Vancomycin MRSA Bactermia

1. Application Paper
Ada Amaya
Lamar University
MSNC 5356 Clinical Approach to Advanced Pharmacology
Dr. Elizabeth Long

2. Drug Chosen:Vancomycin
• Nurse Patient Educator Role
• Teach patients being discharged home on long-term intravenous (IV) therapy
• Commonly prescribed IV antibiotics in acute care setting include: cefazolin,
ceftriaxone, ciprofloxacin, ertapenem, and vancomycin
• Vancomycin
• Drug of choice to treat methicillin-resistant Staphylococcus aureus (MRSA) infections
• IV vancomycin utilized to treat MRSA bacteremia in the acute care setting and
potentially continued at home

3. Pathophysiological ConditionTreated:
MRSA Bacteremia
• S. aureus repeals methicillin’s therapeutic effects
• Encodes penicillin-binding protein 2a with mec gene
• Imparts resistance with fem gene
• Teichoic acid, a polymer on exterior, empowers pathogen to adhere and colonize to its
host causing severe infections (e.g. bloodstream)
• Secretes exfoliative toxins, hemolysins, and several enzymes to invade tissue

4. Intended Drug Response
• Vancomycin
• Tricyclic glycopeptide agent
• Treats gram-positive infections (e.g. MRSA)
• Bactericidal cell wall-active antibiotic
• Inhibits binding of the D-alanyl-D-alanine portion
• Interferes with polymerization and cross-linking of peptidoglycan
• Changes permeability of bacterial cell membrane and ribonucleic acid (RNA) synthesis

5. Potential Interactions
• Aminoglycosides
• Gentamicin, tobramycin, and amikacin
• Augment nephrotoxic effects
• Non-steroidal anti-inflammatory drugs
• Increase the serum concentration of vancomycin
• Neuromuscular blocking agents—extreme caution
• Rapacuronium and succinylcholine
• Cause neurotoxicity

6. Adverse Drug Reactions
• Cardiovascular system: severe hypotension and cardiac arrest
• Skin: drug-induced erythroderma or red man syndrome (characterized by
flushing of the face, neck, and upper torso); phlebitis
• Hematological (rare): neutropenia, thrombocytopenia, and eosinophilia
• Other: ototoxicity, nephrotoxicity, and interstitial nephritis

7. Side Effects
• Flu-like signs and symptoms
• Chills, fever, and sore throat
• Wheezing and chest tightness
• Rash, hives, and itching
• Painful urination and changes in hearing

8. Pharmacokinetics:Vancomycin
• Slow bactericidal and time-dependent antimicrobial killing agent
• Absorption: 60% intra-parenteral
• Peaks immediately after infusion completion
• Trough best drawn 30 minutes before the 4th dose
• Target trough 15 to 20 mg/L in complicated infections (e.g. MRSA bacteremia)
• Distribution: fairly well in the urine, skin, and soft tissues; poor penetration to deeper
tissues (e.g. lung and cerebrospinal fluid)
• 55% protein bound
• Volume of distribution: not available.
• Metabolism: no apparent action
• Excretion: occurs via kidney by glomerular filtration
• Within the first 24 hours, about 75% of the administered dose is excreted in urine
• Half-life: 4-6 hours; 7.5 days with end-stage renal disease
• Steady state: approximately occurs prior to fourth or fifth dose

9. Drug Binding Issues
• Literature is scarce
• Protein binding for vancomycin ~55%
• Mainly binds to albumin
• Albumin infusion
• Increases vancomycin binding
• Elevate serum concentration of drug
• Pharmacodynamic response is overstressed leading to toxic levels

10. Improving Communication
• Collaboration with pharmacist
• Presentation for new intern/resident doctors during orientation
• Pharmacist consult
• Vancomycin in-service
• Inform nursing staff during monthly meeting
• Plan with unit manager
• Bridge patient to the outpatient
• Referral to outpatient nurse case manager
• Lab and ID follow-up appointments

11. Application to the Practice Setting
• Therapeutic drug monitoring for agent vancomycin
• Nursing aware patients’ physiological alterations require higher doses of antibiotic
• Diligently monitor trough, creatinine levels, and intake/output
• Emergence of MRSA strains cause safety hazard as vancomycin’s dosing is adjusted to
effectively attack organisms at source of infection
• Inform patient of potential ADRs and side effects that may occur with vancomycin
• During administration, careful monitoring for previously mentioned ADRs and side effects is warranted
• Accurately drug monitor serum concentrations throughout therapy and stop the medication when levels are
toxic before permanent injury occurs
• ID consultation complete
• Review electronic medical record (e.g. ID recommendations, trough)
• Central line access for IV vancomycin administration
• Collaborate with clinical nurse case manager to ensure patient will have home health set-up to
reinforce teaching
• Emphasize importance of obtaining vancomycin trough at precise time
• Appointment at nearest Harris Health clinic for patient’s convenience

12. References
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• Droege, M. E.,Van Fleet, S. L., & Mueller, E.W. (2016). Application of antibiotic pharmacodynamics and dosing principles in patients with
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• Rybak, M., Lomaestro, B., Rotschafer, J. C., Moellering, R., Craig,W., Billeter, M., . . . Levine, D. P. (2009).Therapeutic monitoring of
vancomycin in adult patients: A consensus review of the American society of health-system pharmacists, the infectious diseases society of
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• Schafer, J. J. & Foy, F. C. (2017). Bacterial infections of the skin. InV. Arcangelo, A. M. Peterson,V.Wilbur, & J. A. Reinhold (Eds.),
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• Uribe, L. M. (2016).Vancomycin (vancocin). CINAHL Nursing Guide. Retrieved from
http://web.b.ebscohost.com/nup/pdfviewer/pdfviewer?vid=7&sid=1c651e2e-884a-402b-8287-3098d19ddfd6%40pdc-v-sessmgr01