From the Guidelines
I strongly recommend stopping the vancomycin infusion immediately due to the elevated trough level of 24.9 mg/L, which indicates potential toxicity. The patient's vancomycin trough level is above the recommended range of 15-20 mg/L for trough serum vancomycin concentrations, as suggested by the Infectious Diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists 1.
Given the patient received a dose at 2100 and another infusion was started at 0513 despite the high trough at 0454, there is a significant risk of accumulation and worsening toxicity. The guidelines recommend measuring at least 1 steady-state trough serum concentration just before the fourth dose for patients receiving prolonged courses of vancomycin treatment, but in this case, the high trough level necessitates immediate action to prevent potential harm 1.
Key considerations include:
- Monitoring the patient's renal function closely, including BUN and creatinine levels
- Watching for signs of ototoxicity such as hearing loss or tinnitus
- Documenting the error in the patient's chart and completing an incident report according to the facility's protocol
- Obtaining a repeat vancomycin level before resuming therapy
- Adjusting the dosing regimen based on the patient's renal function and clinical status, considering alternative therapies if necessary, especially if the vancomycin MIC is 2 mg/L or higher, as achieving a targeted AUC/MIC of 1400 may not be possible with conventional dosing methods 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Vancomycin Trough Levels and Nephrotoxicity
- The patient's vancomycin trough level was 24.9 at 0454, which is above the widely accepted range of 5 to 10 mg/L 2.
- A new bag of vancomycin was started at 0513, which may lead to further elevated trough levels and increase the risk of nephrotoxicity.
- The patient had vancomycin earlier in the day at 2100, which may also contribute to the elevated trough level.
Risk Factors for Nephrotoxicity
- Elevated vancomycin trough concentrations (> 20 μg/mL) are associated with an increased risk of nephrotoxicity 3.
- Concomitant use of renal hypoperfusion medications, such as loop/thiazide diuretics, may also increase the risk of nephrotoxicity 3.
- The patient's trough level of 24.9 is above the threshold for increased risk of nephrotoxicity.
Monitoring and Management
- Regular monitoring of vancomycin trough levels is essential to minimize the risk of nephrotoxicity 2, 4.
- Adjusting the vancomycin dose based on trough levels and renal function may help prevent nephrotoxicity 5.
- Close monitoring of renal function and audiometry may be necessary to detect any potential toxicity 2, 6.