PHARMACY VANCOMYCIN DOSING GUIDELINE SUMMARY (Revised 7/2014)

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1 PHARMACY VANCOMYCIN DOSING GUIDELINE SUMMARY (Revised 7/2014) GUIDELINES FOR DOSING AND MONITORING PATIENTS ON VANCOMYCIN Cnsult Respnsibilities: Pharmacy will initiate and mdify vancmycin fr ALL patients admitted t PAMC upn receipt f the initial vancmycin rder unless therwise specified in the vancmycin rder r if rdered by an Infectius Disease physician withut a pharmacy t dse vancmycin cnsult. The Infectius Diseases Clinical Pharmacy Specialist will evaluate all vancmycin regimens with dses >4 gm/day fr apprpriateness and pprtunity fr pharmackinetic/pharmacdynamic dse ptimizatin. Labratry Tests: The fllwing labratry tests may be rdered by a pharmacist fr ANY patient currently receiving vancmycin at PAMC. BMP (Or individual BUN/SCr) NOTE: SCr MUST be btained and assessed prir t placement f an rder fr nging vancmycin administratin. First dses may be given prir t btaining a SCr Vancmycin levels (randm, pst-infusin, and trugh) Vancmycin Etest if MRSA islated frm bld r CSF Adult Lading Dse Recmmendatins: Lading dses will ONLY be given t individuals with the fllwing indicatins: bacteremia, endcarditis, meningitis, and hspital acquired pneumnia caused by methicillin resistant Staph. Aureus, severe sepsis, r as specified by prescriber. See definitin f severe sepsis under lading dse sectin belw Recmmended Lading Dse: Patient s ABW <120% f IBW: mg/kg x 1 dse based n actual bdy weight. Max 3 grams. Patient s ABW >120% IBW: mg/kg x 1 dse based n adjusted bdy weight. Max 3 grams. Patients > 150 Kg: See serial kinetic sectin belw Adult Maintenance Dse Recmmendatins: The pharmackinetic calculatr apprved fr use at PAMC as the primary calculatr fr dsing is the Excel PAMC Vancmycin Pharmackinetic Calculatr available n the pharmacy intranet. Maintenance Dse Recmmendatins: Patient s ABW <120% f IBW: mg/kg/dse based n actual bdy weight. Max 2 grams Patient s ABW 120% f IBW: mg/kg/dse based n adjusted bdy weight as calculated abve. Max 2 grams Patients > 150 Kg: See serial kinetic sectin belw. Adult Interval Recmmendatins: Nrmal renal functin (CrCl > 90 ml/min): q8-12hrs Mild renal impairment (CrCl ml/min) r age >60 y/: q12-24hrs Mderate renal impairment (CrCl ml/min): q24hrs Severe renal impairment (nn-hd): Interval determined by serum vancmycin levels May be unable t schedule a regular maintenance interval (i.e. dse by levels fr duratin f therapy). Adult Dse Adjustment:

2 See prcedure utlined belw in Adjustment f Vancmycin Dsing Based n Trugh Levels sectin Vancmycin Dsing in Special Adult Ppulatins: See belw sectin Vancmycin Dsing in Special (ADULT) Patient Ppulatins fr infrmatin regarding vancmycin dsing in: Hemdialysis CRRT Pregnancy Patients >150 Kg AUC:MIC dsing Nenatal Initial Vancmycin Dsing: Initial Dsing: mg/kg/dse (all ages with nrmal renal functin) fr all indicatins Interval is determined by age related renal functin (see table belw): Pstmenstrual Age (wks) Pstnatal Age (days) Interval (hrs) < > > >7 8 >45 All 6 Pediatric Initial Dsing Recmmendatins: Age: 1 mnth (and pst-menstrual age >44 weeks) 12 years: mg/kg/dse IV q6hrs (60-80 mg/kg/day) Age: 12 years 18 years: mg/kg/dse IVq6-8hrs (60-80 mg/kg/day) Interval in renally impaired pediatric patients determined n case by case basis based n SCr and UOP. Gal Trugh Recmmendatins: Adults: All indicatins in adults will be maintained > 10 mcg/ml in rder t prevent emergence f resistance and MIC creep. NOTE: Exceptin may be AUC:MIC dsing strategies as utlined belw under Vancmycin Dsing in Special Patient Ppulatins. Trugh gal = mcg/ml: Staphylcccus aureus bacteremia, endcarditis, meningitis, stemyelitis/septic arthritis, necrtizing fasciitis, and hspital-acquired pneumnia caused by MRSA. Trugh gal = mcg/ml: All ther indicatins/rganisms. AUC:MIC pharmackinetic dsing may be recmmended as utlined in the belw AUC:MIC Pharmackinetic sectin. Nenates: Trugh gal = mcg/ml: Staphylcccus aureus bacteremia, endcarditis, meningitis, stemyelitis/septic arthritis, necrtizing fasciitis, and hspital-acquired pneumnia caused by MRSA. Trugh gal = mcg/ml: All ther indicatins/rganisms. There is insufficient evidence in nenates t suggest efficacy with utilizatin f lwer trugh gals (as in pediatrics) r AUC:MIC dsing. Pediatric Patients: Trugh gal = fr all indicatins/rganisms Higher trugh gals (15-20 mcg/ml) may be cnsidered fr patients with Staphylcccal meningitis r VP shunt infectin; hwever, vancmycin serum levels may nt crrelate well with CSF levels given pr penetratin. Little

