Weight-Based Loading of Vancomycin in Patients on Hemodialysis

Brown, M. A.; Polisetty, Radhika S; Gracely, Edward J.; Çuhaci, Bülent; Schlecht, Hans P.

doi:10.1093/cid/cir322

Cited by 23 publications

(25 citation statements)

References 10 publications

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“…4 Current vancomycin guidelines recommend that the trough serum concentration should be maintained between 15 and 20 mg/L for serious infections, [9][10][11] but they do not address dosing strategies or appropriate pre-hemodialysis concentration for administration of vancomycin to patients undergoing hemodialysis. 3,12 Furthermore, the recommended serum concentration of 15-20 mg/L was validated with patients who had normal kidney function, but the accuracy of this range for patients with stage 5 CKD who were receiving hemodialysis was not clearly addressed.…”

Section: Résumémentioning

confidence: 99%

“…2,3,6,12 For instance, in various studies, different high-flux dialysis membranes removed different amounts of the drug (25% to 50%) in each dialysis session. [13][14][15][16] This variability may have been related to the differing composition of the dialysis membranes and whether or not vancomycin was infused during the last 30-90 min of dialysis.…”

Section: Résumémentioning

confidence: 99%

“…Similarly, Lucksiri and others 15 detected that 24% of vancomycin was removed if the dose was administered during the last hour of dialysis, whereas none of the dose was lost if it was administered after completion of the session. Unlike most of the existing studies, maintenance doses of vancomycin in the current study and a few others 13,[28][29][30] were always administered after completion of hemodialysis. These differences are worthy of mention because they affect the net dose of vancomycin received.…”

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confidence: 99%

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Predicting Maintenance Doses of Vancomycin for Hospitalized Patients Undergoing Hemodialysis

Nekidy

El-Masri

Umstead

et al. 2016

CJHP

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Background: Methicillin-resistant Staphylococcus aureus is a leading cause of death in patients undergoing hemodialysis. However, controversy exists about the optimal dose of vancomycin that will yield the recommended pre-hemodialysis serum concentration of 15-20 mg/L. Objective: To develop a data-driven model to optimize the accuracy of maintenance dosing of vancomycin for patients undergoing hemodialysis. Methods: A prospective observational cohort study was performed with 164 observations obtained from a convenience sample of 63 patients undergoing hemodialysis. All vancomycin doses were given on the floor after completion of a hemodialysis session. Multivariate linear generalized estimating equation analysis was used to examine independent predictors of pre-hemodialysis serum vancomycin concentration. Results: Pre-hemodialysis serum vancomycin concentration was independently associated with maintenance dose (B = 0.658, p < 0.001), baseline pre-hemodialysis serum concentration of the drug (B = 0.492, p < 0.001), and interdialytic interval (B = -2.133, p < 0.001). According to the best of 4 models that were developed, the maintenance dose of vancomycin required to achieve a pre-hemodialysis serum concentration of 15-20 mg/L, if the baseline serum concentration of the drug was also 15-20 mg/L, was 5.9 mg/kg with interdialytic interval of 48 h and 7.1 mg/kg with interdialytic interval of 72 h. However, if the baseline pre-hemodialysis serum concentration was 10-14.99 mg/L, the required dose increased to 9.2 mg/kg with an interdialytic interval of 48 h and 10.0 mg/kg with an interdialytic interval of 72 h. Conclusions: The maintenance dose of vancomycin varied according to baseline pre-hemodialysis serum concentration of the drug and interdialytic interval. The current practice of targeting a pre-hemodialysis concentration of 15-20 mg/L may be difficult to achieve for the majority of patients undergoing hemodialysis.

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Section: Résumémentioning

confidence: 99%

Section: Résumémentioning

confidence: 99%

mentioning

confidence: 99%

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Predicting Maintenance Doses of Vancomycin for Hospitalized Patients Undergoing Hemodialysis

Nekidy

El-Masri

Umstead

et al. 2016

CJHP

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“…Studies have suggested using loading doses of 15–20 mg/kg followed by maintenance doses of 500–1500 mg [6,26]. In a three-way randomized crossover trial conducted by Mason et al, a loading dose of 15 mg/kg resulted in a pre-hemodialysis vancomycin serum concentration of 23.8 mcg/mL ± 4.8 two days later [27].…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Factors which Influence Mortality in Gram-positive Bacteremia in Hemodialysis Patients

