When not to trust therapeutic drug monitoring.
Therapeutic drug monitoring (TDM) is the measurement of serum or plasma drug concentration to allow the individualization of dosing. We describe the case of a patient who was prescribed inappropriately large doses of vancomycin due to inaccurate TDM. Specifically, our laboratory reported progressively lower vancomycin concentrations despite dose increases. Eventually, when duplicate samples were sent to a different laboratory vancomycin concentrations were found to be in the toxic range. We hypothesize this was due to the patient generating immunoglobulin antibodies against her infection that interfered with the original TDM immunoassay. Immunogenic TDM interference has been known to rarely occur in patients with immune related comorbidities; however, if we are correct, this is a unique case as this patient did not have such a background. This case illustrates the importance of using clinical judgement when interpreting TDM as, in this case, substantial harm to the patient was likely only narrowly avoided.
Renal Unit, Renal Admin Block, Kent & Canterbury Hospital, Canterbury , Kent XT3 1RX , UK.
Mathew
M
Westergreen-Thorne
Renal Unit, Renal Admin Block, Kent & Canterbury Hospital, Canterbury , Kent XT3 1RX , UK.
Sook Yan
SY
Lee
Renal Unit, Renal Admin Block, Kent & Canterbury Hospital, Canterbury , Kent XT3 1RX , UK.
Nilesh
N
Shah
Laboratory Medicine, William Harvey Hospital, Ashford , Kent TN24 0LZ , UK.
Alan
A
Dodd
Immunoassay interference; Therapeutic drug monitoring; Vancomycin