Vancomycin is commonly under-dosed in critically ill children and neonates

Area of Science:

• Pediatric Critical Care Medicine
• Pharmacokinetics and Pharmacodynamics
• Infectious Disease Management

Background:

• Vancomycin dosing in critically ill children is challenging due to altered pharmacokinetics.
• Therapeutic drug monitoring (TDM) is recommended to maintain vancomycin trough concentrations between 10-20 mg/L.
• Current dosing strategies may not consistently achieve therapeutic targets in this population.

Purpose of the Study:

• To review vancomycin dosing, TDM, and treatment outcomes in pediatric and neonatal intensive care unit (ICU) patients.
• To identify optimal dosing strategies for achieving target vancomycin concentrations.
• To assess the incidence of adverse events associated with vancomycin therapy.

Main Methods:

• Retrospective review of medical records for patients receiving intravenous vancomycin in a tertiary pediatric and neonatal ICU.
• Data collection included demographic information, vancomycin dosage, TDM results, and drug-related adverse effects.
• Analysis of 126 vancomycin courses in 115 children over a 10-month period.

Main Results:

• Only 30% of patients achieved initial target vancomycin trough concentrations (10-20 mg/L).
• Dose adjustments were made in only 56% of courses with initial sub-therapeutic levels.
• Higher empiric doses (≥30 mg/kg/day for neonates <35 weeks corrected gestational age, ≥50 mg/kg/day for older children) were required to reach target concentrations.
• Vancomycin-associated nephrotoxicity occurred in 8% of courses.

Conclusions:

• Individualized vancomycin dosing is essential for critically ill children.
• Empiric doses of at least 30 mg/kg/day (neonates <35 weeks corrected gestational age) and 50 mg/kg/day (older children) should be considered in the absence of Bayesian dosing.
• Optimization of TDM practices, potentially integrated into electronic medical records, is recommended.