Professional Documents
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General information:
Physicians order "Vancomycin Protocol". This document describes the steps the pharmacy will
take to accomplish the goal of delivering the correct dose, monitoring applicable kinetic
parameters and adjusting the dose accordingly.
Physicians need to specify indications and/or target trough desired.
Input needed:
Name, Date, Account Number, age, weight, initial creatinine, ongoing aminoglycoside treatment,
diagnosis, and follow-up measurements of vancomycin level and creatinine.
Output generated:
Population parameter-based vancomycin dosing regimen
Dose and Interval for vancomycin therapy to be filled out on forms sent to nursing and the
patient chart
Special considerations:
Most conditions require only trough monitoring.
Target Trough (TABLE 1)
Infected Hardware
Diabetic Foot
Osteomyelitis Pneumonia(ventilator-
Endocarditis associated, hospital-
General +
General Pneumonia + AMG acquired, healthcare-
AMG
Severe Infections associated)
Community acquired Meningitis
pneumonia
Leukemia
Target Trough 5 – 15 5 - 10 10 - 15 15 - 20
AMG = Aminoglycoside
Exclusions:
Renal failure or rapidly changing renal function (these conditions require physicians to write
custom orders or request assistance for kinetic dosing):
creatinine clearance less than 10
ongoing dialysis treatments
Determination of initial dose:
Initial Dosing (based on actual body weight, round to the nearest 100mg)
Reduce dose by 250mg for weight over 120kg
Reduce dose by 500mg for weight over 200kg
Maximum dose 3000mg
Target trough 5 – 10: Dose = 15 mg/kg
Target trough 10 – 15: Dose = 18 mg/kg
Target trough 15 – 20: Dose = 20 mg/kg
Suspected Meningitis: Initial Dose 30 mg/kg, do 1st dose kinetics to determine subsequent
dose and interval
Set subsequent doses for peak of ~ 40 and trough of ~ 20 (Q8hr interval if needed).
Estimate Creatinine Clearance (CrCl): for patients with stable renal function ONLY
(recorded on log sheet)
-Males: CrCl (ml/min) = [(140-age)(IBW)] [(serum creatinine) x72]
-Females: CrCl (ml/min) = CrCl (males) x 0.85
-A minimum SCr value of 1mg/dL should be used for elderly or malnourished patients
i.e. if their measured value is < 1mg/dl) to prevent overestimating CrCl.
***For Q36H, Q48H: one dose only, then 1st dose kinetics ***
A. General information:
- Designed to achieve peak vancomycin levels in the range of 20 - 40 mcg/ml.
- Measurements of peak levels are not needed for this protocol.
- Use table 4 for dose adjustment once the trough level is available
Trough > 5 below 1-5 below At Goal 1-5 above 6-10 above > 10 above goal
goal goal goal goal
Q12H Dose Dose No D Interval to D Interval to Hold further dosing,
500mg 250mg change Q18H Q24H redraw level at 24
hours
Q18H D interval D Interval No D Interval to D Interval to Hold further dosing,
to Q12H to Q12H change Q24 Q36- Obtain redraw level at 36
and dose trough before hours
250mg 2nd dose
Q24H D interval D Interval No D Interval to D Interval to Hold further dosing,
to Q12H to Q18H change Q36 –Obtain Q48 – Obtain redraw level at 48
trough before trough before hours
2nd dose 2nd dose
Q36H D interval D Interval No D Interval to Hold further Dose by levels,
to Q18H to Q24H change Q48 –Obtain dosing, inform MD
before 2nd Redraw level
dose at 72 hours
Q48H D interval D Interval No Decrease Dose by Dose by levels,
to Q24H to Q36H change dose 250mg levels, inform inform MD
MD
*** If trough < 4 –8 x MIC use kinetic software to target trough in the range of 4 –8 x MIC ***