THERAPEUTIC DRUG MONITORING

Vancomycin serum levels should be ordered in the following situations:

1.      Pre-vancomycin level on 3^rd or 4^th dose (within 48 hours) if:

·        a higher level of 15-20 mg/L is desired  OR

·        patient is at risk for accumulation (e.g. Q8H interval) OR

·        patient is receiving other nephrotoxic agents OR

·        serum creatinine is above normal, renal function is changing or uncertain OR

·        patient is obese (>125% IBW), pregnant, pediatric or hypermetabolic (e.g. burn patient, cystic fibrosis)

Repeat at least weekly to ensure pre-vancomycin level is within desired therapeutic range

2.      Pre-vancomycin level after 7 days of therapy (for prolonged course) if aiming for levels < 15 mg/L AND no other risk factors as per above

3.      Pre-vancomycin level if patient is not responding to therapy

4.   Pre- and 3 hour post-vancomycin level (target 20-40 mg/L) if calculation of precise kinetic parameters are necessary (e.g. in a case when a target pre-vancomycin level of 15-20 mg/L cannot be achieved while on prolonged therapy, or in an obese, pregnant or pediatric patient, especially when aggressive dosing is required