Harper University Hospital, Detroit, Michigan, USA.
Pharmacotherapy. 2021 Jul;41(7):554-561. doi: 10.1002/phar.2535. Epub 2021 Jun 18.
Recommendations regarding vancomycin dosing in critically ill patients on continuous venovenous hemofiltration (CVVH) are limited. The purpose of this study was to evaluate current dosing practices of pharmacists for patients treated with CVVH, develop guidelines for optimal dosing and monitoring of vancomycin to improve target trough attainment, and reduce pharmacist workload.
A retrospective cohort study. was performed of critically ill adult patients from January 2015 to December 2018. Patients were included if they received vancomycin during CVVH for at least 48 h. Patients with significant residual kidney function, defined as daily urine output >400 ml or significant fluctuations (≥1000 ml/h in a 24-h period) in their hemofiltration rates, were excluded. Interruptions in CVVH up to 6 h/day were permitted. Dosing strategies with two dosing categories were defined: (1) dosing based on random serum levels (dosing by level, DBL) or (2) scheduled vancomycin dosing (SD).
Academic medical center in Detroit, Michigan.
Critically ill adult patients.
During the study period, 942 patients were evaluated and 200 met inclusion criteria, for a total of 586 serum vancomycin levels. There were 141 patients with 443 random vancomycin serum levels in the DBL group and 59 patients with143 vancomycin trough levels in the SD group. Mean vancomycin trough levels were similar between groups (17.1 ± 6 vs. 16.5 ± 4 mcg/ml) for the DBL and SD groups, respectively. For the primary end point of overall target trough achievement of 15-20 mcg/ml, significantly more trough levels in the SD group were in the 15-20 mcg/ml range compared with the DBL group, 50% vs. 38%; p < 0.001, respectively. When target trough range was extended to 10-20 mcg/ml, success rates were similar between groups (74% DBL vs. 82% SD, p = 0.021). The number of interventions required by the pharmacist, including notes per day and orders per day, were reduced by approximately 50% when the SD strategy was utilized. Scheduled vancomycin dosing regimens of 15-22 mg/kg every 12-24 h were required to yield trough levels in the 15-20 mcg/ml range.
Target vancomycin trough achievement of 15-20 mcg/ml occurred more frequently when vancomycin was scheduled at a dose of 15-22 mg/kg every 12-24 h based on ultrafiltration rate and may alleviate the time and cost associated with frequent vancomycin serum monitoring.
关于连续静脉-静脉血液滤过（CVVH）中危重症患者万古霉素剂量的建议有限。本研究的目的是评估药师在接受 CVVH 治疗的患者中万古霉素的当前给药方案，制定最佳的万古霉素给药和监测指南，以提高目标谷浓度达标率，并降低药师的工作量。
回顾性队列研究。纳入了 2015 年 1 月至 2018 年 12 月期间接受 CVVH 治疗至少 48 小时的危重症成年患者。纳入标准为：患者在 CVVH 期间接受万古霉素治疗；每日尿量>400ml 或血液滤过率有显著波动（24 小时内>1000ml/h）的患者排除在外。允许 CVVH 中断每天不超过 6 小时。根据两种剂量类别定义了给药策略：（1）根据随机血清水平给药（基于水平给药，DBL）或（2）计划万古霉素剂量（SD）。
密歇根州底特律的学术医疗中心。
危重症成年患者。
在研究期间，共评估了 942 名患者，其中 200 名符合纳入标准，共检测了 586 份血清万古霉素水平。DBL 组 141 名患者中有 443 份随机万古霉素血清水平，SD 组 59 名患者中有 143 份万古霉素谷浓度水平。DBL 和 SD 组的万古霉素谷浓度分别为 17.1±6μg/ml 和 16.5±4μg/ml，两组之间无显著差异。DBL 组和 SD 组的主要终点，即总体目标谷浓度 15-20μg/ml 的达标率，SD 组的谷浓度在 15-20μg/ml 范围内的比例显著高于 DBL 组，分别为 50%和 38%（p<0.001）。当目标谷浓度范围扩展到 10-20μg/ml 时，两组的成功率相似（DBL 组为 74%，SD 组为 82%，p=0.021）。当使用 SD 策略时，药师所需的干预措施（包括每天的笔记数量和医嘱数量）减少了约 50%。每 12-24 小时给予 15-22mg/kg 的计划万古霉素剂量可使谷浓度在 15-20μg/ml 范围内。
根据超滤率，每 12-24 小时给予 15-22mg/kg 的计划万古霉素剂量时，目标万古霉素谷浓度达到 15-20μg/ml 的发生率更高，可能减轻频繁进行万古霉素血清监测相关的时间和成本。
