Vaneska Bottino Da Costa
University of Iowa Hospital and Clinics
Iowa City
Disclosure information not submitted.
Elizabeth Espinoza, DNP, CPNP-AC
Pediatric Nurse Practitioner
University of Iowa Stead Family Childrens's Hospital, United States
Disclosure information not submitted.
Patrick Kinn, PharmD, MPH
Clinical Pharmacist
University of Iowa Hospitals and Clinics, United States
Disclosure information not submitted.
Lukasz Weiner, MD
Clinical Assistant Professor, Pediatric Infectious Diseases
University of Iowa Hospitals and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Madhuradhar Chegondi, MD
Clinical Associate Professor, Division of Pediatric Critical Care Medicine
University of Iowa Stead Family Childrens's Hospital
Iowa City, IA, United States
Disclosure information not submitted.
Title: Improving Vancomycin Dosing and Monitoring in the Pediatric Intensive Care Unit
Introduction: In children, methicillin-resistant Staphylococcus aureus (MRSA) infections are associated with significant morbidity and mortality. Vancomycin, a glycopeptide antibiotic, is a first-line agent for treatment of MRSA with national guidelines historically recommending serum trough monitoring to ensure efficacy and safety; however, pediatric populations had not been thoroughly addressed. Updated guidelines for vancomycin dosing and monitoring extend recommendations to pediatric patients.
Methods: In this quality improvement study, we aimed to improve empiric vancomycin dosing and serum level monitoring among children less than 18 years old admitted to our pediatric ICU. Children following cardiac surgeries and with preexisting renal disease were excluded. We retrospectively assessed baseline vancomycin usage over a 3-month period (Jan-Mar 2019). During the intervention phase, standardized vancomycin dosing was implemented which recommended a loading dose followed by maintenance doses of 15-20 mg/kg/dose administered every 6-8 hours depending on age and severity of infection. In the post-intervention phase, we conducted PDSA cycle evaluations of vancomycin use over 4 months. Baseline and demographic data were summarized using descriptive statistics and Mann-Whitney test to compare vancomycin data.
Results: A total of 97 children (67 pre- and 30 post-intervention) receiving vancomycin were included in the analysis. For both groups, 45 mg/kg/day was the most used initial dose, with this dose used more often in the pre-intervention group (57 [85%] vs 17 [57%], p=0.01). Higher doses were more frequently used in the post-intervention group, with an overall trend toward higher average troughs ³10 mg/L (15 [50%] vs 21 [31%] patients, p=0.08). Therapeutic trough levels ³10 mg/L were demonstrated more often in the post-intervention group (7 [41%] vs 11 [19%] patients, p=0.01) with overall higher median first trough levels (7 mg/L [IQR= 4.6-10.3] vs. 9.95 mg/L [IQR= 6.4-13.4], p=0.04). Documentation of the target trough goal on admission increased significantly from pre- to post-groups (4 [6%] vs 29 [97%] patients, p< 0.01).
Conclusions: Using a standardized empiric vancomycin dosing guideline improved initial target trough levels according to disease severity. More PDSA cycles are needed to confirm our results.