Magazine article Drug Topics

Inept Vancomycin Dosing Boosting Drug Resistance

Magazine article Drug Topics

Inept Vancomycin Dosing Boosting Drug Resistance

Article excerpt

Despite guidelines from the Centers for Disease Control & Prevention, vancomycin dosing in U.S. hospitals is often inappropriate, stimulating drug resistance and higher costs, according to a top CDC official.

Vancomycin has been the hospital drug of last resort for severe gram-positive infections for about a decade. But now, vancomycin-resistant enterococci (VRE) threaten to get out of hand, said William R. Jarvis, M.D., chief of the CDC's Investigation & Prevention Branch, Hospital Infection Program. "They're resistant to virtually all available antibiotics including vancomycin."

He told a crowded scientific symposium held in New Orleans prior to the 36th Interscience Conference on Antimicrobial Agents & Chemotherapy (ICAAC) that a recent study in a large university hospital showed a 20-fold rise in vancomycin usage over 10 years, with 63% of use regarded by experts as inappropriate.

"Most was due to faulty drug monitoring rather than initial selectionthat is, blood levels [of vancomycin] were either not obtained, or, when they were [obtained] and found to be unacceptably high or low, no dosing change was made."

Also considered inappropriate were the following uses: empiric therapy with vancomycin in patients from whom no cultures had been taken; use of vancomycin as surgical prophylaxis; and use as first-line therapy for antibiotic-associated colitis.

When all patients receiving IV vancomycin were evaluated, he said, "those with transplants had a 30-fold greater risk of receiving IV vancomycin, oncology patients had a 10-fold greater risk, and those with indwelling medical devices, particularly catheters, had over a 13-fold greater risk."

In another study, community hospital researchers prospectively looked at all patients who received IV vancomycin during a three-month period. They found: only 19 (40%) of the 48 patients, who ranged in age from 15 to 80, received the appropriate serum concentration.

"Older patients were more likely to be overdosed. Younger ones were underdosed," reported Jarvis. "The investigators suggested that if a nomogram had been used, it could have yielded the correct initial dose in over 80% of patients." In this and other hospitals, he said, CDC dosage guidelines were not followed in more than half of patients. Thus, "we have a long way to go to improve vancomycyin use."

In an interview with Drug Topics, Jarvis also stated, "Too often there's a 'one-size-fits-all' approach to dosing in many hospitals that doesn't take individual patients into account. Vancomycin's standard adult dose of 2,000 mg a day fits the average patient but not those who need higher or lower blood levels of drug. However, careful monitoring of the standard dose from the start helps ensure that each patient gets proper therapy. …

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