Vancomycin is regarded as the last resort of defense for a wide range of infections due to drug resistance and toxicity. The detection of vancomycin in plasma has always aroused particular concern because the performance of the assay affects the clinical treatment outcome. With the update of technology, bioassay, immunoassay, LC appreared in sequence with respective characteristic.characteristic.
1. Introduction
Vancomycin is a tricyclic glycopeptide antibiotic produced by the fermentation of Streptomyces orientalis that was isolated in soil samples from the jungles of Borneo, Indonesia in 1956
[1]. It inhibits bacterial synthesis by three main mechanisms: inhibition of the synthesis of peptidoglycan, alteration of the cell membrane permeability, and interference with RNA synthesis in the cytoplasm
[2]. The antibacterial spectrum of vancomycin mainly includes aerobic Gram-positive bacteria such as Staphylococcus, Streptococcus, Enterococcus, Corynebacterium, Listeria, and Clostridium difficile
[1]. Currently, vancomycin is primarily used for the treatment of infections due to methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus epidermidis (MRSE), pseudomembranous enteritis due to Clostridium difficile, an alternative to β-lactam allergy, the prevention of endocarditis, and infections during prosthetic implantation
[3].
Vancomycin is poorly absorbed in the digestive tract, and intramuscular injection can cause severe local pain and tissue necrosis. It is routinely administered intravenously via 5% dextrose or 0.9% saline. After injection, vancomycin is rapidly distributed to many body tissues, reaching effective therapeutic concentrations in the lung, heart, synovial fluid, peritoneal fluid, bone, and kidney. However, it cannot cross the blood–brain barrier in a non-inflammatory state. Its protein binding rate is about 55%. Moreover, in patients with normal renal function, more than 90% of the drug is excreted in the unchanged form via the kidneys
[1,4][1][4]. Its pharmacokinetics is influenced by several factors including the patient’s age, body weight, serum albumin, urine pH, and combined medications
[5]. The half-life of vancomycin is closely related to renal function, ranging from 6 h in those with normal renal function to 7 days in anuric patients
[1].
Vancomycin is a time and concentration-dependent (AUC-dependent) antibiotic with a post-antibiotic effect. According to pharmacokinetic (PK)/pharmacodynamic (PD) theory, the evaluation indicator for therapeutic drug monitoring (TDM) of vancomycin is the area under the concentration–time curve (AUC)/minimum inhibitory concentration (MIC) ratio, while with a AUC/MIC ratio ≥ 400 (based on MIC ≤ 1 µg mL
−1), vancomycin can achieve a clinical effect
[4,6][4][6]. However, when MIC > 1 µg mL
−1, it is recommended to switch to another drug
[6]. Vancomycin has a narrow therapeutic window (effective concentration is close to toxic concentration). Insufficient drug concentration can easily lead to the development of bacterial resistance, and too high a concentration is prone to serious adverse effects on the body
[7] such as nephrotoxicity, ototoxicity, hypotension, phlebitis, hypersensitivity reactions, red man syndrome, neutropenia, chills, fever, and interstitial nephritis. Therefore, it is necessary to perform a TDM for vancomycin.
2. Bioassay
Bioassays provide a more visual assessment of vancomycin concentrations based on the antibacterial activity of vancomycin in vitro. Bioassay methods for vancomycin were studied mainly in the 1980s (
Table 1)
[9,10,11,12,13,14][8][9][10][11][12][13]. The basic steps are as follows: uniform inoculation of an indicator bacterium on a suitable medium, punching holes in the medium with a punch and pouring in vancomycin solution
[8][14], or soaking paper sheets in vancomycin-containing solution and sticking them on the medium
[10,11,12,13,14][9][10][11][12][13]. The inhibition circle diameter is linearly related to the vancomycin concentration or its logarithm. The corresponding vancomycin concentration can be calculated from the standard curve and the inhibition circle diameter. The key in this method is the selection and preparation of the indicator bacterium and medium. Bacillus spp. is sensitive to most antibiotics and is often used as an indicator bacterium. Furthermore, the medium should neither affect the indicator bacterium’s growth nor the antibiotic activity
[15]. Other factors such as the pore size, incubation time, and incubation temperature can also affect the diameter of the antibacterial coil. This method’s standard concentration range (0.8–80 µg mL
−1) covers the routine dose concentration range of vancomycin, which meets the clinical needs. Moreover, it is cheaper compared to immunoassays and liquid chromatography. The bioassay results were consistent with those of FPIA, HPLC, RIA, and fluorescence immunoassay
[9,13][8][12]. Nevertheless, the operational steps are more cumbersome than other methods such as immunoassay and overnight incubation, which further prolong the experimental operation time. Although investigators often repeat a single test ten times
[9][8] or four times
[10][9] in trials to avoid random error, the precision and accuracy are still not better than other methods. In addition, patients are often not mono-medicated in clinical settings. It is true that aminoglycosides can be inhibited by increasing the concentration of NaCl to 6.0% in the plate, and rifampicin does not affect the inhibitory activity of vancomycin. However, other drugs such as β-lactams, macrolides, and sulfonamides still affect the application of this method
[9,12][8][11].
Table 1.
Bioassay for vancomycin.