3 evidence exists regarding use f serum vancmycin levels as predictrs f success in this infectin type. Infectius Diseases and Neursurgery shuld be cnsulted and intraventricular vancmycin shuld be cnsidered. AUC:MIC pharmackinetic dsing may be recmmended as utlined in the belw AUC:MIC Pharmackinetic sectin. During therapy there may be an indicatin fr a trugh gal t be mdified. The dsing pharmacist will cntact the prvider prir t adjusting gal vancmycin trugh shuld this circumstance arise. Vancmycin Trugh Frequency/Timing (Adults, NEONATES, AND Pediatrics): Timing in Relatin t Dse: Draw trugh within 30 minutes prir t the next dse. Initial Trughs: Obtain trugh when vancmycin steady state is achieved (i.e. just prir t 4 th dse f vancmycin (including lading dse)). In sme patients vancmycin trughs may nt be needed. If patient s meet ALL f the belw criteria they may be eligible t NOT have trugh levels drawn. Anticipate duratin f therapy <5 days N vancmycin induced nephrtxicity risk factrs See Nephrtxicity sectin belw Indicatin warranting gal trugh target f mcg/ml Onging: Obtain trugh levels just prir t 4 th dse (i.e. when cncentratin steady state has been reached) f new regimens as apprpriate when previus regimen is changed in respnse t subtherapeutic r supratherapeutic vancmycin level. Trughs shuld be drawn WEEKLY at minimum thrughut prlnged therapy in hemdynamically stable patients. Trughs need t be drawn mre ften (every 3-5 days at minimum) in: Hemdynamically unstable patients Thse with rapidly changing/unstable renal functin Patient with wrsening renal functin may need t be evaluated fr likelihd f develpment f vancmycin induced nephrtxicity. Onging use/additin f cncurrent nephrtxin (i.e. NSAIDs, lp diuretic, aminglycside, piperacillin/tazbactam, r amphtericin B). Lab Frequency/Timing fr Mnitring: Serum Creatinine (SCr) shuld be btained: At baseline NOTE: Baseline BUN/SCr MUST be btained prir t scheduling f nging vancmycin regimen (i.e. must be btained at minimum prir t 2 nd dse). Onging: Weekly at minimum in patients n vancmycin Daily in patients with unstable renal functin At least every 3 days fr patients with: Ttal daily dses >4 gm/day On cncurrent nephrtxins (i.e. NSAIDs, lp diuretics, aminglycsides, piperacillin/tazbactam, r amphtericin B). Vancmycin trugh levels maintained >15 mcg/ml Cncurrent vaspressr administratin NOTE: Urine utput shuld be mnitred as able alng with evaluatin f serum creatinine values. Efficacy: The dsing pharmacist will assess the efficacy f therapy n a daily basis. This evaluatin will include the fllwing as applicable: pertinent labs, intake/utput, MD ntes, nursing ntes, culture results, vital signs, xygenatin (xygen delivery methd and xygen supplementatin needs), vaspressr requirements, and radilgy reprts.

4 Txicity: The dsing pharmacist will assess fr signs f nephrtxicity n a daily basis. See belw Nephrtxicity sectin fr mre infrmatin. Situatins in Which the Use f Vancmycin Shuld Be Discuraged: Rutine surgical prphylaxis ther than in a patient wh has a life-threatening allergy t betalactam antibitics Empiric antimicrbial therapy fr a febrile neutrpenic patient, unless initial evidence indicates that the patient has an infectin caused by gram-psitive micrrganisms (e.g., at an inflamed exit site f Hickman catheter) and the prevalence f infectins caused by MRSA in the hspital is substantial Treatment in respnse t a single bld culture psitive fr cagulase-negative staphylcccus, if ther bld cultures taken during the same time frame are negative (i.e., if cntaminatin f the bld culture is likely). Because cntaminatin f bld cultures with skin flra (e.g., S. epidermidis) culd result in inapprpriate administratin f vancmycin, phlebtmists and ther persnnel wh btain bld cultures shuld be trained t minimize micrbial cntaminatin f specimens Cntinued empiric use fr presumed infectins in patients whse cultures are negative fr betalactam-resistant gram-psitive micrrganisms Systemic r lcal (e.g., antibitic lck) prphylaxis fr infectin r clnizatin f indwelling central r peripheral intravascular catheters Selective decntaminatin f the digestive tract. Eradicatin f MRSA clnizatin Primary treatment f antibitic-assciated clitis Rutine prphylaxis fr very lw-birthweight infants (i.e., infants wh weigh less than 1,500 g {3 lbs 4 z}) Rutine prphylaxis fr patients n cntinuus ambulatry peritneal dialysis r hemdialysis Treatment (chsen fr dsing cnvenience) f infectins caused by beta-lactam-sensitive grampsitive micrrganisms in patients wh have renal failure Use f vancmycin slutin fr tpical applicatin r irrigatin.

5 PHARMACY VANCOMYCIN DOSING GUIDELINES (Revised 6/2014) GUIDELINES FOR DOSING AND MONITORING PATIENTS ON VANCOMYCIN Backgrund: Vancmycin is a glycpeptides antibitic that is active against aerbic and anaerbic gram-psitive ccci. It is slwly bactericidal with a mechanism f actin that cnsists f binding t peptidglycan precursrs and thus interfering with cell wall synthesis and repair. The pharmacdynamic parameter that best predicts the drug s efficacy is free area under the time curve ver the MIC (AUC:MIC rati) f >400 mg*hr/l. Vancmycin has been in use since the 1950s; hwever, resurgence in use has been seen as a result f increasing rates f methicillinresistant staphylcccus aureus (MRSA) in bth the cmmunity and healthcare envirnments ver the previus 20 years. Specific dsing f the drug has been the subject f debate ver this time perid with relatively regular alteratins in dsing recmmendatins. The subject cntinues t evlve tday. Current ASHP/IDSA/SIDP guidelines fr vancmycin dsing: Rybak M, Lmaestr B, Rtschafer JC, et al. Therapeutic mnitring f vancmycin in adult patients: a cnsensus review f the American Sciety f Health-Systems Pharmacists, the Infectius Diseases Sciety f America, and the Sciety f Infectius Diseases Pharmacists. Am J Health-Syst Pharm 2009;66: NOTE: This lcal guideline attempts t address several circumstances frequently encuntered in the dsing and mnitring f vancmycin; hwever, given the vast inter-patient variability in vancmycin pharmackinetics, it is nt exhaustive by any means. Clinical judgment shuld be applied t each individual case and thught prcesses/dsing justificatin carefully dcumented. Vancmycin Pharmacdynamics: Vancmycin efficacy (in the treatment f Staphylcccus aureus) is thught t mst clsely crrelate with attainment f AUC:MIC ratis >400 mg*hr/l. Given pr vancmycin penetratin int certain tissues (i.e. bne, lungs, and bld-brain barrier penetratin) and high prtein binding (50-55%) an AUC:MIC >400 mg*hr/l may nt be attainable if the rganisms MIC is >1 mcg/ml depending n the site f infectin. E-tests shuld be rdered n MRSA islated frm the bld r CSF Only vancmycin trugh cncentratins are recmmended fr nging mnitring f vancmycin therapy as, depending n the indicatin fr therapy, trugh gals f mcg/ml r mcg/ml have been shwn t crrelate with AUC:MIC ratis > 400 mg*hr/l. Staphylcccus aureus and Vancmycin: Clinical Labratry Standards Institute (CLSI) and the FDA have specified that Staphylcccus aureus with an MIC 2 mcg/ml are susceptible t vancmycin. If MRSA with MIC 2 mcg/ml is encuntered, regardless f methd f susceptibility testing, the prescribing prvider will be cntacted and the pharmacist will recmmend an alternative therapy as AUC:MIC >400 mg*hr/l is unlikely t be achieved withut higher than standard dses and increased risk fr nephrtxicity. NOTE: Current evidence (in adult patients and extraplated t pediatrics) indicates that patients wh are infected with rganisms with MICs f mcg/ml are slwer t clear the rganism, have lnger duratins f vancmycin therapy, are mre likely t fail vancmycin therapy, and experience increased rate f mrtality (mrtality rate increase in studies driven by bldstream infectins as a surce and rganisms with Etest MIC f 2 mcg/ml). Situatins in Which the Use f Vancmycin Shuld Be Discuraged: Rutine surgical prphylaxis ther than in a patient wh has a life-threatening allergy t betalactam antibitics Empiric antimicrbial therapy fr a febrile neutrpenic patient, unless initial evidence indicates that the patient has an infectin caused by gram-psitive micrrganisms (e.g., at an inflamed

