Abstract Corresponding Author Hoang A. Huynh, PharmD, Memorial Hermann Hospital at TMC, 6411 Fannin Street, Houston, TX, 77030, USA, 660 S. Euclid Ave, St. Louis, MO 63110, USA, (713) 704-7398, hoang.huynh@memorialhermann.org Funding No funding required for this project. Conflict(s) of Interest Emily Hutchison, no conflict; Hoang Huynh, no conflict; Jessica Babic, no conflict; Ardath Plauche, no conflict; Michael Chang, no conflict. Background Historically, therapeutic drug monitoring (TDM) with intravenous (IV) vancomycin has always been based on obtaining trough levels to ensure optimal dosing and outcomes. Minimal literature defined the optimal therapeutic range in pediatric patients, while there is evidence that higher trough levels are associated with an increased risk of nephrotoxicity. Vancomycin area-under-the-curve (AUC) guided TDM is now recommended in adult and pediatric patients. Adult literature indicated a reduced risk of acute kidney injury (AKI) when using AUC versus trough monitoring, but no literature so far has been found in pediatrics. Our objective is to evaluate the incidence of AKI in general pediatric patients admitted to Children’s Memorial Hermann Hospital (CMHH), treated with IV vancomycin with pharmacist-supported AUC-guided vancomycin TDM compared to traditional trough-based monitoring. Methods This single-center, retrospective cohort study analyzes pediatric patients (ages 3 months to 18 years) treated with IV vancomycin at CMHH from July 2021 to September 2024. Patients included were treated with IV vancomycin for at least 4 days and had at least 2 vancomycin levels drawn. Patients were excluded if they had baseline kidney dysfunction (eGFR 60 mL/min per 1.73 m2), were on renal replacement therapy, or were admitted to the intensive care units. Data collection includes baseline characteristics, confirmed MRSA infection, indication of use, dose (mg/kg/day), duration of therapy, and concurrent nephrotoxicity agents. The primary endpoint is the incidence of AKI, defined using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Secondary outcomes are hospital length of stay (LOS) and time to therapeutic range. Results Data analysis of 78 patients, including 48 patients in the trough-based monitoring group and 30 patients in the AUC-guided group, has been completed. Baseline characteristics include a median age and weight of 9.6 years and 25.9 kg in the trough group versus 8.8 years and 28.2 kg in the AUC group. Male patients comprised 31 (64.6%) of the trough group and 16 (53.3%) of the AUC group. The baseline serum creatinine is 0.41 and 0.48 mg/dL in the trough vs AUC group, respectively, while baseline eGFR was the same for both groups, at 115 mL/min/1.73 m2. Only 8 (16.7%) and 4 (13.3%) confirmed MRSA infection by culture in trough and AUC groups, respectively. Most of the indications for the use of IV vancomycin assessed came from pneumonia, suspected sepsis, bacteremia, meningitis, and osteomyelitis. No statistical significance was found when comparing both groups. Vancomycin duration of therapy is similar at 5.3 and 5.7 days between trough versus AUC groups, respectively, which is not significant. Concurrent use of nephrotoxicity agents also indicated no significant difference in AKI risk while on vancomycin for both groups. Our primary outcomes indicated that AKI incidences are similar, with 7 (14.6%) and 4 (13.3%) in the trough and AUC groups, respectively. Hospital LOS is around 14 days, while the time to therapeutic is 0.91 days for both groups, which is not statistically significant. Conclusion We found that the incidence of AKI, hospital LOS, and time to therapeutic days are not statistically significant. However, this could be due to the low sample size. The general pediatric patient population is more clinically stable with stable kidney function, so we were not able to find the differences. Potentially, we can consider expanding the study timeline and including more populations for analysis to determine if AUC reduces the risk of AKI compared to trough monitoring.
Hutchison et al. (Mon,) studied this question.