Vancomycin Backaround Vancomycin is a tricyclic glycopeptide antibiotic most commonly utilized for the treatment of mult

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Vancomycin Backaround Vancomycin is a tricyclic glycopeptide antibiotic most commonly utilized for the treatment of multi-drug resistant Gram- bacterial infections (0.9 MRSA, penicillin resistant Streptococcus pneumoniae, and penicillin resistant Enterococcus). It inhibits bacterial cell wall synthesis and is categorized as a *concentration Independent killing antibiotic. Therefore, as opposed to aminoglycoside antibiotics increasing antibiotic concentrations beyond the therapeutic threshold will not result in faster killing or eliminate a larger portion of the bacterial population Pharmacokinetic/Pharmacodynamic (PKIPD) Parameters Absorption Oral absorption is negligible; however, it does concentrate at high levels in the colon (for treatment of C. difficile). Distribution Widely distributed into the body tissues except the CSE Penetration into the CSF is enhanced with inflamed meninges (e.g. meningitis). Other areas with only moderate penetration are the pulmonary tissue and bone o Volume of distribution = 0.7 L/kg (range 0.5-1.0) of total body weight and does not significantly change for most conditions Elimination - When given intravenously, primarily excreted via the kidneys. Elimination hallife is 4-6 hours in those with normal renal function and is prolonged in patients with renal insufficiency. Concentration-Efficacy Relationship O Multiple therapeutic parameters have been proposed as the appropriate value for which to predict vancomycin efficacy and/or toxicity. With respect to efficacy, these parameters include: peak/MIC ratio, AUC/MIC ratio, and the time vancomycin concentration remains above an organism's Mic during a dosing interval The area under the curve (AUC) over 24 hours to minimum inhibitory concentration (MIC) ratio (AUC/MIC) has been documented as the primary PK/PD target for vancomycin. 2009 vancomycin dosing guidelines stated AUC/MIC ratio is the preferred parameter that correlates best with therapeutic outcomes. However, the ability to obtain the values necessary for this calculation have been challenging in the clinical setting in the past. Not all hospitals have the ability to obtain true MIC values for S. aureus and obtaining multiple vancomycin concentrations to determine the true AUC value is not always practical. As a result, trough serum levels have been utilized as surrogate markers for the AUC based up, on literature support. Also, in the absence of vancomycin MIC values, AUC/MIC calculations will be extrapolated utilizing average MIC values reported in current literature (ie. MIC of 1) Optimal concentrations Troughs, AUC, and Resistance Recent investigations have found that exposures to suboptimal vancomycin concentrations can not only lead to failures of therapy, but also lead to increased S. aureus MIC values and possible resistance. Mostly demonstrated in in vitro studies, but also seen clinically, the development of resistance has been associated with serum trough concentrations < 10 mcg/mL, AUC <400 mgh. For this reason, it will be the goal to maintain vancomycin trough levels > 10 mcg/mL and AUC >400 mgh. . Therapeutic Plasma Concentrations Peak 25-40, trough: 10-20 (trough goal dependent upon Infectious indication), o Update: 2020 vancomycin dosing guidelines - AUC 400 to 600 mgh/L for invasive MRSA infections Exceptions: CNS infections and mild/non-invasive infections (SSTIS, UTIS) 1
Patient Care Skills Lab TV-Sterile Process AUC targets should be achieved early in the course of therapy (24 48 hours) given the importance of early and appropriate therapy . Dosing Loading doses: Rapidly achieve targeted ranges of serum vancomycin concentrations and decreases the risk of under dosing during the initial days of therapy. Weight based dosing is preferred: 20mg/kg of actual body weight (25mg/kg in severe or life threatening infections due to MRSA) Cap at 3000mg in obese patients Suggested for patients who are critically ill or in the ICU, requiring renal replacement therapy, or receiving continuous Infusion therapy Specific recommendations for patients with obesity, patients on renal replacement therapy, and pediatric patients are now included in the revised guidelines D Maintenance doses: 1: Vancomycin Empiric Dosing Equations o 1. Calculate ideal body weight (IBW): IBW (males): 50+ (2.3 x number of inches above 60) 0 IBW (females): 45.5+ (2.3 x number of inches above 60) 2. Is the patient obese (i.e. is the TBW >120% above IBW)? If yes, calculate adjusted body weight (AdBW): AdjBW = [(TBW-IBW) x 0.4] + IBW TBW = total (actual) body weight 0 3. Calculate creatinine clearance (CICL) using Cockroft-Gault equation CrcL = (140-age) x IBW (0.85 if female) IBW = ideal body weight (72 x SCP) SCr= serum creatinine *Use AdBwITBW > 120% above IBW; use TBW i TBW <BW