6 exit site f Hickman catheter) and the prevalence f infectins caused by MRSA in the hspital is substantial Treatment in respnse t a single bld culture psitive fr cagulase-negative staphylcccus, if ther bld cultures taken during the same time frame are negative (i.e., if cntaminatin f the bld culture is likely). Because cntaminatin f bld cultures with skin flra (e.g., S. epidermidis) culd result in inapprpriate administratin f vancmycin, phlebtmists and ther persnnel wh btain bld cultures shuld be trained t minimize micrbial cntaminatin f specimens Cntinued empiric use fr presumed infectins in patients whse cultures are negative fr betalactam-resistant gram-psitive micrrganisms Systemic r lcal (e.g., antibitic lck) prphylaxis fr infectin r clnizatin f indwelling central r peripheral intravascular catheters Selective decntaminatin f the digestive tract. Eradicatin f MRSA clnizatin Primary treatment f antibitic-assciated clitis Rutine prphylaxis fr very lw-birthweight infants (i.e., infants wh weigh less than 1,500 g {3 lbs 4 z}) Rutine prphylaxis fr patients n cntinuus ambulatry peritneal dialysis r hemdialysis Treatment (chsen fr dsing cnvenience) f infectins caused by beta-lactam-sensitive grampsitive micrrganisms in patients wh have renal failure Use f vancmycin slutin fr tpical applicatin r irrigatin. Gal Vancmycin Trughs: Unless therwise specified by the rdering prvider, the dsing pharmacist will target the belw vancmycin gal trughs: All indicatins in adults will be maintained > 10 mcg/ml in rder t prevent emergence f resistance and MIC creep. NOTE: Exceptin may be AUC:MIC dsing strategies as utlined belw under Vancmycin Dsing in Special Patient Ppulatins. Trugh gal = mcg/ml: Staphylcccus aureus bacteremia, endcarditis, meningitis, stemyelitis/septic arthritis, necrtizing fasciitis, and hspitalacquired pneumnia caused by MRSA. Trugh gal = mcg/ml: All ther indicatins/rganisms. During therapy there may be an indicatin fr a trugh gal t be mdified. The dsing pharmacist will cntact the prvider prir t adjusting gal vancmycin trugh shuld this circumstance arise. PAMC Recmmended Calculatr: Dse selectin shuld be rdered based n apprpriate weight based dsing and verified using ppulatin r patient specific parameters as apprpriate. The ppulatin/patient specific parameter based pharmackinetic calculatr t be used at PAMC is the Excel calculatr made available n the PAMC pharmacy intranet website. Glbal RPh is nt t be used as a sle methd fr ppulatin based pharmackinetic calculatins as it des nt apprpriately rund serum creatinine and may lead t inapprpriately high initial dsing. Als, it requires the pharmacist t chse the desired vancmycin Vd. This may lead t inapprpriate variatin in dsing between pharmacists based upn value selected and the individuals knwledge f ppulatin estimates f vancmycin Vd. THE PAMC PHARMACOKINETIC CALCULATOR IS INTENDED TO AID WITH DECISION MAKING REGARDING VANCOMYCIN DOSING AND IS NOT INTENDED TO REPLACE CLINICAL JUDGMENT!!! NOTE: The calculatr shuld NOT be used in patients with unstable renal functin r patients with unpredictable/unstable vlumes f distributin r clearance.

7 It shuld be nted that, based n currently published literature, the IDSA guideline dsing (utilizatin f actual bdy weight) may verestimate vancmycin needs in bese individuals. The PAMC vancmycin dsing calculatr prvides bth mg/kg dse fr bth actual and adjusted bdy weight; hwever, dsing shuld be based n bdy weights specified belw. It has recently been shwn that bth initial empiric dses > 4 gm/day and bdy weight >100 Kg are risk factrs fr develpment f VIN. Bth f these are likely t cme int play in bese and mrbidly bese individuals. Ppulatin Parameter Calculatins (as Prgrammed in the PAMC Vancmycin Calculatr): Estimated CrCl: CrCl (ml/min) = [(140-Age)*IBW (kg)]/[72*scr] * (0.85 if female) NOTE: Use AdjBW (as specified belw) in place f IBW when patient is >120% f their IBW. Ideal Bdy Weight (IBW): Male: IBW (Kg) = *(Ht > 60 inches) Female: IBW (Kg) = *(Ht > 60 inches) Adjusted Bdy Weight (AdjBW): AdjBW (Kg) = [Ttal Bdy Weight IBW)*0.4]+IBW Prcedure/Prtcl Authrity: Patient Selectin/Cnsult Authrity: Pharmacy will initiate and mdify vancmycin therapy fr all patients admitted t the hspital upn receipt f the initial vancmycin rder unless therwise specified in the vancmycin rder r if rdered by an Infectius Disease physician withut a pharmacy t dse vancmycin cnsult. The Infectius Diseases Clinical Pharmacy Specialist will evaluate all vancmycin regimens with dses >4 gm/day fr apprpriateness and pprtunity fr pharmackinetic/pharmacdynamic dse ptimizatin. Labratry Tests: Per this guideline/prtcl, the fllwing labratry tests may be rdered by a pharmacist in rder t apprpriately dse/mnitr vancmycin usage. Basic metablic panel BUN/SCr NOTE: Baseline BUN/SCr MUST be btained prir t scheduling f nging vancmycin regimen (i.e. must be btained at minimum prir t 2 nd dse). Vancmycin levels (NOTE: Inpatient cst f vancmycin level is rughly $225) Trugh Pst-infusin Randm NOTE: Even in nn-cnsult patients n vancmycin, levels may be btained as deemed clinically necessary by a mnitring pharmacist in rder t apprpriately mnitr fr txicity develpment. Vancmycin Etest n MRSA islates btained frm bld r CSF. Vancmycin Administratin Times: Usual Administratin Times: 1000 mg: Infuse ver 1 hur mg: Infuse ver 1.5 hurs mg: Infuse ver 2 hurs >2000 mg: Infuse ver 3 hurs NOTE: Infusin times lnger than thse listed abve may be used per the pharmacist s judgment in pediatric patients depending n dse and/r if redman syndrme ccurs with the abve infusin times.

