Observational Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Nov 26, 2018; 10(11): 234-241
Published online Nov 26, 2018. doi: 10.4330/wjc.v10.i11.234
Incidence and risk factors for potentially suboptimal serum concentrations of vancomycin during cardiac surgery
Paolo Cotogni, Cristina Barbero, Mauro Rinaldi
Paolo Cotogni, Department of Anesthesia, Intensive Care and Emergency, Molinette Hospital, University of Turin, Turin 10126, Italy
Cristina Barbero, Mauro Rinaldi, Cardiovascular Surgery, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin 10126, Italy
Author contributions: Cotogni P designed the study and drafted the manuscript; Barbero C participated in the study design, carried out the study and helped to draft the manuscript; Rinaldi M participated in the study design and coordination and revised it critically for important intellectual content; all authors read and approved the final manuscript.
Supported by the Public Health Program of Regione Piemonte (Italy), No. 2472/DA2001 (to Paolo Cotogni, in part).
Institutional review board statement: The study protocol was reviewed and approved by our Institutional Ethics Committee (Comitato Etico Interaziendale A.O.U. San Giovanni Battista di Torino - A.O.C.T.O. Maria Adelaide di Torino) (approval No. 0078553).
Informed consent statement: All patients provided written informed consent before their enrollment in the study.
Conflict-of-interest statement: All authors have no conflicts of interest to disclose.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement - checklist of items, and the manuscript was prepared and revised according to the guidelines of the STROBE Statement.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author to: Paolo Cotogni, MD, MSc, Adjunct Professor, Doctor, Department of Anesthesia, Intensive Care and Emergency, Molinette Hospital, University of Turin, C.so Bramante, 88/90, Turin 10126, Italy. paolo.cotogni@unito.it
Telephone: +39-338-7018496 Fax: +39-11-5171634
Received: July 9, 2018
Peer-review started: July 10, 2018
First decision: August 2, 2018
Revised: September 2, 2018
Accepted: October 11, 2018
Article in press: October 11, 2018
Published online: November 26, 2018
Processing time: 140 Days and 3.6 Hours
Abstract
AIM

To investigate the incidence and risk factors for vancomycin concentrations less than 10 mg/L during cardiac surgery.

METHODS

In this prospective study, patients undergoing cardiac surgery received a single dose of 1000 mg of vancomycin. Multiple arterial samples were drawn during surgery. Exclusion criteria were hepatic dysfunction; renal dysfunction; ongoing infectious diseases; solid or hematologic tumors; severe insulin-dependent diabetes; body mass index of < 17 or > 40 kg/m2; pregnancy or lactation; antibiotic, corticosteroid, or other immunosuppressive therapy; vancomycin or nonsteroidal anti-inflammatory drug therapy in the previous 2 wk; chemotherapy or radiation therapy in the previous 6 mo; allergy to vancomycin or cefazolin; drug abuse; cardiac surgery in the previous 6 mo; previous or scheduled organ transplantation; preoperative stay in the intensive care unit for more than 24 h; emergency procedure or lack of adequate preparation for surgery; and participation in another trial.

RESULTS

Over a 1-year period, 236 patients were enrolled, and a total of 1682 serum vancomycin concentrations (median 7/patient) were measured. No vancomycin levels under 10 mg/L were recorded in 122 out of 236 patients (52%), and 114 out of 236 patients (48%) were found to have at least 1 serum sample with a vancomycin level < 10 mg/L; 54 out of 236 patients (22.9%) had at least 5 serum samples with a vancomycin level lower than 10 mg/L. Vancomycin infusion was administered for 60 min in 97 out of 236 patients (41%). In 47 patients (20%), the duration of infusion was longer than 60 min, and in 92 patients (39%) the duration of infusion was shorter than 60 min. The maximum concentration and area under the concentration-time curve were significantly higher in patients with no vancomycin levels less than 10 mg/L (P < 0.001). The multivariate analysis identified female gender, body mass index (BMI) > 25 kg/m2, and creatinine clearance above 70 mL/min as risk factors for vancomycin levels less than 10 mg/L.

CONCLUSION

Results of this study identified female gender, BMI > 25 kg/m2, and creatinine clearance above 70 mL/min as risk factors for suboptimal vancomycin serum concentration during cardiac surgery; no relationship was found between infusion duration and vancomycin levels less than 10 mg/L. These findings call attention to the risk of facilitating the emergence of vancomycin-resistant methicillin-resistant Staphylococcus aureus strains.

Keywords: Cardiopulmonary; Bypass; Surgical site infections; Vancomycin pharmacokinetics; Antibiotic therapy; Methicillin-resistant Staphylococcus aureus

Core tip: The aim of this study was to investigate the incidence and risk factors for vancomycin concentrations less than 10 mg/L during cardiac surgery. Over a 1-year period, 236 patients were enrolled, and a total of 1682 serum vancomycin concentrations were measured. A total of 48% of patients were found to have ≥ 1 sample with a vancomycin level < 10 mg/L. The maximum concentration and area under the concentration-time curve were significantly higher in patients with no vancomycin levels less than 10 mg/L (P < 0.001). The multivariate analysis identified female gender, body mass index > 25 kg/m2, and creatinine clearance above 70 mL/min as risk factors for vancomycin levels less than 10 mg/L.