Children with prior steroid exposure more often had low vancomycin troughs

Design

Retrospective cohort

Population

245 hospitalised children receiving vancomycin with drug monitoring

Primary outcome

Vancomycin clearance (dose-to-level ratio) and subtherapeutic trough

Effect

Subtherapeutic trough OR 1.45 (95% CI 1.04–2.01); adjusted clearance β −0.0077 (p=0.40)

A retrospective cohort of 245 hospitalised children on vancomycin with drug monitoring found 64% had received glucocorticoids in the previous two years. Steroid-exposed children had higher dose-to-level ratios, suggesting faster clearance, and higher odds of a trough below 10 mg/L (OR 1.45).

After adjustment for age, sex, eGFR and inflammatory markers, cumulative steroid dose was no longer associated with clearance. The authors read this as steroid exposure marking illness and physiology, such as augmented renal clearance, rather than acting directly.

The practical point does not depend on the mechanism. Children with complex illness, recent steroid courses or apparent augmented renal clearance are more likely to start below target. Early monitoring, ideally area-under-the-curve guided where available, finds this before days of underdosing.

• Check vancomycin levels early in children with recent or cumulative glucocorticoid exposure.
• Suspect augmented renal clearance in young, critically ill or post-surgical children with normal creatinine.
• Use AUC-guided dosing where your service supports it rather than trough alone.
• Adjust the dose promptly after the first level rather than waiting for steady state twice.

Why it matters

Underdosing early in serious infection is common and preventable with timely monitoring.

Don't overread it

After adjustment, steroid dose was not an independent driver of vancomycin clearance.

The statistics, in plain English

An odds ratio of 1.45 means about 45% higher odds of a low trough. The loss of association after adjustment suggests steroids are a marker for other clearance factors rather than a cause.

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