C3.1 R4(e): Perform & document a vancomycin or aminoglycoside pharmacokinetic interpretation

Patient’s Vancomycin Doses:

Dose # of Doses Prior to Level Level
1g IV Q12H 5 24.3 (High)
750mg IV Q24H 2 15.3
  • Aspirate from L shoulder: MRSA +
  • Challenging to obtain information from patient (e.g. wasn’t able to ask about side effects like sxs of ototoxicity). Patient is mostly in bed, but appears to be improving.

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Clinical Pharmacy Note: Re: Vancomycin

s/0 77 yo male with MRSA septic arthritis L shoulder. Target vanco should be: 15-20mg/L.

vanco to 750mg Q24H since Jun 19. Vanco level at 2147 on Jun 21: 15.3 mg/L

eGFR~ 89, stable for last few days.
Jun 21 – WBC: 10.3, CRPH 57.7 ↑
Jun 22 – 36.8oC T, BP 130/87, HR 87

Pain was worse last night (pt crying), as per nurse. Settled with PRN hydromorphone dose. No complaints of pain today. Swelling same as yesterday, as per nurse.

A

  1. Septic arthritis appropriately treated with vancomycin for MRSA.
  2. Level is drawn appropriately at steady state and is within target.
  3. Renal function stable
  4. All doses charted as given.

P

  1. Continue vancomycin 750mg IV Q24H
  2. Awaiting ID consult to determine duration of tx.
  3. If prolonged duration, weekly vanco level
  4. Monitor renal function 3 times a week.
  5. Monitor s/s of septic arthritis (pain, swelling, mobility), WBC, CRPH, vital signs. If clinically worsening, increase vanco monitoring and R/A.

Order:

  • Continue vancomycin IV with no stop date. Awaiting ID consult RE: duration of treatment.
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