8 Initial Assessment: Initial assessment f vancmycin dsing by the dsing pharmacist shuld include review f all f the fllwing: Indicatin fr usage and severity f infectin Vital signs (i.e. respiratry rate, heart rate, bld pressure) Signs f end rgan damage (i.e. altered mental status, increased SCr, lactate >4, increased LFTs, etc.) Physical findings (i.e. descriptin f cellulitis, descriptin f pulmnary status, etc) Knwn medicatin allergies Height/Weight Available/pertinent labs BUN/SCr NOTE: SCr must be assessed prir t scheduling an nging vancmycin regimen WBC Inflammatry markers (ESR, CRP, and prcalcitnin) Vancmycin trughs (if cming frm utside facility) Available cultures Bth current and frm recent hspitalizatins if applicable NOTE: Whenever pssible, encurage cultures t be taken prir t antibitic administratin, but d nt delay therapy in septic patients as every hur antimicrbials are delayed in patients with septic shck may increase the dds f mrtality by up t 7.6% Available radilgy/prcedure reprts Pertinent past medical histry C-mrbid cnditins (i.e. CHF, CKD, ESRD, etc) Recent hspitalizatins Scial histry (i.e. IVDU, residence in ALF, etc) Anticipated duratin f therapy Initial Adult Vancmycin Dsing: Initial Vancmycin Dse Selectin (Use Vanc Initial Dsing Tab in Calculatr): Lading DOSE Recmmendatins: In critically ill patients, lading dses may be used t achieve target trugh cncentratins mre quickly than standard dsing regimens. Critical illness: bacteremia, endcarditis, meningitis, stemyelitis/septic arthritis, suspected necrtizing fasciitis, hspital acquired pneumnia caused by methicillin resistant Staph. Aureus, severe sepsis, r as specified by prescriber. NOTE: Severe sepsis is defined as meeting SIRS criteria + evidence f infectin + end rgan damage. SIRS Criteria: Temperature: >38C r <36C HR >90 bpm RR >20 r pco2 < 32 WBC >12K r <4K End rgan damage: LFT elevatin SCr elevatin Altered mental status Elevated serum lactate NOTE: Lading dses are NOT necessary fr all indicatins and shuld be reserved t the abve indicatins. Recmmended Dse:

9 Patient s ABW <120% f IBW: mg/kg x 1 dse based n actual bdy weight. Max 3 grams. Patient s ABW >120% IBW: mg/kg x 1 dse based n adjusted bdy weight. Max 3 grams. Patients > 150 Kg: See serial kinetic sectin belw Maintenance DOSE Recmmendatins: Patient s ABW <120% f IBW: mg/kg/dse based n actual bdy weight. Max 2 grams Patient s ABW 120% f IBW: mg/kg/dse based n adjusted bdy weight as calculated abve. Max 2 grams Patients > 150 Kg: See serial kinetic sectin belw. Initial Maintenance INTERVAL Selectin: Nrmal renal functin (CrCl > 90 ml/min): q8-12hrs Mild renal impairment (CrCl ml/min) r age >60 y/: q12-24hrs Mderate renal impairment (CrCl ml/min): q24hrs Severe renal impairment (nn-hd): Interval determined by serum vancmycin levels May be unable t schedule a regular maintenance interval (i.e. dse by levels fr duratin f therapy). Adjustment f Vancmycin Dsing Based n Trugh Levels: Adjustment f Vanc Dsing: NOTE: Vancmycin dsing may be adjusted based n a single level; hwever, this requires the utilizatin f at least ne ppulatin based pharmackinetic parameter in the estimatin f a mre patient specific eliminatin rate cnstant. In the case f the PAMC calculatr the retained ppulatin pharmackinetic parameter is the vlume f distributin. Trugh levels shuld be btained at steady state (just prir t the 4 th r 5 th vancmycin dse) in mst circumstances; hwever, circumstances d exist when earlier levels may be necessary (i.e. cncern fr txicity r unstable renal functin). NOTE: When levels are btained and the regimen is NOT at steady state this shuld be taken int cnsideratin and nted in cmmunicatin t prviders and ther pharmacists (i.e. prgress ntes, interventins, and handff). Prcedure: Stable Renal Functin (Use Vanc Dse Adjustment Tab in Vanc Calculatr): Obtain a trugh level at steady state and rughly 0.5 hur prir t the dse. PAMC Vancmycin Calculatr: Step 1: Input data fr ppulatin kinetic parameter calculatin (namely Vd in this circumstances). Step 2: Input dsing regimen, trugh level, and level timing. Nte true trugh btained. Nte estimated AUC(0-24). Step 3: Input desired peak/trugh Nte recmmended dsing regimen based n previusly input desired peak/trugh

