Vancomycin Dosing and Pharmacokinetics in Adults Undergoing Continuous Renal Replacement Therapy: A Narrative Review
DOI:
https://doi.org/10.70672/5f33ew46Keywords:
Continuous renal replacement therapy, pharmacokinetics, vancomycinAbstract
Vancomycin is a cornerstone therapy for severe Gram-positive infections, but dosing in critically ill patients on continuous renal replacement therapy (CRRT) is challenging due to significant pharmacokinetic variability. This narrative review synthesizes current evidence on vancomycin pharmacokinetics, dosing strategies, and therapeutic drug monitoring. Twelve articles were included, encompassing 398 adult patients receiving vancomycin across different CRRT modalities, including continuous veno-venous hemofiltration (CVVH), hemodialysis (CVVHD), and hemodiafiltration (CVVHDF). Vancomycin pharmacokinetics during CRRT are influenced by CRRT modality, effluent flow rate, filter integrity, residual renal function, and patient-specific factors such as expanded volume of distribution. Clearance estimates range from 0.7 to 2.6 L/h, with CVVHDF achieving the highest removal (up to 76% of total body clearance). An initial loading dose of 20 to 25 mg/kg is consistently recommended, followed by maintenance dosing of 5-7.5mg/kg every 12 hours, adjusted according to the CRRT intensity. Continuous infusion strategies may offer more stable concentrations but require close monitoring. TDM is essential, with a clear evolution from trough-based monitoring (target 15–20 mg/L) toward AUC₂₄/MIC-guided dosing (target 400–600 mg·h/L), consistent with current guidelines. This review highlights the critical interplay between CRRT parameters and vancomycin clearance, emphasizing the need for individualized, TDM-guided therapy to optimize efficacy and minimize toxicity in this complex patient population.
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