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Vancomycin is one of only a few antibiotics available to treat patients infected with methicillin-resistant
Staphylococcus aureus and methicillin-resistant, coagulase-negative Staphylococcus species. Therefore, understanding the clinical implications of the pharmacokinetic and pharmacodynamic properties of vancomycin is
a necessity for clinicians. Vancomycin is a concentration-independent antibiotic (also referred to as a timedependent antibiotic), and there are factors that affect its clinical activity, including variable tissue distribution,
inoculum size, and emerging resistance. This article reviews the pharmacokinetic and pharmacodynamic data
related to vancomycin and discusses such clinical issues as toxicities and serum concentration monitoring.
of in vitro assessments that have demonstrated a 18-fold increase in the MIC as a result of the presence of albumin, whereas
the presence of serum has had a more variable effect [1719].
VANCOMYCIN CONCENTRATION AND KILLING
ACTIVITY
Figure 1. Schematic representation of a 2-compartment pharmacokinetic model, wherein C is the concentration, a and b are the respective
elimination constants, e is the base of the natural logarithm, t is time,
A and B are the respective zero time intercepts for a and b, Ko is the
infusion rate constant, Vc is the volume of the central compartment, Vp
is the volume of the peripheral compartment, K12 and K21 are intracompartmental rate constants, and KEL is the elimination rate constant from
the central compartment.
that display heteroresistance to glycopeptides (i.e., heteroresistant GISA strains) have also been reported to be associated
with vancomycin therapy failure [30, 31]. These strains typically
have an MIC of 14 mg/L but contain a subpopulation of cells
that exhibit higher MIC values when plated onto agar plates
containing vancomycin or when tested with a heavy inocula
by use of the Etest (AB BIODISK) methods for antimicrobial
susceptibility. Similar to GISA strains, these organisms are difficult to detect in the clinical laboratory, and their prevalence
may be underreported [32]. Recent in vitro evaluations have
demonstrated a relationship between exposure to low vancomycin serum concentrations and the development of heteroresistant GISA [33]. However, because of the difficulty in detecting these strains clinically, the overall prevalence and clinical
significance of heteroresistant GISA have not been established
[32, 34].
TOXICITY
In recent years, there appears to be less controversy with regard
to the relationship between serum vancomycin concentrations
and toxicity. Historically, vancomycin toxicities were related to
impurities in the manufacturing process [1]. Although most
animal studies have not found that vancomycin causes nephrotoxicity, there have been a number of studies involving
humans that have attempted to link elevated serum vancomycin
serum concentrations with renal damage [3539]. Most of these
studies are retrospective, and definitions for nephrotoxicity are
highly variable. In many cases, serum vancomycin concentrations were measured after an elevation in serum creatinine
Figure 2. Relationship between pharmacokinetic/pharmacodynamic indices for vancomycin and bacteriologic efficacy against methicillin-susceptible
Staphylococcus aureus. This plot, which delineates the change in colony-forming units (cfu) in an experimental mouse infection model 3 different
ways, suggests that the area under the curve divided by the MIC (AUC/MIC) is the most valuable pharmacokinetic/pharmacodynamic parameter for
predicting the activity of vancomycin against methicillin-susceptible S. aureus. Peak/MIC, peak serum concentration divided by the MIC. Data are from
Ebert [23].
respect to patient outcome [48]. Although precise and aggressive pharmacokinetic adjustments via the successive measurement of serum concentrations may not be necessary for most
infections, empirical adjustments made using standard pharmacokinetic equations or a validated nomogram that maintains
trough serum concentrations at 45 times the MIC would seem
to be reasonable. Higher concentrations may be needed for
sequestered infections or in situations where vancomycin penetration has been documented to be poor. Further research
examining the outcome of patients as it relates to vancomycin
serum concentrations is warranted.
Acknowledgments
Potential conflicts of interest. M.J.R. receives grant and/or research
support from Advancis, Bayer, Cubist, and Oscient, is a consultant for
Advancis, Bayer, Cubist, and Oscient, and is on speakers bureaus of Aventis,
Bayer, and Cubist.
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Pestotnik et al. [40] reported that the incidence of nephrotoxicity among 1750 patients was 1.4%. Of interest, vancomycin
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The so-called therapeutic range most often quoted for vancomycin monitoring is peak and trough serum concentrations
of 3040 mg/L and 510 mg/L, respectively [46, 47]. As stated
earlier, there is little evidence to support a relationship between
specific serum concentrations and efficacy and toxicity. Because
vancomycin is a concentration-independent, or time-dependent, antibiotic and because there are practical issues associated
with determining a precise peak serum concentration with this
multicompartment antibiotic, most clinicians have abandoned
the routine practice of determining peak serum concentrations.
Therefore, most clinicians rely solely on monitoring trough
serum concentrations for this antibiotic.
The overall AUC/MIC value may be the pharmacodynamic
parameter that best correlates with a successful outcome associated with the use of vancomycin; however, further studies
seem to be warranted. The nephrotoxic and ototoxic effects of
this drug are minimal and are not related to specific serum
concentrations. Prolonged exposure to serum concentrations
close to the MIC are associated with the emergence of resistance; therefore, it is important to maintain adequate serum
concentrations in patients with fast or rapidly changing creatinine clearance. There are several body compartments in
which penetration is poor, such as the lung and the CNS. It
would also seem prudent to keep concentrations from being
suboptimal in patients with pneumonia or meningitis, as well
as in patients receiving vancomycin who are receiving dialysis
for renal failure. The American Thoracic Society recently published guidelines for hospital-acquired, ventilator-associated,
and health careassociated pneumonia. These guidelines recommend vancomycin trough concentrations of 1520 mg/L for
the treatment of methicillin-resistant S. aureus pneumonia. The
recommendations are based on vancomycin susceptibility and
pharmacokinetic/pharmacodynamic properties, as well as reported clinical experience, since no definitive clinical studies
have evaluated the recommended serum concentrations with
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