Intermittent versus continuous infusion of vancomycin in pediatrics: which is the most effective and safest option?

Abstract

Objectives: To describe and analyze vancomycin serum levels achieved by intermittent and continuous infusion, as well as Clinical and microbiological outcomes and the occurrence of adverse events in pediatric patients with probable or confirmed infections by penicillin‑resistant Gram‑positive bacteria. Methods: Quantitative, observational study with retrospective and prospective data collection conducted from August 2021 to August 2024 in a pediatric hospital. Analyzed parameters included serum levels obtained after transitioning from intermittent to continuous infusion; treatment‑related nephrotoxicity; clinical and microbiological outcomes; and adverse events. Results: Seventy‑one patients were included; most were infants (63.4%), male (61.9%), and had a neurological comorbidity (49.3%), with initiation of continuous infusion in an intensive care unit (57.7%). Most infections involved the central nervous system, and the most frequently isolated bacteria were coagulase‑negative Staphylococcus. Median serum level during intermittent infusion was 9.4 mg/L and during continuous infusion was 17.7 mg/L (reference range: 8–25 mg/L). Vancomycin level monitoring was performed 2.6 times less often during continuous infusion. Microbiological and clinical cure was observed in 76.3% of antibiogram‑guided treatments, and clinical cure in 62.2% of empirical treatments. There were no deaths or initiation of renal replacement therapy within 30 days after antibiotic completion. Nephrotoxicity was less frequent with continuous than intermitente infusion (56.3% vs. 64.8%), with a 4.86‑fold higher risk of acute kidney injury during intermittent infusion, and a 1% increase in the risk of nephrotoxicity for each unit decrease in creatinine clearance. More adverse events occurred with continuous than intermittent infusion, primarily process errors. In most patients, infusion was administered via a venous access dedicated exclusively to vancomycin, and no infusion reactions were observed. Conclusion: The analysis indicated that continuous vancomycin infusion was an effective alternative with manageable adverse events in the study population and demonstrated a more favorable renal safety profile. However, implementation of continuous infusion requires strict adherence to institutional protocols, ongoing staff training, and process monitoring by the clinical pharmacy to minimize operational errors and ensure patient safety.