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A Systematic Review of Vancomycin Dosing in Patients with Hematologic Malignancies or Neutropenia

Authors He N, Dong F, Liu W, Zhai S

Received 18 November 2019

Accepted for publication 4 May 2020

Published 16 June 2020 Volume 2020:13 Pages 1807—1821


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Dr Joachim Wink

Na He,1,2 Fei Dong,3 Wei Liu,1 Suodi Zhai1

1Department of Pharmacy, Peking University Third Hospital, Beijing, People’s Republic of China; 2Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, People’s Republic of China; 3Department of Hematology, Peking University Third Hospital, Beijing, People’s Republic of China

Correspondence: Suodi Zhai; Wei Liu
Department of Pharmacy, Peking University Third Hospital, 49 Huayuan North Road, Haidian District, Beijing 100191, People’s Republic of China
Tel +86 10-82266686; +86 10-82265740

Objective: To provide a comprehensive review of vancomycin dosing in patients with hematologic malignancies or neutropenia.
Methods: PubMed, Embase and the Cochrane Library were searched through April 2, 2020. Original studies relevant to vancomycin dosing regimen in adults with hematologic malignancies or neutropenia were included. No restriction was applied in study design and language. A descriptive analysis was performed.
Results: Twenty-three studies were included eventually, of which eighteen were case series studies, four were cohort studies and another one was a randomized controlled trial. Five case series studies made a clinical audit of conventional vancomycin dosing in patients with malignancies or neutropenia, showing that the proportion of patients with sub-therapeutic trough levels remained high, ranging from 32% to 88%. Seven case series studies and four cohort studies demonstrated that vancomycin clearance (CLva) tended to be higher in patients with hematologic malignancies or neutropenia, whereas volume of distribution (V) seemed to be comparable to the control group. Five studies proposed individualized initial dosing regimen per the pharmacokinetic changes; however, no prospective validation has been conducted in clinical setting. Additionally, four case series studies suggested that the correlation between vancomycin clearance and estimated creatinine clearance was relatively poor, bringing a great challenge to proper dosing strategy. A randomized controlled trial stated that therapeutic drug monitoring (TDM) of vancomycin could decrease the incidence of nephrotoxicity in immunocompromised febrile patients with hematologic malignancies.
Conclusion: The available evidence indicates that conventional vancomycin dosing leads to suboptimal concentration in patients with hematologic malignancy or neutropenia. TDM accompanied by pharmacokinetic interpretation can decrease the risk of nephrotoxicity. The individualization of the initial dosing regimen and mechanisms of augmented clearance require further research.

Keywords: vancomycin, hematologic malignancy, neutropenia, pharmacokinetics, evidence-based practice

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