Unexpected falsely high vancomycin concentrations in a patient with endocarditis during routine therapeutic drug monitoring

Introduction: Vancomycin is a glycopeptide antibiotic indicated for the treatment of infections caused by methicillin-resistant Staphylococcus aureus. Appropriate vancomycin therapeutic drug monitoring is an essential exercise to improve the achievement of the target therapeutic levels. Case descrip...

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Main Authors: Laura Galán-Caballero, María del Rosario Salas-Butrón, Daniel Lozano-Martín, Iván Alejandro Díaz-Rengifo, Isabel Ortega-Madueño, Lucia Diaz-Garcia, Ana Isabel Terleira-Fernández
Format: Article
Language:English
Published: SMC MEDIA SRL 2025-06-01
Series:European Journal of Case Reports in Internal Medicine
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Online Access:https://www.ejcrim.com/index.php/EJCRIM/article/view/5464
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author Laura Galán-Caballero
María del Rosario Salas-Butrón
Daniel Lozano-Martín
Iván Alejandro Díaz-Rengifo
Isabel Ortega-Madueño
Lucia Diaz-Garcia
Ana Isabel Terleira-Fernández
author_facet Laura Galán-Caballero
María del Rosario Salas-Butrón
Daniel Lozano-Martín
Iván Alejandro Díaz-Rengifo
Isabel Ortega-Madueño
Lucia Diaz-Garcia
Ana Isabel Terleira-Fernández
author_sort Laura Galán-Caballero
collection DOAJ
description Introduction: Vancomycin is a glycopeptide antibiotic indicated for the treatment of infections caused by methicillin-resistant Staphylococcus aureus. Appropriate vancomycin therapeutic drug monitoring is an essential exercise to improve the achievement of the target therapeutic levels. Case description: An 87-year-old female was admitted with diagnosis of endocarditis. She was started on antibiotic therapy with intravenous vancomycin. The first vancomycin level registered in our hospital was 36.4 µg/ml. Because this value exceeded the critical threshold (15–20 µg/ml) the prescription was interrupted. New vancomycin concentration tests were indicated for the next days with 65.8 µg/ml, 73 µg/ml, 55.1 µg/ml, 77.9 µg/ml and 100 µg/ml results. Two samples were reanalysed in Hospital Universitario La Paz and were undetectable. Our Clinical Analysis Department found an analytical interference; however, the responsible molecule could not be identified, so the clinical team changed antibiotic treatment to daptomycin, and the infectious condition of the patient improved. Conclusions: It is recommended that clinicians have a high index of suspicion to investigate cases where drug concentrations do not correlate with clinical expectations. Healthcare professionals need to understand that occasional interference still occurs due to the binding of proteins.
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publishDate 2025-06-01
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series European Journal of Case Reports in Internal Medicine
spelling doaj-art-4ddb2a51e82b4f44aaaabdab547c6f212025-08-20T03:30:40ZengSMC MEDIA SRLEuropean Journal of Case Reports in Internal Medicine2284-25942025-06-0110.12890/2025_0054644999Unexpected falsely high vancomycin concentrations in a patient with endocarditis during routine therapeutic drug monitoringLaura Galán-Caballero0María del Rosario Salas-Butrón1https://orcid.org/0009-0001-6040-6403Daniel Lozano-Martín2Iván Alejandro Díaz-Rengifo3Isabel Ortega-Madueño4Lucia Diaz-Garcia5Ana Isabel Terleira-Fernández6Department of Clinical Pharmacology, Hospital Clínico San Carlos; IdISSC, Madrid, SpainDepartment of Clinical Pharmacology, Hospital Clínico San Carlos; IdISSC, Madrid, Spain; Department of Pharmacology and Toxicology, Universidad Complutense; IdISSC, Madrid, SpainDepartment of Clinical Pharmacology, Central de la Defensa “Gómez Ulla” Hospital, Madrid, SpainDepartment of Clinical Pharmacology, Hospital Clínico San Carlos; IdISSC, Madrid, SpainDepartment of Clinical Analysis, Hospital Clínico San Carlos, Instituto de Medicina del Laboratorio, Madrid, SpainDepartment of Clinical Pharmacology, IdiPAZ, La Paz University Hospital, School of Medicine, Autonomous University of Madrid, Madrid, SpainDepartment of Clinical Pharmacology, Hospital Clínico San Carlos; IdISSC, Madrid, Spain; Department of Pharmacology and Toxicology, Universidad Complutense; IdISSC, Madrid, SpainIntroduction: Vancomycin is a glycopeptide antibiotic indicated for the treatment of infections caused by methicillin-resistant Staphylococcus aureus. Appropriate vancomycin therapeutic drug monitoring is an essential exercise to improve the achievement of the target therapeutic levels. Case description: An 87-year-old female was admitted with diagnosis of endocarditis. She was started on antibiotic therapy with intravenous vancomycin. The first vancomycin level registered in our hospital was 36.4 µg/ml. Because this value exceeded the critical threshold (15–20 µg/ml) the prescription was interrupted. New vancomycin concentration tests were indicated for the next days with 65.8 µg/ml, 73 µg/ml, 55.1 µg/ml, 77.9 µg/ml and 100 µg/ml results. Two samples were reanalysed in Hospital Universitario La Paz and were undetectable. Our Clinical Analysis Department found an analytical interference; however, the responsible molecule could not be identified, so the clinical team changed antibiotic treatment to daptomycin, and the infectious condition of the patient improved. Conclusions: It is recommended that clinicians have a high index of suspicion to investigate cases where drug concentrations do not correlate with clinical expectations. Healthcare professionals need to understand that occasional interference still occurs due to the binding of proteins.https://www.ejcrim.com/index.php/EJCRIM/article/view/5464vancomycininterferenceimmunoassaytherapeutic drug monitoring
spellingShingle Laura Galán-Caballero
María del Rosario Salas-Butrón
Daniel Lozano-Martín
Iván Alejandro Díaz-Rengifo
Isabel Ortega-Madueño
Lucia Diaz-Garcia
Ana Isabel Terleira-Fernández
Unexpected falsely high vancomycin concentrations in a patient with endocarditis during routine therapeutic drug monitoring
European Journal of Case Reports in Internal Medicine
vancomycin
interference
immunoassay
therapeutic drug monitoring
title Unexpected falsely high vancomycin concentrations in a patient with endocarditis during routine therapeutic drug monitoring
title_full Unexpected falsely high vancomycin concentrations in a patient with endocarditis during routine therapeutic drug monitoring
title_fullStr Unexpected falsely high vancomycin concentrations in a patient with endocarditis during routine therapeutic drug monitoring
title_full_unstemmed Unexpected falsely high vancomycin concentrations in a patient with endocarditis during routine therapeutic drug monitoring
title_short Unexpected falsely high vancomycin concentrations in a patient with endocarditis during routine therapeutic drug monitoring
title_sort unexpected falsely high vancomycin concentrations in a patient with endocarditis during routine therapeutic drug monitoring
topic vancomycin
interference
immunoassay
therapeutic drug monitoring
url https://www.ejcrim.com/index.php/EJCRIM/article/view/5464
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