Factors associated with inadequate early vancomycin levels in critically ill patients treated with continuous infusion

Abstract

Vancomycin administration using a loading dose and continuous infusion (CI) results in more rapid attainment of adequate concentrations. The aim of this retrospective study of ICU patients receiving vancomycin was to determine the efficacy of a vancomycin dosing protocol using a weight-based loading dose and to identify factors associated with inadequate concentrations. Patients received a loading dose (<65 kg, 1000 mg; ≥65 kg, 1500 mg), and 2000 mg/24 h CI with subsequent dose adaptation. Adequate levels were defined as concentrations ≥15 mg/L. In total, 227 patients (154 males) were included in the study (mean age 56.5 ± 16.1 years; mean APACHE II score 19.30 ± 7.7). The mean loading dose was 1129 ± 369 mg (15.07 ± 4.99 mg/kg). The dosing protocol was applied in 126 patients (55.5%). Mean vancomycin levels were 19.32 mg/L and 21.08 mg/L on Days 2 and 3, respectively. Vancomycin levels on Day 2 were adequate in 70.5% of patients, increasing to 84.1% on Day 3. Patients who received an appropriate loading dose more often had adequate vancomycin levels on Day 2. Older age, female sex, higher creatinine concentration, lower body temperature and use of a loading dose according to the vancomycin dosing protocol were independently associated with adequate vancomycin levels. A weight-based loading dose plus CI of vancomycin resulted in adequate concentrations in most patients and was superior compared with a non-standardised loading dose. Some patients may require higher doses, and factors other than weight, such as kidney function, age and sex, play a role.