10 Step 4: Select dse that prvides mst apprpriate trugh and estimated AUC(0-24). Input previus/future dsing int chart if desired fr visual aid/graph fr prgress nte. NOTE: This graph/strategy may be useful with regards t determining when t initiate the new regimen based n the trugh level btained if regimen adjustment invlves lengthening the dsing interval. Stable, impaired renal functin: If tw levels n the same vancmycin eliminatin curve are btained AND serum creatinine is elevated but stable, the Vanc Renal Nn-HD tab f the vancmycin calculatr may be used t determine a patient specific eliminatin rate cnstant and ptentially a regularly scheduled dsing interval r estimated time t next dse. Unstable Renal Functin: Obtain trughs as clinically indicated based n fluctuatins in renal functin in rder t minimize txicity/assure apprpriate trugh/auc(0-24) being attained. Clinical judgment is necessary with regards t when t btain trughs, evaluatin f levels, and dsing adjustment in patients with unstable renal functin. NOTE: Vancmycin calculatr may be used fr ROUGH ESTIMATION f parameters/levels in these patients; hwever, shuld be used EXTREMELY CAUTIOUSLY as it assumes stable renal functin! Vancmycin Dsing in Special (ADULT) Patient Ppulatins: Vancmycin Dsing in Pregnant Patients r Patients Within 30 Days f Delivery: Pregnant patients have an elevated vlume f distributin as cmpared t ther adult ppulatins. This vlume f distributin will typically return t nrmal within rughly 14 days f delivery; hwever, may remain elevated fr as lng as 30 days after delivery. Pregnant patients and thse wh have delivered within the previus 30 days shuld be dsed within the abve listed dsing ranges fr adults; hwever, the upper end f the dsing range, r mre frequent dsing may be cnsidered given the alternatin in pharmackinetic parameters in these patients (i.e. elevated Vd). Serial Vancmycin Kinetics (Use Vanc Serial Initial Tab n PAMC Vanc Calculatr): Due t variatins in vancmycin pharmackinetics in the mrbidly bese patient ppulatin PAMC guidelines recmmend serial vancmycin pharmackinetics be perfrmed in rder t rapidly btain patient specific dsing parameters. By btaining tw levels n the same eliminatin curve a patient specific eliminatin rate cnstant, half-life, vlume f distributin, and clearance can be calculated thus allwing fr mre accurate dsing. Serial kinetics shuld nly be perfrmed n patients with stable renal functin. NOTE: When serial vancmycin kinetics are perfrmed an AUC:MIC rati may be useful in guiding dse selectin given the utilizatin f patient specific pharmackinetic parameters; hwever, the trugh (with gals as abve) remains the primary vancmycin target unless therwise recmmended t prvider wh is in agreement with AUC:MIC kinetics per belw AUC:MIC dsing strategy. Prcedure: Order an apprpriate dse:

11 If lading dse desired: 3 grams If n lading dse desired: 15 mg/kg x 1 dse using adjusted bdy weight. Max 3 grams. Infusin Time: 3 hurs (r as apprpriate if n lading dse necessary) Serial levels: 1 st level: 3 hurs after the end f a 3 hur infusin 2 nd level: 6 hurs after the 1 st level was btained Input levels int the calculatr in rder t generate patient specific parameters. Use these calculated parameters t calculate dse anticipated t prduce peak ~30 mcg/ml and trugh within desired range. Vancmycin Dsing in Hemdialysis: Initial Dsing: Patients <120% f IBW: 15 mg/kg x 1 dse based n actual bdy weight Max 2 grams Patients 120% f IBW: mg/kg x 1 dse based n adjusted bdy weight as calculated abve Max 2 grams Maintenance Dsing: Vancmycin is 39% +/- 13% remved by high flux hemdialysis membranes. NOTE: Sme hemdialysis patients retain minimal urine utput. This slw, additinal eliminatin f the drug must be cnsidered when applicable during hemdialysis dsing. Vancmycin levels shuld be btained prir t the dialysis sessin after the 1 st pst dialysis dse. i.e. Lading dse dialysis pst-dialysis dse level dialysis new pst-dialysis dse Vancmycin levels shuld be drawn just PRIOR TO hemdialysis in rder t assess the level at which the patient has been maintained thrughut the intradialytic perid. Patient shuld be re-dsed when the serum vancmycin cncentratin psthemdialysis is anticipated t be belw the lwer limit f the gal trugh range. Typical pst-dialysis dses will be mg after each dialysis sessin. Dses >1000 mg after each dialysis sessin are nt likely t be necessary unless the patient has retained significant urinary utput. Hemdialysis and Vancmycin Epic Order Specifics: When rdering a vancmycin trugh call the dialysis unit t determine when the patient is t dialyze. Order the trugh at 0800 fr AM sessin and 1200 fr PM sessins with the rder cmment, TO BE DRAWN JUST PRIOR TO DIALSYS. Ntify the hemdialysis RN that pharmacy will be rdering a trugh and be sure they knw they will need t draw it. They will make nte f this n the whitebard in the unit t cmmunicate this infrmatin t the ther HD nurses When placing vancmycin drug rders fr hemdialysis patients the drug must be rdered with the rder frequency After Each Dialysis and a dialysis phase f care must be entered at rder verificatin in rder t assure that the dialysis RN will see the rder in the Dialysis tab f the medicatin administratin recrd and subsequently administer the medicatin. This rder will be discntinued by the hemdialysis RN at the end f every dialysis sessin and will need t be rerdered by the

12 pharmacist each time. Careful attentin shuld be paid t these rders t prevent the patient frm missing dses. Vancmycin Dsing in Cntinuus Renal Replacement Therapy: Clearance: Clearance f vancmycin is highly dependent n the methd f CRRT, the filter type, and the flw rate. Patients shuld be mnitred clsely fr clinical imprvement, adverse reactins, and drug accumulatin (i.e. levels). NOTE: These recmmendatins are based n dialysate flw rate f 3 L/hr, an ttal effluent rate f 0-1 L/hr, and n residual renal functin. PAMC utilizes CVVH (mst cmmn), CVVHD, r CVVHDF via the NxStage dialyzer. Initial Dsing: Lading Dse: Patients <120% f IBW: mg/kg x 1 dse based n actual bdy weight Max 3 grams Patients 120% f IBW: mg/kg x 1 dse based n adjusted bdy weight as calculated abve Max 3 grams Maintenance Dse: Patients <120% f IBW: 15 mg/kg (actual bdy weight) IV q24hrs Max 2 grams Patients 120% f IBW: 15 mg/kg (adjusted bdy weight) IV q24hrs Max 2 grams Onging Maintenance Dsing: Vancmycin levels shuld be btained prir t the 4 th ttal vancmycin dse assuming CRRT cntinues t that pint. Changes in methd f renal replacement therapy will drastically alter vancmycin clearance. Changes in type f renal replacement (i.e. CRRT t HD r CRRT t n renal replacement) shuld prmpt re-evaluatin f dsing and utilizatin f early level after the change t avid txicity due t accumulatin. Given the cntinuus nature f CRRT vancmycin levels shuld be btained 30 minutes prir t the next schedule dse. Vancmycin target trugh gal d nt change and are as listed abve. AUC:MIC Kinetics (Use AUC t MIC Rati Dsing Tab n PAMC Vanc Calculatr): General Infrmatin: Vancmycin gal trughs as specified by IDSA has been determined as they appear t mst clsely crrelate with an AUC:MIC rati f >400 mg*hr/l in the general ppulatin. Use f these trughs may verestimate AUC:MIC rati prduced in certain patients, therefre making calculatin f a patient specific AUC:MIC rati imprtant t avid unnecessary verexpsure t vancmycin and minimize the incidence f nephrtxicity. AUC:MIC pharmackinetics are NEVER t be perfrmed withut the prescribing physician s understanding and apprval f the dsing strategy. AUC:MIC dsing shuld nly be cnsidered fr recmmendatin t the physician if the patient meets all f the fllwing criteria: Stable renal functin Anticipated duratin f therapy >14 days

