Vancomycin use for haemodialysis patients-Development of a new dosing protocol

To develop a dosing and monitoring protocol to achieve therapeutic vancomycin levels on intermittent haemodialysis.

We identified 15 vancomycin treatment courses received by patients on intermittent haemodialysis at a district health board in Auckland, New Zealand. Demographic, biochemical and clinical parameters were gathered from their health records. We subsequently devised and implemented a new vancomycin protocol consisting of weight-based loading dose, and subsequent dose titration according to same-day measured pre-dialysis levels. We then re-audited 16 vancomycin treatment courses to assess the performance of the protocol.

A significantly higher proportion of vancomycin levels were within the target range (15-20 mg/L) following the implementation of protocol, from 23% to 46% (p < .005). Additionally, a greater proportion of treatment courses had >50% of pre-dialysis levels within the target range, rising from 13% to 56% (p < .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. A total of 62% of total maintenance doses were administered in adherence to protocol. Length of hospital stay and number of positive blood cultures while on treatment were reduced.

Our initial 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 and fewer doses were withheld. Our sample size was too small to allow for interpretation of clinical outcome data.