Rambaran

Alzghari²,

Seifert

2018

Cureus

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Vascular access infection is one of the major contributors to hemodialysis (HD) patient morbidity and mortality. There is a paucity of consensus guidelines on vancomycin use in the HD population. The primary objective of this study was to determine if vancomycin serum concentrations were associated with positive outcomes in HD patients with Gram-positive bacteremia. A retrospective cohort study conducted at a 443-bed tertiary teaching county hospital from January 1, 2010 to January 1, 2016 was performed. Patients aged 18-89, with chronic renal failure on hemodialysis who presented with positive blood cultures with Gram-positive bacteria and received intravenous vancomycin for at least 24 hours were evaluated. A multivariate analysis was utilized comparing factors related to outcomes including Simplified Acute Physiology Score II (SAPS II), loading dose, 30-day mortality and vancomycin serum concentrations. A total of 139 patients were obtained, 90 of whom had documented pre-dialysis serum vancomycin concentrations. A multivariate analysis showed that a lower SAPS II score [OR 1.220 (95% CI: 1.086-1.370, p < 0.0001)], a higher loading dose/kg [OR 0.7911 (0.6302-0.9929, p = 0.0239)], and pre-dialysis concentrations between 15 and 20 mcg/mL [0.05437 (95% CI: 0.0033-0.8891, p = 0.0099)] were associated with decreased mortality (overall multivariate model, p < 0.0001). When patient acuity and loading dosing are taken into account, pre-dialysis vancomycin serum concentrations between 15 and 20 mcg/mL were associated with decreased mortality in Gram-positive bacteremic intermittent HD patients. Further prospective studies are needed to assess whether targeting a pre-dialysis serum vancomycin concentration of 15-20 mcg/mL can improve mortality.

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“…Consequently, postdialysis dosing became the preferred method of vancomycin dosing in this population. The postdialysis dosing is either given during the last 30 to 90 minutes of dialysis in outpatients or after completing the dialysis session in hospitalized patients who have additional peripheral or central lines …”

Section: Introductionmentioning

confidence: 99%

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

Nekidy

El-Masri

Ghazi

et al. 2019

Hemodialysis International

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Background Vancomycin is the default antibiotic to treat methicillin‐resistant Staphylococcus aureus (MRSA) in hemodialysis (HD) units. Current guidelines recommend a vancomycin trough range of 15 to 20 mg/L for serious infections. Data regarding the clinical success of these recommendations are scarce in HD patients. Purpose The purpose of this studies is to evaluate the treatment outcomes of vancomycin in HD patients. Methods A retrospective chart review of HD outpatients who received parenteral vancomycin for suspected or documented MRSA infections in a community hospital in southwestern Ontario, Canada. Stepwise binary logistic regression analysis was conducted to identify the independent predictors of the treatment outcomes. Results Of 77 HD patients, 113 vancomycin treatment courses were identified. The unadjusted bivariate comparisons suggested that there was no difference between treatment success and failure groups in terms of: mean loading dose (1663.6 ± 451.9 mg vs. 1614.3 ± 471 mg, P = 0.621), mean pre‐HD concentration after loading dose (12.78 ± 4.4 mg/L vs. 13.34 ± 4.5 mg/L, P = 0.601), and mean maintenance dose (1012.1 ± 108 mg vs. 1069.7 ± 227 mg, P = 0.093). The groups were, however, different on their mean pre‐HD drug concentration after maintenance dose (15.99 ± 4.6 mg/L vs. 19.9 ± 5.8 mg/L, P = 0.002). The adjusted logistic regression results, however, suggested that the type of infection was the only independent predictor of vancomycin success (OR = 11.07; 95% confidence interval [CI] = 3.2–38.48). Specifically, patients treated for bacteremia were 11 times more likely to experience cure as compared with diabetic foot infection and/or osteomyelitis. Similarly, those with skin and soft tissue infections were 10.7 times more likely to experience cure than those with diabetic foot infection and/or osteomyelitis (OR = 10.7; 95% CI = 3.63–31.58). Conclusion The suggested vancomycin pre‐HD concentration in the guidelines did not predict the treatment outcomes. Patients with bacteremia and/or skin or soft tissue infections were more likely to achieve clinical cure than patients with diabetic foot/osteomyelitis infections.

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Weight-Based Loading of Vancomycin in Patients on Hemodialysis

Cited by 23 publications

References 10 publications

Predicting Maintenance Doses of Vancomycin for Hospitalized Patients Undergoing Hemodialysis

Predicting Maintenance Doses of Vancomycin for Hospitalized Patients Undergoing Hemodialysis

Evaluation of Factors which Influence Mortality in Gram-positive Bacteremia in Hemodialysis Patients

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

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