title: Simple approach to improving vancomycin dosing in intensive care: a standardised loading dose results in earlier therapeutic levels.
abstract: BACKGROUND
  Patients in the Intensive Care Unit (ICU) often have sub-therapeutic vancomycin levels in the initial stages of therapy. Loading doses have been demonstrated to overcome this problem.
  
  
  OBJECTIVE
  The aim of this study was to determine the impact of a standardised loading dose and increased clinician awareness of under-dosing on the achievement of early therapeutic vancomycin trough concentrations in the ICU.
  
  
  METHODS
  A pre- and post-intervention observational study was conducted in the ICU following the introduction of a 2-g vancomycin loading dose and demonstration of local under-dosing. All initial vancomycin trough levels were examined, except those from neurosurgical patients. Primary outcome measures were the proportion of patients achieving therapeutic vancomycin levels and mean trough concentrations. A year after introduction, a review was conducted to further assess the impact and sustainability of the intervention.
  
  
  RESULTS
  There were 31 courses of vancomycin in the pre-intervention period (no loading doses given) and 21 courses in the post-intervention period, of which 11 had a loading dose. In the pre-intervention group, 13% of courses achieved therapeutic concentrations. This increased to 33% in the post-intervention group (P= 0.08). A statistically significant increase in mean trough concentration, from 9.8 ± 6.6 mg/L to 14.9 ± 6.3 mg/L (P= 0.01), between the pre- and post-intervention groups was observed. During the follow-up period, results were similar to the post-intervention audit.
  
  
  CONCLUSIONS
  A standardised loading dose is a simple and sustainable intervention that may improve early achievement of therapeutic vancomycin levels in critically ill patients. The clinical significance of this requires further study.
authors.affiliation: Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia. j.truong@alfred.org.au
authors.forename: J
authors.initials: J
authors.lastname: Truong
authors.forename: B J
authors.initials: BJ
authors.lastname: Levkovich
authors.forename: A A
authors.initials: AA
authors.lastname: Padiglione
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000097:blood / Q000493:pharmacokinetics / Q000627:therapeutic use; D002056:Burns / Q000188:drug therapy; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D016903:Drug Monitoring; D005260:Female; D005500:Follow-Up Studies; D006785:Hospitals, University; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D011183:Postoperative Complications / Q000188:drug therapy; D017410:Practice Guidelines as Topic; D058996:Quality Improvement; D059039:Standard of Care; D013203:Staphylococcal Infections / Q000188:drug therapy; D014640:Vancomycin / Q000008:administration & dosage* / Q000097:blood / Q000493:pharmacokinetics / Q000627:therapeutic use; D014739:Victoria
chemical_list: D000900:Anti-Bacterial Agents; D014640:Vancomycin