Although increased vancomycin clearance has been reported with highly permeable hemodialysis membranes (such as polysulfone), failure to consider post-dialysis redistribution could lead to unnecessary dosage supplementation. In protocol 1, twelve hemodialysis patients admitted for vascular access thrombectomy received 15 mg/kg of vancomycin as surgical prophylaxis. Post-operatively, patients underwent high-flux hemodialysis (HFHD) for two hours using a Fresenius F-80 polysulfone dialyzer (QB = 417 +/- 49, QD = 800 ml/min). Vancomycin's intradialytic clearance increased 13-fold compared to the patient's endogenous clearance (120 +/- 59 vs. 9 +/- 8 ml/min, respectively) yet dialysate recovery indicated that only 17% of body stores were removed (179 +/- 70 mg). Although serum vancomycin levels decreased 33% during HFHD, vancomycin levels increased in all patients following dialysis and the post-rebound values reached 87% of the pre-dialysis concentration. In protocol 2, eight outpatients receiving maintenance HFHD with a F-80 dialyzer (Kt/V = 1.29 +/- 0.08) were given 20 mg/kg of vancomycin immediately following dialysis on Monday; pre- and post-levels were measured during the next three dialysis treatments. The predialysis serum vancomycin levels were > 7.5 micrograms/ml (9.7 +/- 1.0 micrograms/ml; range 8.0 to 11.0) in all patients the following Monday. Thus, vancomycin clearance is increased during HFHD, but redistribution post-HD minimizes changes in serum levels. We recommend a 20 mg/kg i.v. loading dose and subsequent doses of 15 mg/kg every seven days; to account for individual variability, weekly vancomycin levels should be drawn before dialysis.
Over the past 20 years, pharmacokinetic programs have been developed for clinical decision making. These clinical pharmacokinetic software programs are designed to assist the clinician in the analysis, interpretation and reporting of serum drug concentration data for a variety of medications. The programs vary in the extent of features and range of medications supported and thus warrant careful review before selecting or purchasing such a program for routine use. A series of programs which are commercially available in the United States was reviewed for this article. The focus of the review is not to recommend a single program or to provide a ranked list of commercially available programs. Information is presented to clinicians to better their understanding of the features of these computer-based clinical resources. As an introduction to this topic, the information presented concentrates on the system and support features. Those programs that were reviewed demonstrate the ability to assist in the analysis of serum or plasma drug concentration data for most of the medications that warrant therapeutic drug monitoring. They provide both Bayesian and non-Bayesian methods for predicting serum drug concentrations. Standard personal computers were sufficient to run each of the programs reviewed. In addition, most programs offered technical and clinical support. However, the quality of the user manuals and training material varies among software programs. In-depth analytical comparisons are currently being conducted for future publication.
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