Monica Awad, PGY2

Children's National Medical Center, Washington, District of Columbia

Objectives: 

1. Discuss the evidence supporting the possibility that lower vancomycin troughs (10-15 mcg/mL) may be adequate to successfully treat pediatric patients with complicated pneumonia.
2. Based on study results, conclude an association between high (15-20 mcg/mL) versus low (10-15 mcg/mL) vancomycin trough concentrations and time to clinical improvement in pediatric patients with complicated pneumonia.

Abstract:

Introduction: Vancomycin is often used as a component of an empiric regimen for complicated pneumonia in the pediatric population. However, the ideal goal trough for complicated pneumonia in pediatric patients is not well established. Based on adult literature, the Infectious Diseases Society of America guidelines recommend a goal trough of 15-20 mcg/mL for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) when the minimum inhibitory concentration (MIC) is 1 mcg/mL to achieve a goal area under the curve (AUC) to MIC ratio of greater than or equal to 400. Parapneumonic effusions complicating pneumonia can be polymicrobial in nature, including organisms other than MRSA. This may call into question the applicability of the trough goal suggested by the aforementioned IDSA guideline. Furthermore, several studies suggest that pediatric patients may reach an AUC/MIC ratio of greater than or equal to 400 with lower troughs. The primary objective of this study is to determine whether higher vancomycin troughs of 15-20 mcg/mL are associated with more rapid clinical improvement in the treatment of complicated pneumonia in pediatric patients compared to lower troughs of 10-15 mcg/mL. The secondary objectives are: (1) to quantify the percentage adherence to an institutional vancomycin empiric dosing guideline and (2) to quantify the percentage of initial goal troughs achieved in those adherent to the guideline. Methods: A retrospective, single-center analysis will be conducted in pediatric patients (aged 2 months to 18 years) diagnosed with complicated pneumonia and administered vancomycin for at least 3 days at Children’s National Medical Center between January 2006 and 2018. Medical records will be reviewed for all pediatric patients with ICD-10 codes of complicated pneumonia. Complicated pneumonia, as stated in our hospital guidelines, will be defined as respiratory failure requiring intubation, or the presence of empyema, pleural effusion, necrotizing pneumonia, parapneumonic effusion, and/or lung abscess. Patients will be excluded if they had positive respiratory, pleural fluid, or blood cultures for anything other than MRSA or ceftriaxone-resistant Streptococcus pneumoniae at the time of diagnosis, if they were treated in the neonatal intensive care unit (NICU), admitted for complicated pneumonia within the prior6 months, transferred from an outside institution, had a diagnosis of cystic fibrosis. Results: Results will be submitted within final slides. Conclusion: Conclusion will be submitted within final slides.

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