drug no. Ус your dr cts your that yo to ind Patient Care Skills Lab I - Sterile Products their Toxicity Historically, adverse events associated with vancomycin were related to impunities in the manufacturing process. Since these early formulations, product purity has improved and subsequent reporting of toxicity has decreased. The nephrotoxic potential of vancomycin is reported to be s 5%. In one of the largest investigations to date. Pestotnik et al reported that the incidence of nephrotoxicity among 1750 patients was 1.4% In light of more recent recommendations for aggressive vancomycin dosing strategies, studies have attempted to assess the impact of high doses or elevated trough concentrations on renal toxicity. Although several of these studies have correlated high doses > 4 grams/day) or elevated troughs (15- 20 mog/ml) with a higher incidence of nephrotoxicity, most investigations are limited by small sample sizes and confounding variables. Despite these limitations, monitoring for nephrotoxicity in patients receiving aggressive vancomycin dosing will be standard procedure until more conclusive study results are reported Vancomycin will increase the nephrotoxic potential of other medications, including aminoglycosides when they are administered in combination Both animal and human studies have concluded that vancomycin may increase the nephrotoxicity of aminoglycosides 3-4-fold. With respect to ototoxicity, the overall incidence appears to be low. There are clinical cases reported in the literature of vancomycin induced ototoxicity, but there are no clinical trials available in animals or humans) that have demonstrated this relationship Monitoring: Order peak (1-2 hrs post the end of infusion) and trough (within 30 minutes before next scheduled dose) within 48 hours in patients with normal renal function After achieving 2-3 therapeutic levels on a consistent dosing regimen, once weekly trough level monitoring is reasonable in patients with stable renal function and clinical status, including HD Monitor more frequently in patients with changing renal functions or concurrent use of nephrotoxic antimicrobials Monitor Sor closely. Alterations in serum creatinine may lag several days behind actual changes in GFR. Changes in total daily UOP or hourly UOP (when available) can be more immediate Indicators of fluctuating GFR Normal UOP is anywhere from 1-2L/day (-0.5ml/kg/hour) in adults Monitor CBCs, cultures, administration times, concurrent antimicrobials, and infection indicators daily as available. O O Non AUC based dosing For patients who cannot be dosed using the AUC based dosing methods (CNS infections, non-invasive MRSA infections, infections caused by organisms other than MRSA, etc), traditional trough based dosing strategy should be utilized. The dosing table provided below as an example would be for less severe infections (.e. skin & soft tissue infections, cellulitis) as the nomogram indicates a lower trough goal (10-15 mg/L) to provide a clinician an approximate dose based on the patient's estimated creatinine clearance and actual body weight 3
you drawn prod: th Patient Care Skills Lab IV-Sterile prezi s 49-40 750 mg Actual BW Q24H 50-59 kg 1000 mg 1000 mg 60-69 kg 024H >100 1000 mg Q12H 1000 mg Q12H 1250 mg Q12H 1500 mg Q12H Vancomycin Nomogram for Goal Trough 10-15 mg/l CrCl (min) 59-50 69-60 79-70 89-80 99-90 500 mg 1250 mg 500 mg 750 mg 750 mg Q24H Q12H Q12H Q12H Q12H 500 mg 1250 mg 750 mg 750 mg Q24H Q12H Q12H Q12H Q12H 1500 mg 1250 mg 750 mg 750 mg Q24H Q12H Q12H Q12H Q12H 1250 mg 1000 mg 1750 mg 1750 mg Q12H 024H Q24H Q12H 012H 1000 mg 1750 mg 1750 mg Q12H Q12H Q12H Q18H Q24H 1250 mg 1750 mg 1750 mg Q12H Q12H Q12H Q18H Q24H 1250 mg 70-79 kg 1000 mg Q24H 1500 mg 80-89 kg 1250 mg Q24H 1750 mg 90-99 kg 1500 mg 1250 mg