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To evaluate the vancomycin trough level in patients on inter mittent hemodialysis (IHD), slow low-efficiency dialysis (SLED) and continuous renal replacement therapy (CRRT) and to assess the appropriateness of an improvised protocol, which is to repeat the vancomycin dose (15 mg/kg) after 5 days on IHD, after 3 days on SLED and after 2 days in CRRT.
This study was conducted at AMRI Hospitals, Kolkata between November 2008 and April 2009. Thirty-three patients were studied. Fifteen were on IHD, 15 were receiving SLED and three were on CRRT. Mean age for the IHD group was 56.09 ± 11.4, for SLED was 64.3 ± 13.4, and for CRRT was 68 ± 8.34. The male:female ratio was 2:1 for IHD, 1.5: 1 for SLED and 2:1 for CRRT. Patients with severe hepatic impairment, obesity, cystic fibrosis and neoplastic disorder were excluded from this study. The mean Charlson score was 3.6 ± 4.8 for the IHD group, 5.26 ± 1.16 for SLED and 8.6 ± 11.2 for CRRT, respectively. High-performance liquid chromatography was used for assay of vancomycin.
The mean vancomycin trough levels were 18 ± 3.99 on day 5 for patients on IHD, 15.3 ± 4.1 on day 3 for patients on SLED and 11.9 ± 2.4 for patients on CRRT. This prospective observational study is unique, in the sense that data are sparse regarding vancomycin levels, on various modalities of hemodialysis. The second and more important observation from this study was that our improvised dosing of vancomycin needs revision, since, of the patients on dialysis, 80% (12/15) of patients on IHD and 60% (9/15) of patients on SLED had higher than the recommended trough level (15 μg/ml), whereas for patients on CRRT the trough levels were subtherapeutic at 30 hours.
This pilot study underscores the need for more awareness, mandatory checking of vancomycin trough levels and a larger study in Indian patients to definitively determine dosage guidelines in this ethnic population.