E HO1, S GLEESON1, S ROBERTS2, K BONDESIO2, A SALMON1
1Renal Service, Waitemata District Health Board, 2Pharmacy Department, Waitemata District Health Board
Aim: To develop a dosing and monitoring protocol to achieve therapeutic vancomycin levels on intermittent haemodialysis.
Background: Vancomycin is widely used in the treatment of Gram-positive infections in patients receiving haemodialysis. As it is readily cleared by high-flux dialyzers, serum trough concentration is commonly used as a surrogate for predicting efficacy.
Methods: In 2016, we identified 15 vancomycin treatment courses received by patients on intermittent haemodialysis at Waitemata District Health Board. Demographic, biochemical, and clinical parameters were gathered from their health records. In 2017, we devised and implemented a new vancomycin protocol consisting of weight-based loading dose, and subsequent dose titration according to same-day measured trough levels. In 2018, we re-audited 16 vancomycin treatment courses to assess the performance of the protocol.
Results: A significantly higher proportion of vancomycin levels were within the target range (15-20mg/L) following the implementation of protocol, from 23.3% to 46.3% (p=0.0006). Additionally, a greater proportion of treatment courses had >50% of levels within the target range, rising from 13% to 56% (p=0.01). In the pre-protocol group, 19 out of 117 doses of vancomycin were withheld during treatment, compared to 1 out of 118 doses in the post-protocol group. 52% of total doses were administered in adherence to protocol. Length of hospital stay and number of positive blood cultures while on treatment were reduced.
Conclusions: Our 2016 audit revealed deficiencies in our clinical practice in the absence of a local vancomycin protocol for patients receiving intermittent haemodialysis. Following the implementation of our novel protocol, there was an improvement in therapeutic levels with fewer doses being withheld. Our sample size was too small to allow interpretation of clinical outcome data.
Dr. Enya Ho is an advanced trainee in Nephrology at the Auckland regional hospitals. She completed her medical training with distinction from the University of Auckland.