Vancomycin during the Last Hour of the Hemodialysis Session: A Pharmacokinetic Analysis

Abstract

Background: Vancomycin is usually administered after the dialysis sessions to patients undergoing hemodialysis. Administration of vancomycin during (as opposed to after) sessions would save time, and would be more acceptable to patients and staff, but may lead to vancomycin underexposure. The aim of this study was to propose a new dosing regimen of vancomycin taking into account the dialysis-related losses of vancomycin when administered during dialysis. Methods: In this monocentric prospective study, vancomycin was infused to dialyzed patients during the last hour of the dialysis session at increased doses. Monitoring of vancomycin was performed using repeated blood samples by pharmacokinetics modeling. Patients were treated according to our protocol and guidelines. Results: Twenty patients were included. Vancomycin protocol was efficient: 17 of 20 (85%) patients were cured, 1 needed additional vancomycin treatment, and 2 died (sepsis n = 1, multiple organ failure n = 1). Median pre-dialysis concentration was adequate (16.2 [10.2-24.4] µg/mL), and there was no emergence of resistant bacteria. Infusion of vancomycin during dialysis therefore decreased the exposure to vancomycin by 25% compared to infusion of vancomycin after dialysis. For a typical patient, the dose of vancomycin to be administered during dialysis would be 1.4 g. Conclusion: Administration of vancomycin during the last hour of dialysis session is safe, efficacious with regards to infection control, achieved recommended vancomycin concentrations despite the use of high-flux membranes, and improved patients' quality of life.

Factors predicting vancomycin therapy outcomes in hemodialysis outpatients and the role of the nephrology stewardship pharmacist

“…Nyman et al reported that 35% of the dose would be removed and suggested to increase the dose to account for the intradialytic vancomycin removal . Similarly, Ghouti‐Terki et al reported a 25% percent less exposure to vancomycin recommending to empirically increase the dose to account of amount removed by dialysis. These findings match our current protocol .…”

“…Similarly, Ghouti‐Terki et al reported a 25% percent less exposure to vancomycin recommending to empirically increase the dose to account of amount removed by dialysis. These findings match our current protocol . However, Hui et al suggested to use LD and MD ranged between 1500 and 4500 mg.…”

Removal of vancomycin administered during dialysis by a high‐flux dialyzer

“…There have been attempts to develop regimens for vancomycin administration during dialysis . Vancomycin can be administered during HD when using high‐flux cellulose acetate, cellulose triacetate, and polysulfone membranes if the dose is modified .…”

“…Vancomycin hydrochloride is a glycopeptide antibiotic (MW 5 1485 Daltons), which is frequently used to treat gram-positive infections in patients on chronic hemodialysis (HD), 1 and is administered either after a dialysis session or during the last hour of HD. [2][3][4] Both low-flux and high-flux membrane dialysis removes considerable amounts of vancomycin, although the median percentage removed by low-flux membrane dialysis is about 17%, and high-flux membrane dialysis is about 31%. 5 Dialysis therapy has been evolving with time, with majority of dialysis now being done using high-flux membranes.…”

“…There have been attempts to develop regimens for vancomycin administration during dialysis. [2][3][4] Vancomycin can be administered during HD when using high-flux cellulose acetate, cellulose triacetate, and polysulfone membranes if the dose is modified. 9,[11][12][13][14] The Polyflux (Gambro, Lakewood, CO, USA) dialyzer is now being used widely in the United States and is a high-flux dialyzer composed of a blend of polyarylethersulfone, polyamide, and polyvinylpyrrolidone.…”