Q24H 1500 mg Q12H 1750 mg Q12H 1750 mg >100kg 1500 mg 1500 mg Q24H Administration: Administer vancomycin in an IV solution such as 0,9% normal saline or 5% dextrose in water (ex. concentrations of no more than 5 mg/mL) Infuse vancomycin over a period of no less than 60 minutes or at a rate of 10 to 15 mg/min o 10mg/min or less associated with fewer Infusion related side effects Vancomycin is dosed in increments of 250mg (.e., 750 mg, 1000 mg, 1250 mg, 1500 mg. 1750 mg, 2000 mg) It should be noted that almost all data available on vancomycin PK/PD and toxicodynamics have been derived from patients who have been treated for serious infections of MRSA. Furthermore, the majority of the data have been derived from patients with complicated bloodstream infections. Therefore, caution should be applied when extrapolating this information to mild noninvasive infections or other bacterial species susceptible to vancomycin. These guidelines conclude that AUC-guided dosing and monitoring is the most accurate and safest way to dose vancomycin. The recommendations in this document should not circumvent sound clinical judgment in managing patients who require vancomycin therapy. Specific details for each section of the document, including references, can be found in the primary publication [1]
Products merom Patient Care Skills Lab IV: Vancomycin of Spor ipine, He land this is in ech Student Name: w wore Valsy Date: 1. KL is a 61-year-old, 104.5-kg (height 5ft 6 in) fernale with MRSA bacteremia and cellulitis. Her current serum creatinine is 1.0 mg/dL, and it has been stable since admission. Calculate a loading and maintenance vancomycin dose and frequency for this patient. duet, per nected ther But a) Calculate KL's Ideal Body Weight: kg b) Calculate KL's Adjusted Body Weight: kg c) Calculate KL's Est. Creatinine Clearance: mL/min d) Vancomycin loading dose: _mg (round to the nearest 250mg) e) Vancomycin maintenance dose and frequency: Use nomogram below. mg (round to the nearest 250mg) every hours 2. A trough vancomycin level prior to the 4 dose was reported back on Ms. KL as being 18 mg/L. a. Does Ms. KL's vancomycin dose regimen need to be adjusted? b. if so, how should Ms. KL's vancomycin regimen be adjusted? 3. What type of IV bag can be used to make vancomycin? Select all that apply. a. Normal Saline b. Dextrose 5% in water c. Sterile water d. Other:
Patient Care Skills Lab IV: Vancomycin 4. What size IV bag can be used to make this dose of vancomycin? Select all that apply. (HINT: review the maximum final concentration of vancomycin) a. 50 ml b. 100 mL c. 250 ml d. 500 ml 5. KL's renal function after a few days of receiving vancomycin started to worsen and her now estimated creatinine clearance is 55 mL/min. What dose would she receive, and what size bag should be used when compounding? (Refer to the nomogram) MAKE THIS PRODUCT (HINT: review the maximum final concentration of vancomycin) 750 mg 500 mg 750 mg 750 mg Vancomycin Nomogram for Goal Trough 10-15 mg/L CrCL (mmin) Actual BW 99-90 89-80 >100 79-70 69-60 59-50 49-40 1000 750 mg 500 mg 50-59 kg 1250 mg 750 mg Q12H Q12H Q12H mg Q12H Q24H Q24H Q12H 60-69 kg 1000 1000 mg 750 mg 750 mg 500 mg 1250 mg 1000 mg mg Q12H Q12H Q12H Q12H Q24H Q24H Q12H 70-79 kg 1250 1250 mg 1000 mg 1500 mg 1250 mg mg Q12H Q12H Q12H Q12H Q24H Q24H Q12H 80-89 kg 1500 1250 mg 1250 mg 1000 mg 1750 mg 1750 mg 1500 mg mg Q12H Q12H Q12H Q24H Q24H Q24H Q12H 1500 1500 mg 1250 mg 1000 mg 1750 mg 1750 mg 1750 mg mg Q12H Q12H Q12H Q18H Q24H Q24H Q12H >100kg 1750 1500 mg 1500 mg 1250 mg 1750 mg 1750 mg mg Q12H Q12H Q12H Q18H Q24H Q24H Q12H 90-99 kg 1750 mg
Patient Care Skills Lab IV: Vancomycin apply Actual BW mg Q18H Vancomycin Nomogram for Goal Trough 15-20 mg/L CrCL (mmin) >100 99-90 89-80 79-70 69-60 59-50 49-40 50-59 kg 1250 1000 1000 750 mg 750 mg 1000 1250 mg mg mg mg Q12H Q12H mg Q24H Q12H Q12H Q12H Q18H 60-69 kg 1250 1250 1250 1000 mg 750 mg 1250 1250 mg mg Q12H mg Q24H Q12H mg Q12H Q12H Q12H 1000 mg 70-79 kg 1500 1500 1250 1000 1000 mg mg mg mg Q12H mg Q12H Q12H Q12H Q12H 1250 mg 80-89 kg 1750 1750 1500 1250 mg Q12H mg mg mg Q18H Q12H Q12H Q12H 1750 mg 90-99 kg 1750 1750 1750 1500 mg Q24H mg mg mg mg Q12H Q12H Q12H 1500 mg 1250 1500 mg 1750 1750 1750 >100kg Q12H mg Q12H Q12H Q12H Q12H Q1BH 1250 mg Q18H 1500 mg Q18H 1000 mg Q12H 1000 Q12H Q12H 1000 mg Q12H 1000 mg Q18H mg mg Q12H mg