1. Continuous Infusion Vancomycin Pharmacist Education

2. Purpose Continuous infusion vancomycin is a way to optimize dosing of vancomycin to overcome limitations with the current dosing strategy. The purpose of this dosing strategy is to achieve goal levels more efficiently and accurately in patients with the potential to minimize nephrotoxicity. Vancomycin will be infused continuously until therapy is discontinued or patient is transferred out of the Intensive Care Unit (ICU) or the Coronary Care Unit (CCU).

3. Pros Reaching Goal AUC/MIC faster with less variability than traditional dosing Clearer interpretation of concentration Same or less nephrotoxicity Decrease cost of vancomycin (less bags being sent up) Total exposure is the same between continuous infusion and traditional dosing

4. Cons Dedicated line for continuous infusion Compatibilities at the y-site

5. Inclusion All ICU and CCU patients (with anticipated stay of ≥48hrs within unit) Patients ≥18 years old Patients with creatinine clearance (CrCl) ≥20ml/min Patients with a dedicated line for vancomycin infusion **Make sure you communicate with the nurse about starting Continuous infusion vancomycin

6. Exclusion Patients weighing ≥ 150 Kg Pregnant patients Patients on CRRT <24 hours (SCUF, SLEDD, CVVH, CVVHD, CAVH, CAVHD), intermittent hemodialysis, and peritoneal dialysis patients Neurosurgical patients receiving prophylactic vancomycin

7. Loading Dose Weight (kg)Dose (mg)Infusion time (hours) <64 kg1000 mg X 11.5 hrs 65 kg – 89 kg1500 mg X 12.5 hrs >90 kg2000 mg X 13.3 hrs Loading Dose based on Total Body Weight (TBW) Everyone gets a loading dose

8. Empiric Dosing Use total body weight for all calculations unless TBW >120% of ideal body weight, then use Adjusted body weight Using CrCl follow table. CrCl (ml/min)Total daily dose >9035-40 mg/kg/day 60-8930-35 mg/kg/day 40-5920-30 mg/kg/day 20-3915-20 mg/kg/day

9. Calculating Rate

10. Entering Orders Loading Dose Same as current practice Continuous infusion CPOE order as continuous infusion Order it in mg/hr Shows up under continuous infusions not medication list in CPOE Order Concentrations 1 st and 2 nd HMM entry Protocol for Continuous infusion: standard bag size 3000mg / 500ml NS

11. Target Concentrations

12. Ordering Concentrations Order Vancomycin Random in Portal Concentration 1: 20-30 hours after the start of infusion; preferably on day shift Concentration 2: CrCl >50ml/min ~48 hours with AM labs CrCl <50ml/min ~ 72 hours with AM labs Additional concentrations If Concentration 2 required dose adjustment recheck random in 48 hours with AM labs If 2 concentrations were within therapeutic range then wait 3 – 5 days for more labs

13. Concentration interpretation

14. Dose Adjusting to 25mg/L

15. Dose adjustments Discontinue the existing order in portal Enter new order with new rate (mg/hr) HMM entry Do not dispense another bag unless bag is almost empty MD to RN message alerting nurse to change rate (mg/hr)

16. Transferring Patients Continuous infusion vancomycin is to only be used in ICU/CCU patients Nurse to alert pharmacist if patient is about to transfer Transfer DirectionAction Floor to ICU/CCUAt goal troughs for infectionUse patient current mg/kg/day requirement and infuse over 24 hours Not at goal trough for infectionUse empiric dosing guidelines for continuous infusion ICU/CCU to FloorAt goal CssUse current mg/kg/day requirement and convert to most convenient intermittent dosing schedule (such as q24hr, q12hr, q8hr) Not at goal CssRefer to intermittent dosing guidelines to begin dosing

17. Administration/ Preparing Does patient have dedicated line Check compatibilities at the y-site Do not recommend adding another line for just vancomycin Standard Bag the IV room will make: 3000mg / 500ml sodium chloride (6mg/ml) Beyond use dating 48 hours

18. Questions? If anything is unclear or need to talk through it call James #2694 Jesse Bonnie