UMEM Educational Pearls

Title: Vancomycin Loading in the ED Leads to Higher Trough Levels

Category: Pharmacology & Therapeutics

Keywords: vancomycin, loading dose (PubMed Search)

Posted: 1/26/2015 by Bryan Hayes, PharmD (Updated: 2/7/2015)
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We know vancomycin should be dosed based on weight rather than the default 1 gm dose so many patients receive. A past Academic Life in EM post explores the nuances of proper vancomycin dosing. But do higher loading doses in the ED actually lead to more therapeutic trough levels?

New Data

A new randomized trial compared ED patients receiving 30 mg/kg initial doses vs. 15 mg/kg. [1] There was a significantly greater proportion of patients reaching target trough levels of 15 mg/L at 12 hours among the patients who received a 30 mg/kg loading dose as compared with a traditional 15 mg/kg dose (34% vs 3%, P < 0.01). This study did not use a max dose of 2 gm. They included patients up to 120 kg who received 3.6 gm loading doses! Patients with creatinine clearance < 50 mL/min were excluded. There was no difference in incidence of nephrotoxicity between the groups.

Application to Clinical Practice

Advocate for change in your ED's order sets to weight-based dosing of vancomycin and remove 1 gm as a default option. [2, 3]
While 34% attaininment of adequate trough levels still isn't great, properly loading vancomycin with up to 30 mg/kg is a step in the right direction. It also takes longer than one dose to reach steady-state levels.
This study did not evaluate clinical cure rates, just trough levels.

References

Rosini JM, et al. A randomized trial of loading vancomycin in the emergency department. Ann Pharmacother 2015;49(1):6-13. [PMID 25358330]
Frankel KC, et al. Computerized provider order entry improves compliance of vancomycin dosing guidelines in the emergency department. Am J Emerg Med 2013;31(12):1715-6. [PMID 24144562]
Hall AB, et al. The effects of an electronic order set on vancomycin dosing in the ED. Am J Emerg Med 2015;33(1):92-4. [PMID 25445870]

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