13 Ttal vancmycin need (as verified by initial levels) 4 gm/day AUC:MIC dsing is NOT apprpriate in individuals with the fllwing: CNS infectin Unstable renal functin Hemdialysis r CRRT patients In rder fr mst accurate calculatin f AUC:MIC rati the vancmycin regimen shuld be at steady state when levels are btained. Utilizatin f MIC: AUC:MIC rati gal f >400 mg*hr/l was established in Staphylcccus aureus bldstream infectins and pneumnia, but has nt been studied in ther indicatins r rganisms. Given MIC distributin listed abve under Staphylcccus aureus and vancmycin paired with lgistics f dsing and safety, an MIC f 1 mcg/ml shuld be utilized fr dsing t an AUC:MIC rati when an MIC is nt available r when the MIC f the S. aureus islated is 0.5 mcg/ml. If bth VITEK and Etest MICs are available the Etest MIC shuld be utilized fr AUC:MIC dsing. NOTE: Fr rganisms with an MIC >1 mcg/ml adverse utcmes with regards t failure f therapy and increased mrtality have been bserved as mentined abve under Pharmacdynamics. When the MIC is >1 an AUC:MIC >400 mg*hr/l is ften difficult t btain and either: Alternative therapy shuld be cnsidered Daptmycin Linezlid Ceftarline Clindamycin Sulfamethxazle/Trimethprim Dxycycline Tedizlid Dalbavancin Vancmycin shuld be utilized and ptimized as apprpriate while taking int cnsideratin bth the risk f cntinued use f vancmycin with regards t literature dcumented patient utcmes and safety/txicity f the regimen necessary t btain AUC:MIC ratis f 400 mg*hr/l. Prcedure: Levels: While at steady state btain tw levels as belw: Pst-infusin level: 1 hur after the end f the infusin Trugh level: 0.5 hur prir t the next infusin NOTE: Tw levels are needed fr AUC:MIC calculatin and ideally they wuld ccur n the same eliminatin curve; hwever, as lng as regimen is at steady state a trugh level may be btained befre a dse, the dse then given, and a pst-infusin level btained 1 hur after the infusin is cmpleted if this is easier lgistically with regards t level timing, pharmacist staffing, etc. NOTE: Level timing as abve is ideal; hwever, as lng as timing f levels is taken int cnsideratin with regards t calculating Kel and extraplating peaks and trughs, timing f levels is NOT imperative (i.e. tw levels btained n a steady state eliminatin curve after distributin phase f the dse is cmplete is all that is needed). Input vancmycin dsing regimen (dse, interval, and infusin time), levels, and apprpriate level timing int the PAMC vancmycin calculatr as apprpriate.

14 Step 1: Calculatr will use levels t calculate a Kel, back extraplate a true peak, frward extraplate a true trugh, and then calculate an AUC(0-24hrs). Step 2: Chse a new dsing regimen. Calculatr will use previusly calculated (patient specific) Kel t estimate peak/trugh and AUC(0-24). NOTE: Given literature with regards t MRSA bldstream infectins shwing AUC:MIC 421 mg*hr/l being assciated with less treatment failure and natural variatin in Kel (nt a cmpletely cnstant prcess) it is wise t target an AUC(0-24) f ~475 mg*hr/l. This is based n AMS Pharmacist experience with dsing strategy and nt n published evidence (nt available). Once regimen is altered allw new regimen t achieve steady state then btain repeat levels in rder t verify AUC(0-24) target is being achieved. Make nte f trugh which must be achieved in rder t assure an AUC:MIC >400 mg*hr/l be attained. NOTE: In mst circumstances use f AUC:MIC kinetics will simply allw fr target trugh gal t be reduced t mcg/ml fr indicatins in which guidelines wuld specify higher trugh gal be targeted. Once AUC(0-24) f regimen has been cnfirmed then trughs shuld be mnitred weekly fr develpment f txicity and t assure that trughs remain greater than previusly specified minimum trugh gal necessary t attain AUC(0-24) target. Clear cmmunicatin t prviders (via prgress ntes), pharmacists (via handff, prgress ntes, and ivents), and utside facilities at transitin f care is necessary t assure the prcess functins smthly. Questins regarding AUC:MIC pharmackinetic dse ptimizatin shuld be directed at the ID Clinical Pharmacy Specialist. NEONATAL Vancmycin Dsing: Gal Vancmycin Trughs: Trugh gal = mcg/ml: Staphylcccus aureus bacteremia, endcarditis, meningitis, stemyelitis/septic arthritis, necrtizing fasciitis, and hspitalacquired pneumnia caused by MRSA. Trugh gal = mcg/ml: All ther indicatins/rganisms. NOTE: Lwer gal trugh as mentined belw in PEDIATRIC sectin des nt apply t nenates and ptimal AUC:MIC targets have nt been studied in nenates. AUC:MIC dsing is nt t be perfrmed in this patient ppulatin. Initial Dsing: mg/kg/dse (all ages with nrmal renal functin) fr all indicatins Interval is determined by age related renal functin (see table belw): Pstmenstrual Age (wks) Pstnatal Age (days) Interval (hrs) < > > >7 8 >45 All 6 Obtaining Trughs:

