ICU患者影响万古霉素血药浓度的相关因素分析

目的 通过分析影响重症监护病房(ICU)患者万古霉素血药浓度的相关因素，探讨优化ICU患者万古霉素给药方案。方法 采用回顾性研究方法，收集东莞市人民医院ICU2016年1月至2018年9月使用并监测万古霉素血药浓度的出院患者。统计ICU患者万古霉素血药浓度分布情况，根据肌酐清除率(CrCl)将患者分为CrCl>90mL/min、CrCl 50~90mL/min、CrCl 10~50mL/min及CrCl<10mL/min 4组，分析不同肌酐清除率组对万古霉素血药浓度水平和达标率的影响以及比较指南推荐剂量与实际剂量的差别，并利用多重线性回归分析进一步探讨影响万古霉素血药浓度的相关因素。结果 99例ICU患者监测万古霉素血药浓度共230例次，45例次(19.57%)达到目标浓度(15~20mg/L)，72例次(31.30%)未达标(<15mg/L)，113例次(49.13%)超标(>20mg/L)。CrCl 50~90mL/min和CrCl 10~50mL/min组平均血药浓度[(20.16±7.51)mg/L, (23.12±9.37)mg/L]、血药浓度超标比例(45.45%，62.79%)显著高于CrCl>90mL/min组[(14.65±9.07)mg/L, 19.15%]。CrCl>90mL/min、CrCl 50~90mL/min组实际剂量显著低于推荐剂量，而CrCl 10~50mL/min、CrCl<10mL/min组实际剂量显著高于推荐剂量。多重线性回归分析显示，给药剂量(B=11.631，95%CI=7.030~16.232，P<0.001)、肌酐清除率(B=-0.064，95%CI=-0.097~-0.032，P<0.001)、白蛋白水平(B=-0.334，95%CI=-0.634~-0.035，P=0.029)是影响ICU患者万古霉素血药浓度的主要相关因素。结论 ICU患者万古霉素血药浓度达标率较低，在优化ICU患者万古霉素给药方案时应考虑给药剂量、肌酐清除率和白蛋白水平因素的影响。

Analysis of related influencing factors on serum concentration

Objective To analyze the related influencing factors on serum concentration of vancomycin in intensive care unit (ICU) patients, and explore the optimal dosage of vancomycin in these patients. Methods A retrospective analysis was performed in ICU inpatients who were treated with vancomycin and monitored serum concentration of vancomycin from January 2016 to September 2018 in Dongguan People’s Hospital. The distribution of vancomycin serum concentration was collected. Based on the endogenous creatinine clearance rate (CrCl), these patients were divided into four groups: CrCl>90mL/min, CrCl 50~90mL/min, CrCl 10~50mL/min, and CrCl<10mL/min. The relationship between different CrCl groups and serum concentration level and the rate of reaching vancomycin target concentration were analyzed. The difference between guideline recommended dosage and actual dosage was compared in four different CrCl groups. Furthermore, the related influencing factors on serum concentration of vancomycin were explored by multiple linear regression analysis. Results 230 samples of vancomycin serum concentration in 99 ICU inpatients were enrolled, and it was found that only 45 (19.57%) samples reached the target concentration (15~20mg/L), 72 samples(31.30%)<15mg/L and 113 samples(49.13%)>20mg/L. The serum concentration level and the rate of higher target concentration of CrCl 50~90mL/min [(20.16±7.51)mg/L,45.45%] and CrCl 10~50mL/min group [(23.12±9.37)mg/L, 62.79%] were significantly higher than CrCl>90 mL/min group [(14.65±9.07)mg/L, 19.15%]. The actual dosages of CrCl>90mL/min and CrCl 50~90mL/min group were lower than guideline recommended dosages, while CrCl 10~50mL/min and CrCl<10mL/min group showed opposite results. Multiple linear regression analysis revealed that vancomycin doses (B=11.631, 95%CI=7.030~16.232, P<0.001), CrCl (B=-0.064, 95%CI=-0.097~-0.032, P<0.001), and the level of serum albumin (B=-0.334, 95%CI=-0.634~-0.035, P=0.029) were correlated with the serum concentration of vancomycin. Conclusion The rate of vancomycin serum concentration reaching target concentration is low in ICU patients. Vancomycin doses, CrCl, and the level of serum albumin should be fully taken into account when optimizing dosage of vancomycin in ICU patients.