par Cristallini, Stefano;Kabtouri, Hakim 
;Cotton, Frédéric ;Wolff, Fleur ;Beumier, Marjorie ;Hites, Maya ;Vincent, Jean Louis ;Jacobs, Frédérique ;Taccone, Fabio
Référence Critical care medicine, 40, 12, 362
Publication Publié, 2012-12
;Cotton, Frédéric ;Wolff, Fleur ;Beumier, Marjorie ;Hites, Maya ;Vincent, Jean Louis ;Jacobs, Frédérique ;Taccone, Fabio Référence Critical care medicine, 40, 12, 362
Publication Publié, 2012-12
Article révisé par les pairs
| Résumé : | Introduction: Despite the development of new molecules with anti-Gram positive bacteria activity, vancomycin is still the treatment of choice in septic critically ill patients. Because sepsis can alter drug pharmacokinetics, the development of an administration strategy able to promptly provide adequate antimicrobial concentrations is crucial.Hypothesis: The aim of this study was to prospectively validate a new regimen of vancomycin given by continuous infusion (CI)1 in septic patients.Methods: We prospectively included septic patients admitted to a mixed ICU from January 2011 to May 2012, treated with a new regimen of CI vancomycin, including a loading dose (LD) of 35 mg/kg of body weight given as a 4-hr infusion, followed by a daily CI dose adapted on creatinine clearance (CrCL), estimated by the Cockroft-Gault formula. We excluded patients treated by extracorporeal replacement therapies or less than 18 years of age. Serum vancomycin levels were measured at the end of LD, 12, 24 (n=107) and 48 hours (n=56) after the start of therapy. Dose adjustment was decided on drug concentrations at 24 and/or 48 hours. Adequate vancomycin concentrations were considered between 20 and 30 [micro]g/ml.Results: A total of 107 patients were included (77 male, age: 59 [48-71] years; weight: 75 [65-85] kgs; medical admission 69 (64%). Median APACHE II score on admission was 19 [14-23]. Mechanical ventilation was used in 58 (54%) patients and septic shock was present in 54 (53%). Overall ICU mortality was 22%. Median loading and daily doses were 2650 [2288 +/- 2295] mg and 2112 [1500-2838] mg/day, respectively. Vancomycin concentrations were 44 [37-49] [micro]g/mL at the end of LD and then 25 [21-32], 22 [19-28] and 26 [22-29] [micro]g/mL at 12, 24 and 48 hrs, respectively. Insufficient drug concentrations were found in 17 (16%), 29 (27%) and 4 (7%) patients at 12, 24 and 48 hrs, respectively and excessive levels (>30[micro]g/mL) were found in 30 (28%), 19 (17%) and 5 (9%).Conclusions: Higher than recommended regimen of vancomycin is needed to avoid insufficient drug concentrations levels in septic patients within the first 48 hours of therapy. |
