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Simple approach to improving vancomycin dosing in intensive care: a standardised loading dose results in earlier therapeutic levels

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Background:  Patients in the Intensive Care Unit (ICU) often have sub‐therapeutic vancomycin levels in the initial stages of therapy. Loading doses have been demonstrated to overcome this problem.

Aim:  The aim of this study was to determine the impact of a standardised loading dose and increased clinician awareness of under‐dosing on the achievement of early therapeutic vancomycin trough concentrations in the ICU.

Methods:  A pre‐ and post‐intervention observational study was conducted in the ICU following the introduction of a 2‐g vancomycin loading dose and demonstration of local under‐dosing. All initial vancomycin trough levels were examined, except those from neurosurgical patients. Primary outcome measures were the proportion of patients achieving therapeutic vancomycin levels and mean trough concentrations. A year after introduction, a review was conducted to further assess the impact and sustainability of the intervention.

Results:  There were 31 courses of vancomycin in the pre‐intervention period (no loading doses given) and 21 courses in the post‐intervention period, of which 11 had a loading dose. In the pre‐intervention group, 13% of courses achieved therapeutic concentrations. This increased to 33% in the post‐intervention group (P= 0.08). A statistically significant increase in mean trough concentration, from 9.8 ± 6.6 mg/L to 14.9 ± 6.3 mg/L (P= 0.01), between the pre‐ and post‐intervention groups was observed. During the follow‐up period, results were similar to the post‐intervention audit.

Conclusion:  A standardised loading dose is a simple and sustainable intervention that may improve early achievement of therapeutic vancomycin levels in critically ill patients. The clinical significance of this requires further study.
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Document Type: Research Article

Affiliations: 1: Pharmacy Department 2: Infectious Diseases Department, Alfred Health, Melbourne, Victoria, Australia

Publication date: 01 January 2012

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