Performance of a divided-load intravenous vancomycin dosing strategy for obese patients.

BACKGROUND: Current guidelines recommend vancomycin trough concentrations of 15 to 20 µg/mL in complicated infections and all trough concentrations >10 µg/mL to avoid developing microbial resistance. To date, no published protocol reliably meets these recommendations for obese patients. OBJECTIVE: We assessed the performance of a novel, obese-specific, divided-load vancomycin protocol for attaining target trough concentrations within 12 to 24 hours of dosing initiation, and during maintenance dosing, in obese patients. METHODS: The protocol was evaluated through prospective medical record review in 54 consecutive obese patients. Vancomycin serum concentrations were drawn before the third and fifth dose after initiation. Steady-state concentrations were drawn after the third dose once maintenance dosing was achieved and periodically thereafter. RESULTS: Within 12 hours after dosing initiation, 48 (89%) study patients exhibited trough concentrations of 10 to 20 µg/mL averaging 14.5 ± 3.2 µg/mL; 51 (94%) study patients exhibited trough concentrations >10 µg/mL within 12 hours after dosing initiation, and 3 (6%) had trough concentrations >20 µg/mL. Thirty-one participants had second trough concentrations drawn within 24 hours of dosing initiation, averaging 15.0 ± 3.1 µg/mL; 24 patients had a total of 32 trough concentrations drawn during maintenance dosing, averaging 15.1 ± 2.5 µg/mL. CONCLUSION: Obese-specific, divided-load dosing achieved trough concentrations of 10 to 20 µg/mL for 89% of obese patients within 12 hours of initial dosing and 97% of obese patients within 24 hours of initial dosing while preventing doses given during supratherapeutic trough levels; 97% of troughs measured during steady state were within target range.

Immigrant health: legal tools/legal barriers.

The United States is a country of immigrants, our government having been formed by recent arrivals. This trend has continued throughout our history; according to the Center for Immigration Studies, more than 26 million immigrants have settled in the United States since 1970, and approximately one million new immigrants come to the United States each year. The immigrant population faces highly diverse health issues that states, cities, and counties must address, many of which pose significant legal and policy issues. Social, cultural, and linguistic factors complicate those challenges, as does the overlay of federal immigration and health policy. Two federal laws, the Welfare Reform Act of 1996 and Title VI of the federal Civil Rights Act of 1964, have affected immigrants in two very different ways. The former made it difficult for immigrants to qualify for publicly funded benefits. In contrast, Title VI made it easier for immigrants to obtain benefits by requiring federally funded service providers to offer translating services to persons with limited English language skills. Tuberculosis treatment is perhaps the most pressing health need among recent arrivals to the United States. Methods to slow down and hopefully eliminate this disease are underway, but a more comprehensive approach to not only tuberculosis but to immigrant health in general is needed. Indeed, it will benefit those directly affected by tuberculosis and will have serious implications for the entire population for generations to come.