15 Obtain levels as per Obtaining Vancmycin Trughs sectin belw. PEDIATRIC Vancmycin Dsing: Pharmackinetic Parameters Unique t Pediatrics: Vancmycin Renal Eliminatin Pediatric patients 6 mnths t 12 years eliminate vancmycin at rughly twice the rate as adult patients. Newbrns typically eliminate vancmycin similarly t r slwer than d adult patients. Estimated vancmycin terminal half-lives: Newbrns: 6-10 hurs 3 mnths 3 years: 4 hurs >3 years: hurs Adults: 5-8 hurs Gal Vancmycin Trughs (age 3 mnths 18 years): Trugh gal = fr all indicatins/rganisms Higher trugh gals (15-20 mcg/ml) may be cnsidered fr patients with Staphylcccal meningitis r VP shunt infectin; hwever, vancmycin serum levels may nt crrelate well with CSF levels given pr penetratin. Little evidence exists regarding use f serum vancmycin levels as predictrs f success in this infectin type. Infectius Diseases and Neursurgery shuld be cnsulted and intraventricular vancmycin shuld be cnsidered. NOTES: During therapy there may be an indicatin fr a trugh gal t be mdified. The dsing pharmacist will cntact the prvider prir t adjusting gal vancmycin trugh shuld this circumstance arise. Given the mre frequent administratin f vancmycin in pediatric patients (typically q6hr r q8hr interval) AUC(0-24) f 400 mg*hr/l may be attained by targeting lwer trugh gals than thse previusly specified in the available IDSA guidelines. Available evidence suggests that vancmycin trughs f 7-10 mcg/ml shuld be sufficient t prduce AUC(0-24) f 400 mg*hr/l in 90% f patients. AUC:MIC Dsing in pediatric patient is likely a mre apprpriate dsing strategy and shuld be cnsidered n a case by case basis (i.e. anticipated lng duratin f therapy, large dses required (as verified by levels), and in patients with stable renal functin). See abve sectin fr AUC:MIC dsing Initial Dsing: Age: 1 mnth (and pst-menstrual age >44 weeks) 12 years: mg/kg/dse IV q6hrs (60-80 mg/kg/day) Age: 12 years 18 years: mg/kg/dse IV q6-8hrs (45-80 mg/kg/day) Interval in renally impaired pediatric patients determined n case by case basis based n SCr and UOP. Obtaining Trughs: Vancmycin trugh levels shuld be btained accrding t the same standards utlined belw. Obtaining Vancmycin Trughs (Adults, NEONATES, AND Pediatrics): Timing in Relatin t Dse: Draw trugh within 30 minutes prir t the next dse. Initial Trughs: Obtain trugh when vancmycin steady state is achieved (i.e. just prir t 4 th dse f vancmycin (including lading dse)).

16 NOTE: True steady state is achieved at 4-5 drug eliminatin half-lives (i.e. rughly 4-5 vancmycin dses); thus, if level is btained just prir t 4 th dse, a relatively small degree f accumulatin may ccur with nging administratin f the currently rdered regimen. In sme patients vancmycin trughs may nt be needed. If patient s meet ALL f the belw criteria they may be eligible t NOT have trugh levels drawn. Anticipate duratin f therapy <5 days N vancmycin induced nephrtxicity risk factrs See Nephrtxicity sectin belw Indicatin warranting gal trugh target f mcg/ml Onging: Obtain trugh levels just prir t 4 th dse (i.e. when cncentratin steady state has been reache) f new regimens as apprpriate when previus regimen is changed in respnse t subtherapeutic r supratherapeutic vancmycin level. Trughs shuld be drawn weekly at minimum thrughut prlnged therapy in hemdynamically stable patients. Trughs need t be drawn mre ften (every 3-5 days at minimum) in: Hemdynamically unstable patients Thse with rapidly changing/unstable renal functin Patient with wrsening renal functin may need t be evaluated fr likelihd f develpment f vancmycin induced nephrtxicity. Onging use/additin f cncurrent nephrtxin (i.e. NSAIDs, lp diuretic, aminglycside, piperacillin/tazbactam, r amphtericin B). Obtaining Labs fr Mnitring: Serum Creatinine (SCr) shuld be btained: At baseline: NOTE: Baseline BUN/SCr MUST be btained prir t scheduling f nging vancmycin regimen (i.e. must be btained at minimum prir t 2 nd dse). Onging: Weekly at minimum in patients n vancmycin Daily in patients with unstable renal functin At least every 3 days fr patients with: Ttal daily dses >4 gm/day On cncurrent nephrtxins (i.e. NSAIDs, lp diuretics, aminglycsides, piperacillin/tazbactam, r amphtericin B). Vancmycin trugh levels maintained >15 mcg/ml Cncurrent vaspressr administratin NOTE: Urine utput shuld be mnitred as able alng with evaluatin f serum creatinine values. Efficacy: The dsing pharmacist will assess the efficacy f therapy n a daily basis. This evaluatin will include the fllwing as applicable: Pertinent labs MD ntes Nursing ntes Culture results Vital signs Oxygenatin, xygen delivery methd, and xygen supplementatin needs Vaspressr requirements Radilgy reprts Intake and utput

17 Shuld culture data becme available that allws fr the streamlining/de-escalatin f antimicrbials the dsing pharmacist r AMS pharmacist will cntact the apprpriate prvider and give recmmendatins fr nging therapy. NOTE: Available literature (primarily in bldstream infectins) indicates beta-lactam therapy is mre effective (less treatment failure, shrter duratin f hspital stay, and lwer mrtality rate) than vancmycin therapy fr the treatment f MSSA. In slw t respnd/nn-respnding patients being treated fr severe MRSA infectins and/r MRSA infectins in difficult t penetrate tissue (meningitis, endcarditis, bacteremia, stemyelitis, septic jints, and pneumnia) and the rganism has a VITEK reprted MIC f 1 mcg/ml an Etest may be f benefit. If the Etest MIC returns >1 mcg/ml transitin t alternate therapy r mre aggressive vancmycin dsing may be needed t assure AUC:MIC >400 mg*hr/l are being reached. May cnsider AUC:MIC dse ptimizatin if vancmycin t be used. NOTE: The Etest MIC is ptentially mre accurate with regards t true MIC and crrelates t utcmes/measurements frm available literature (primarily MRSA bldstream infectin studies) regarding vancmycin efficacy. The VITEK 2 autmated micrbrth dilutin instrument may underestimate the MIC f MRSA islates by: One micrbrth dilutin in ~ 50% f islates with a true MIC f 1 mcg/ml 1-2 micrbrth dilutins in ~20% f islates with a true MIC f 2 mcg/ml Dcumentatin: Prgress Ntes: Initial Prgress Nte: An initial pharmacy t dse vancmycin cnsult nte will be written by either the pharmacist ding the initial dsing r if rdered vernight the pharmacist assuming care in the mrning after the cnsult was placed. This prgress nte will cntain, at minimum: Indicatin fr vancmycin A brief descriptin f clinical curse t this pint MRSA histry (if applicable) Target trugh Additinal antimicrbials Current plan/dsing regimen Patient height/weight (and adjusted bdy weight if applicable) The weight used fr dsing will be indicated Pertinent labratry values WBC % bands BUN/SCr Inflammatry markers (ESR, CRP, and prcalcitnin) Any previus applicable vancmycin trughs Intake/Output Vital signs Vaspressr administratin (if applicable) Estimated CrCl Available micrbilgy Including vancmycin MIC if MRSA islated A brief descriptin f available and pertinent radilgy reprts and/r prcedures perfrmed Mnitring Prgress Nte: Onging mnitring prgress ntes will be written by the dsing pharmacist as indicated by change in patient status, change in renal functin, levels btained, dse adjustment, r micrbilgy updates. This nte will cntain, at minimum:

