trough achievement was compared between treatment arms with and without adjustment for potential confounders. Setting & Participants 3 medical and surgical ICUs at a single tertiary medical center. Quality Improvement Plan During January 2012 to October 2013, vancomycin was dosed according to eCLcr using the Cockcroft-Gault formula (control arm). During December 2013 to May 2015, a multidisciplinary quality improvement team implemented a novel vancomycin dosing algorithm according to eGFRcr-cys using the CKD-EPI equation (intervention arm). Outcome Steady-state initial goal vancomycin trough concentration achievement. Measurements & Results More patients in the intervention arm (67 of 135 [50%]) achieved therapeutic trough vancomycin levels than in the control arm (74 of 264 [28%]; OR, 2.53; 95% CI, 1.65-3.90; P < 0.001). Improved trough achievement was maintained even after adjustment for age, sex, APACHE (Acute Physiology and Chronic Health Evaluation) III score, fluid balance, baseline CLcr, surgical admission diagnosis, presence of sepsis, and goal trough concentration range (adjusted OR, 2.79; 95% CI, 1.76-4.44; P < 0.001). Clinical outcomes were similar between groups. Limitations Nonrandomized, incomplete algorithm compliance. Conclusions A vancomycin dosing nomogram based on eGFRcr-cys significantly improved goal trough achievement compared to eCLcr among ICU patients with stable kidney function. Further studies are warranted to characterize the relationship between use of cystatin C−guided dosing and clinical outcomes.
AB - Background The aim of the study was to determine whether a vancomycin dosing algorithm based on estimated glomerular filtration rate from creatinine and cystatin C levels (eGFRcr-cys) improves target trough concentration achievement compared to an algorithm based on estimated creatinine clearance (eCLcr) in critically ill patients. Study Design This prospective quality improvement project evaluated intensive care unit (ICU) patients started on intravenous vancomycin using one of 2 different strategies. Dosing regimens were selected and implemented after an individualized goal trough range was established (10-15 or 15-20 mg/L). Steady-state goal trough achievement was compared between treatment arms with and without adjustment for potential confounders. Setting & Participants 3 medical and surgical ICUs at a single tertiary medical center. Quality Improvement Plan During January 2012 to October 2013, vancomycin was dosed according to eCLcr using the Cockcroft-Gault formula (control arm). During December 2013 to May 2015, a multidisciplinary quality improvement team implemented a novel vancomycin dosing algorithm according to eGFRcr-cys using the CKD-EPI equation (intervention arm). Outcome Steady-state initial goal vancomycin trough concentration achievement. Measurements & Results More patients in the intervention arm (67 of 135 [50%]) achieved therapeutic trough vancomycin levels than in the control arm (74 of 264 [28%]; OR, 2.53; 95% CI, 1.65-3.90; P < 0.001). Improved trough achievement was maintained even after adjustment for age, sex, APACHE (Acute Physiology and Chronic Health Evaluation) III score, fluid balance, baseline CLcr, surgical admission diagnosis, presence of sepsis, and goal trough concentration range (adjusted OR, 2.79; 95% CI, 1.76-4.44; P < 0.001). Clinical outcomes were similar between groups. Limitations Nonrandomized, incomplete algorithm compliance. Conclusions A vancomycin dosing nomogram based on eGFRcr-cys significantly improved goal trough achievement compared to eCLcr among ICU patients with stable kidney function. Further studies are warranted to characterize the relationship between use of cystatin C−guided dosing and clinical outcomes.
KW - Vancomycin
KW - antimicrobial dose regimen
KW - creatinine
KW - critically ill patients
KW - cystatin C
KW - dosing algorithm
KW - estimated glomerular filtration rate (eGFR)
KW - goal trough concentration
KW - intensive care unit (ICU)
KW - methicillin-resistant Staphylococcus aureus (MRSA)
KW - pharmacokinetics
KW - quality improvement project
KW - renal function
KW - sepsis
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U2 - 10.1053/j.ajkd.2016.11.016
DO - 10.1053/j.ajkd.2016.11.016
M3 - Article
C2 - 28131530
AN - SCOPUS:85010402371
SN - 0272-6386
VL - 69
SP - 658
EP - 666
JO - American Journal of Kidney Diseases
JF - American Journal of Kidney Diseases
IS - 5
ER -