Vancomycine bij intensivecare- patienten met continue dialyse

Vancomycin during continuous renal replacement therapy in ICU patients Background Vancomycin is used in intensive care unit (ICU) patients for the treatment of infections caused by Gram-positive bacteria. For severe infections, the vancomycin pharmacodynamic target of 24-hour area under the curve to minimum inhibitory concentration ratio (AUC24h/MIC) > 400-600 h∗mg/L can generally be achieved by a plasma concentration 20 to 25 mg/L. Together with the pathophysiological alterations and pharmacokinetic variability associated with critical illness, the use of continuous renal replacement therapy (CRRT) may complicate the attainment of adequate vancomycin concentrations. ObjectiveIn this study we investigated the attainment of adequate vancomycin concentrations after 24 hours in adult ICU patients receiving CRRT. Secondary objectives were to evaluate vancomycin clearance (CL) by CRRT and the influence of residual urine and CRRT intensity on the attainment of adequate vancomycin concentrations at day 2 and 3. After a method comparison, samples were collected in residual blood. Design A prospective observational pharmacokinetic study was performed at the ICU of Erasmus MC University Medical Center. Vancomycin was administrated according to protocol: a loading dosing of 20 mg/kg followed by 1000 mg/24h continuous infusion. Methods Between May 2020 and February 2021 daily vancomycin residual blood gas and dialysate samples were collected every 6 hours and if possible vancomycin urine samples. Vancomycin was analyzed with a particle enhanced turbidimetric inhibition immunoassay (PETINIA) method. The extracorporeal clearance by CRRT was calculated. Results A total of 20 patients were analyzed. The proportion of patients achieving vancomycin concentrations ≥ 20 mg/L was 50% (n = 10). Patients with adequate vancomycin exposure after 24 hour had significantly lower dialysate flow rates (38.3 mL/min [33.3-44.2]), than patients with insufficient exposure (45 mL/min [43.3-56.7], P = 0.029). Conclusion Fifty percent of the ICU patients on CRRT showed adequate vancomycin concentrations 24 hours after start of the infusion. The present study reveals that optimization of the vancomycin dosage during CRRT therapy is needed.