18 Any vancmycin levels btained Any current dsing changes Plan fr next trugh level Pharmacist s perceived assessment f efficacy (if cncerned) Pharmacist s perceived assessment f txicity (if cncerned) Pertinent labs (as defined abve) Updated available micrbilgy NOTE: Neither initial nr mnitring vancmycin prgress ntes need be written fr vancmycin cnsultatin invlving surgical prphylaxis fr which the anticipated duratin f therapy is 48hrs. Adverse Event Reprting: All adverse events pertaining t the administratin f vancmycin shuld be entered as an ADR ivent +/- UOR is apprpriate. Reasnable indicatins fr dcumentatin f adverse events includes: Redman s syndrme Vancmycin induced nephrtxicity (VIN) Please dcument all cases where patient is n vancmycin and SCr increases >0.5 mg/dl frm baseline r 50% frm baseline fr tw cnsecutive days as pssible VIN and reprt them t the ID Pharmacist Unexplained neutrpenia Unexplained thrmbcytpenia Extravasatin f the drug Fr all true trugh levels >25 mcg/ml resulting frm regularly scheduled vancmycin the AMS pharmacist shuld be ntified. Nephrtxicity: One f the primary txicity cncerns with regards t vancmycin has been pssible assciated nephrtxicity. Initially, the high rates f nephrtxicity were attributed t impurities in earlier frmulatins and after reslutin f this issue nephrtxicity was reprted t ccur at rates f <5%. New, mre aggressive guidelines, with regards t dsing and target trughs, were released in 2009 by the Infectius Disease Sciety f America (IDSA) and available literature since this time has reprted vancmycin induced nephrtxicity (VIN) rates as high as 43% and as lw as 5%. VIN is typically reversible. One study in adult medicine patients nted that VIN mst typically ccurred arund 2-5 days int therapy, peaked at 5-10 days, and reslved within 19 days. A meta-analysis, published in 2013, fund VIN t ccur days after the initiatin f therapy. They als fund that mst patients renal functin reslved within 7 days f discntinuatin f vancmycin and nly 3% f VIN patients were fund t require shrt-term hemdialysis. They als fund VIN t be assciated with increasing length f hspitalizatin, length f ICU stay, and verall mrtality. In the adult ppulatin risk factrs fr VIN include: Cncurrent expsure t ther knwn nephrtxins Amphtericin Aminglycsides IV cntrast Lp diuretics Piperacillin/tazbactam Adult Critical Care Admissin Vaspressr administratin Weight 101 Kg Histry f acute r chrnic kidney injury Empiric vancmycin dses >4 gm/day Prlnged curses (>5 days) Unstable renal functin Initial (within 96 hrs) vancmycin trugh cncentratin (cntrversial data) Highest incidence: >20 mcg/ml Lwest incidence: <10 mcg/ml

19 In the pediatric ppulatin VIN has been shwn t ccur at a rate f %; hwever, this data is limited t a few small studies. There is cnflicting evidence regarding whether r nt the trugh levels have an impact n the ccurrence f VIN. Risk factrs reprted in studies which have shwn t increase the risk f VIN in the pediatric ppulatin include: Lnger duratins f therapy ( 7 days) Use f extracrpreal membrane xygenatin (ECMO) Use f vaspressrs PICU admissin Cncurrent lp diuretic expsure Trugh levels >15 mcg/ml (cnflicting evidence) Patients with the abve risk factrs (bth adult and pediatric) shuld be clsely mnitred fr VIN as per the belw definitin. VIN definitin: An increase f >0.5 mg/dl (r a 50% increase frm baseline whichever is greater) in cnsecutively btained daily SCr values A drp in calculated CrCl f 50% frm baseline n tw cnsecutive days withut anther reasnable explanatin The dsing pharmacist shuld assess the renal functin f every patient receiving vancmycin daily. This evaluatin shuld include mnitring fr GFR/CrCl, SCr, BUN, and urine utput (vlume and/r dcumented unmeasured vids). Additinally, each patient s MAR shuld be mnitred daily fr the initiatin f nephrtxins (as listed abve). When the pharmacist respnsible fr the vancmycin dsing suspects VIN (as per the abve definitin) the prvider shuld be cntacted fr further instructin and the AMS pharmacist ntified. Ottxicity: Vancmycin induced ttxicity is cntrversial. N evidence f vancmycin induced hearing lss has been bserved in animal mdels and again early studies suggested that vancmycin induced ttxicity may have actually been caused by impurities in the frmulatin. These studies als suggest that there may be additive tttxicity when vancmycin is used in cnjunctin with aminglycsides. These lder studies estimate that ttxicity with vancmycin ccurs at a rate f 1-9% and crrelated mst clsely with serum vancmycin cncentratins >40 mcg/ml. Tday, the actual ccurrence f vancmycin induced hearing lss with vancmycin mntherapy is rare; hwever, data is limited after release f guidelines targeting mre aggressive trughs. Ottxicity has nt been shwn t crrelate well with serum vancmycin cncentratins. The hearing lss is characterized by the damage f the auditry nerve and is usually irreversible. It mst cmmnly presents with the lss f high-frequency tnes and/r tinnitus and then slwly prgresses t lss f mid-tne, lw-tnes, and eventual ttal deafness. Vancmycin levels need nt be mnitred t prevent ttxicity; hwever, patients receiving cncurrent aminglycsides shuld be mnitred mst clsely fr hearing lss. If the pharmacist managing the vancmycin determines that the patient is experiencing tinnitus r high frequency hearing lss the prvider shuld be cntacted fr further instructin and the AMS pharmacist ntified REFERENCES: 1. Rybak M, Lmaestr B, Rtschafer J, et al. Therapeutic mnitring f vancmycin in adult patients: A cnsensus review f the American Sciety f Health System Pharmacists, the Infectius Diseases Sciety f America, and the Sciety f Infectius Diseases Pharmacists. Am J Health-Syst Pharm. 2009;66:82-98.

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