Lin Hsin, Yeh Daniel Dante, Levine Alexander R
Department of Pharmacy, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
Departments of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
Crit Care. 2016 Jul 1;20(1):205. doi: 10.1186/s13054-016-1363-9.
Limited data are available assessing vancomycin concentrations in obese critically ill patients. Currently, there are no studies evaluating dosing requirements in this population who receive vancomycin administered as a continuous infusion (CI). The aim of this study was to assess whether there was a difference in the weight-based maintenance dose required to reach a therapeutic vancomycin concentration at 24 hours when given as a CI in obese versus non-obese critically ill patients.
A retrospective cohort study of adult obese patients admitted to the SICU between 2013 and 2015 receiving a vancomycin CI (CIV), and with 24-hour serum measurements were included. Obese patients (body mass index (BMI) ≥35 kg/m(2)) were matched with non-obese patients (BMI <30 kg/m(2)) based on renal function, age and acute physiology and chronic health evaluation (APACHE)-II score at admission. All patients in this study received a loading dose of 25 mg/kg then a maintenance dose based on renal function according to the protocol. The study was approved by the Institutional Review Board. The primary outcome was the weight-based total daily maintenance dose required to achieve a vancomycin level of 20 mg/L. The secondary endpoints included the achievement of a therapeutic level at 24 hours.
Twenty-six matched pairs of patients met the inclusion criteria. Of these, 17 pairs had preserved renal function and 9 pairs required continuous venovenous hemofiltration. Mean BMI was 40.9 kg/m(2) in obese and 24.8 kg/m(2) in non-obese patients. To achieve a vancomycin concentration of 20 mg/L, the weight-based daily maintenance dose in obese patients was 25.6 mg/kg versus 43.8 mg/kg in non-obese patients (p <0.01). Therapeutic 24-hour levels were achieved in 24/26 obese versus 23/26 no-obese patients (p = 0.63). Mean 24-hour vancomycin level was 20.3 ± 3.81 mcg/ml in obese compared to 20.03 ± 3.79 mcg/ml in non-obese patients (p = 0.77). Mean daily maintenance doses required to achieve a level of 20 mcg/ml were 2961 ± 1670 mg in obese compared to 3189 ± 1600.69 mg in non-obese (p = 0.61).
The results of our study suggest that critically ill obese patients treated with CIV required a significantly lower maintenance dose per unit of body weight than non-obese patients to achieve the same target level.
评估肥胖重症患者万古霉素浓度的数据有限。目前，尚无研究评估接受万古霉素持续输注（CI）的该人群的给药需求。本研究的目的是评估肥胖与非肥胖重症患者以CI方式给药时，达到24小时治疗性万古霉素浓度所需的基于体重的维持剂量是否存在差异。
对2013年至2015年入住外科重症监护病房（SICU）且接受万古霉素CI（CIV）治疗并进行24小时血清测量的成年肥胖患者进行回顾性队列研究。肥胖患者（体重指数（BMI）≥35kg/m²）根据入院时的肾功能、年龄和急性生理与慢性健康状况评估（APACHE）-II评分与非肥胖患者（BMI<30kg/m²）进行匹配。本研究中的所有患者均接受25mg/kg的负荷剂量，然后根据方案给予基于肾功能的维持剂量。该研究获得了机构审查委员会的批准。主要结局是达到万古霉素水平20mg/L所需的基于体重的每日总维持剂量。次要终点包括24小时达到治疗水平。
26对匹配患者符合纳入标准。其中，17对患者肾功能正常，9对患者需要持续静静脉血液滤过。肥胖患者的平均BMI为40.9kg/m²，非肥胖患者为24.8kg/m²。为达到万古霉素浓度20mg/L，肥胖患者基于体重的每日维持剂量为25.6mg/kg，而非肥胖患者为43.8mg/kg（p<0.01）。24/26例肥胖患者与23/26例非肥胖患者达到了24小时治疗水平（p = 0.63）。肥胖患者24小时万古霉素平均水平为20.3±3.81mcg/ml，非肥胖患者为20.03±3.79mcg/ml（p = 0.77）。达到20mcg/ml水平所需的平均每日维持剂量，肥胖患者为2961±1670mg，非肥胖患者为3189±1600.69mg（p = 0.61）。
我们的研究结果表明，接受CIV治疗的重症肥胖患者每单位体重所需的维持剂量明显低于非肥胖患者，以达到相同的目标水平。
