Title: Vancomycin Loading in the ED Leads to Higher Trough Levels
題目：在急診科使用萬古霉素負荷會導致較高的最低有效治療水平
Author: Bryan Hayes
作者：Bryan Hayes
翻譯：江利冰 校對：肖鋒

We know vancomycin should be dosed based on weight rather than the default 1 gm dose so many patients receive. But do higher loading doses in the ED actually lead to more therapeutic trough levels?
我們知道萬古霉素的劑量應該根據體重進行調整，而不是所有的患者都默認使用1 gm。急診室高負荷量真的可以帶來更長時間的最低有效治療水平？

New Data
新數據
A new randomized trial compared ED patients receiving 30 mg/kg initial doses vs. 15 mg/kg. 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! There was no difference in incidence of nephrotoxicity between the groups.
一項新的隨機對照研究，比較了急診科患者使用30 mg/kg 和15 mg/kg的初始劑量。和接受15 mg/kg負荷劑量的患者相比，更多的接受30 mg/kg負荷劑量的患者，在12h到達了目標治療有效最低水平(34% vs 3%, P < 0.01)。該研究沒有使用最大劑量2gm。納入的患者中包括體重120kg接受3.6gm負荷量的患者！兩組之間腎毒性的發生率沒有區別。

Application to Clinical Practice
應用于臨床實踐
• 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]
• 建議急診科萬古霉素應該改為根據體重調整劑量，并去除默認的1gm。
• 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.
• 盡管達到34%的最低有效濃度仍然是不夠的，適當的增加萬古霉素的劑量，直到最大劑量30mg/kg是正確的。要想到達穩定的水平是需要多于一個劑量的萬古霉素。
• This study did not evaluate clinical cure rates, just trough levels.
• 該研究沒有評估臨床治愈率，僅僅是最低有效濃度。

References
參考文獻
Rosini JM, et al. A randomized trial of loading vancomycin in the emergency department. Ann Pharmacother 2015;49(1):6-13. http://www.ncbi.nlm.nih.gov/pubmed/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):1715-1716.
http://www.ncbi.nlm.nih.gov/pubmed/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):92-94. http://www.ncbi.nlm.nih.gov/pubmed/25445870