Impact of vancomycin administration modality on target attainment in acutely ill children-a propensity score matching...

Vancomycin is widely used in children, yet achieving therapeutic targets is challenging. Vancomycin continuous infusions (CI) may facilitate area under the curve (AUC)-based therapeutic drug monitoring and improve target attainment (TA), but pediatric efficacy and safety data with this strategy are limited. This study compared first-line strategies of vancomycin CI and intermittent dosing (II) in acutely ill hospitalized children. This is a retrospective single-center study with propensity score matching (PSM) and inverse probability of treatment weighting (IPWT) including pediatric inpatients (0-17 years) receiving intravenous vancomycin between January 2022 and May 2024 with at least one plasma level measured. Patients were allocated to CI or II based on vancomycin administration modality. One hundred five children were included (22 CI; 83 II). CI patients were younger and more frequently hospitalized in intensive care settings. CI achieved significantly higher TA at first measurement (50% vs 23%, p = 0.013) and at any time during therapy (77.3% vs 45.8%, p = 0.009). Similar results were observed in propensity score-adjusted analyses for TA at first measurement (IPWT 49% vs 23%; aOR 3.3 [12-8.9]; p = 0.018 and PSM 50% vs 23%; aOR 3.3 [1.3-8.4]; p = 0.013) and at any time during therapy (IPWT 77% vs 46%; aOR 4.0 [1.3-12.2]; p = 0.011 and PSM 77% vs 51%; aOR 3.2 [1.1-9.4]; p = 0.030). Time to TA was shorter with CI (median 2 vs 3 days). Adverse events were rare and comparable between groups.

Vancomycin CI as a first-line strategy instead of classic II in acutely ill children seems promising for efficient TA without an increase in adverse events. Prospective multicenter studies are needed to confirm optimal dosing regimens.

• Achieving therapeutic vancomycin exposure in children is difficult due to high pharmacokinetic variability, and intermittent infusion frequently fails to reach recommended AUC-based targets. • Continuous infusion has shown promising results in neonates and adults for improving target attainment, but comparative pediatric data-especially evaluating continuous infusion as a first-line strategy-are scarce.

• In acutely ill children, first-line continuous infusion significantly improves early, and overall target attainment compared with intermittent infusion, even in a population with high clinical severity. • Continuous infusion may allow therapeutic targets to be reached with lower daily mg/kg doses without increasing adverse events, supporting continuous infusion as a more efficient first-line vancomycin administration method in acutely ill children.