Prognostic Implications of Vancomycin Therapeutic Drug Monitoring for Critically Ill Stroke Patients: Evidence From a
Hongbo San1, Jing Feng1, Hongyu Zhang2
1Department of Neurosurgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China.
Background:
Post-stroke infections, particularly those caused by Gram-positive pathogens, are frequent in neurocritical care and worsen outcomes. Vancomycin is widely used against severe Gram-positive infections, and therapeutic drug monitoring (TDM) is recommended to optimize efficacy and minimize toxicity. However, its prognostic value in critically ill stroke patients remains unclear.
Methods:
Clinical data were obtained from the MIMIC-IV (v3.1) database. Adult patients with ischemic or hemorrhagic stroke receiving intravenous vancomycin were included. Patients were stratified by stroke subtype and TDM status. Propensity score matching (PSM) was performed to balance baseline characteristics. The primary outcome was 28-day mortality; secondary outcomes included ICU, hospital, 60-, 90-, and 365-day mortality.
Results:
A total of 1266 patients were analyzed (543 hemorrhagic, 723 ischemic). In hemorrhagic stroke, 28-day mortality was lower in the TDM group (24.6% vs. 48.2%, p < 0.001), and the association persisted after PSM (23.3% vs. 40.8%, p = 0.007). Multivariable Cox analysis confirmed TDM as an independent predictor of reduced 28-day mortality (adjusted HR = 0.29, 95% CI 0.15-0.56, p < 0.001). No significant association was observed in ischemic stroke.
Conclusions:
Vancomycin TDM was independently linked to improved survival in hemorrhagic but not ischemic stroke, supporting individualized antimicrobial optimization in neurocritical care.
Insights
Therapeutic drug monitoring for vancomycin improved survival in critically ill patients with hemorrhagic stroke. This approach did not show a significant survival benefit in ischemic stroke patients.
Area of Science:
- Neurocritical care
- Infectious diseases
- Pharmacology
Background:
- Post-stroke infections are common in neurocritical care and associated with poor outcomes.
- Vancomycin is a key antibiotic for Gram-positive infections, with therapeutic drug monitoring (TDM) recommended for optimizing its use.
- The prognostic impact of vancomycin TDM in critically ill stroke patients requires further investigation.
Purpose of the Study:
- To evaluate the prognostic value of vancomycin therapeutic drug monitoring (TDM) in critically ill patients with stroke.
- To determine if vancomycin TDM is associated with improved survival outcomes in different stroke subtypes.
Main Methods:
- Retrospective analysis of 1266 adult patients with ischemic or hemorrhagic stroke receiving intravenous vancomycin from the MIMIC-IV database.
- Patients were stratified by stroke subtype and TDM status.
- Propensity score matching (PSM) was used to control for baseline differences, with 28-day mortality as the primary outcome.
Main Results:
- In hemorrhagic stroke, 28-day mortality was significantly lower in the vancomycin TDM group (24.6%) compared to the non-TDM group (48.2%), an association that persisted after PSM.
- Vancomycin TDM was identified as an independent predictor of reduced 28-day mortality in hemorrhagic stroke (adjusted HR = 0.29).
- No significant association between vancomycin TDM and 28-day mortality was observed in ischemic stroke patients.
Conclusions:
- Vancomycin TDM is independently associated with improved survival in critically ill patients with hemorrhagic stroke.
- The findings suggest that individualized vancomycin dosing through TDM may be beneficial in specific neurocritical care populations.
- Further research is warranted to explore the role of vancomycin TDM in ischemic stroke and other neurological conditions.
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