Decreasing the time to achieve therapeutic vancomycin concentrations in critically ill patients: developing and testing of a dosing nomogram

João Pedro Baptista, Jason A Roberts, Eduardo Sousa, Ricardo Freitas, Nuno Deveza, Jorge Pimentel

IntroductionAchievement of optimal vancomycin exposure is crucial to improve the management of patients with life-threatening infections caused by susceptible Gram-positive bacteria and is of particular concern in patients with augmented renal clearance (ARC). The aim of this study was to develop a dosing nomogram for the administration of vancomycin by continuous infusion for the first 24 hours of therapy based on the measured urinary creatinine clearance (8 h CLCR).MethodsThis single-center study included all critically ill patients treated with vancomycin over a 13-month period (group 1), in which we retrospectively assessed the correlation between vancomycin clearance and 8 h CLCR. This data was used to develop a formula for optimised drug dosing. The efficiency of this formula was prospectively evaluated in a second cohort of 25 consecutive critically ill patients (group 2). Vancomycin serum concentrations between 20 to 30 mg/L were considered adequate. ARC was defined as 8 h CLCR more than 130 ml/min/1.73 m2.ResultsThe incidence of ARC was 36% (n =29/79) and 40% (10/25) in group 1 (n =79) and 2 (n =25), respectively. The mean serum vancomycin concentration on day 1 was 21.5 (6.4) and 24.5 (5.2) mg/L, for both groups respectively. On the treatment day, vancomycin plasma clearance was 5.12 (1.9) L/h in group 1 and correlated significantly with the 8 h CLCR (r2¿=¿0.66; P <0.001). The achievement of adequate vancomycin serum concentrations in group 2 was 84% (n =21/25) versus 51% (n =40/79) ¿ P <0.005.ConclusionsThis new vancomycin nomogram enabled the achievement of adequate serum concentrations in 84% of the patients on the first day of treatment.