This document is an application paper for a clinical pharmacology course that discusses vancomycin. It summarizes the role of vancomycin in treating MRSA bacteremia and outlines key aspects of vancomycin including its pharmacokinetics, potential drug interactions, adverse effects, and monitoring considerations for patients discharged home on long-term IV vancomycin therapy. The application of vancomycin monitoring and education is discussed for the clinical practice setting.

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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(61-87). NewYork City, NY: McGraw-Hill Education
• Choo, E. J., & Chambers, H. F. (2016). Treatment of methicillin-resistant Staphylococcus aureus bacteremia. Infection & Chemotherapy.
Advance online publication. doi:10.3947/ic.2016.48.4.467
• Droege, M. E.,Van Fleet, S. L., & Mueller, E.W. (2016). Application of antibiotic pharmacodynamics and dosing principles in patients with
sepsis. Critical Care Nurse, 36(2), 22-32. doi:10.4037/ccn2016881
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• Lim, H., Chong,Y. P., Noh,Y., Jung, J., & Kim,Y. S. (2014). Exploration of optimal dosing regimens of vancomycin in patients infected with
methicillin-resistant Staphylococcus aureus by modeling and simulation. Journal of Clinical Pharmacy &Therapeutics, 39(2), 196-203.
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Pharmacotherapeutics for advanced practice: A practical approach (pp. 145-152). Philadelphia, PA:Wolters Kluwer
• Naber, C. K. (2009). Staphylococcus aureus bacteremia: Epidemiology, pathophysiology, and management strategies. Clinical Infectious
Diseases, 48(Suppl 4), S231-S237. doi:10.1086/598189
• Peterson, A. M. (2017). Pharmacokinetics basis of therapeutics and pharmacodynamic principles. InV.Arcangelo, A. M. Peterson,V.Wilbur, &
J. A. Reinhold (Eds.), Pharmacotherapeutics for advanced practice: A practical approach (pp. 17-31). Philadelphia, PA:Wolters Kluwer
• 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
America, and the society of infectious diseases pharmacists. AmJ Health-Syst Pharm, 66, 82-98. doi: 10.2146/ajhp080434
• Schafer, J. J. & Foy, F. C. (2017). Bacterial infections of the skin. InV. Arcangelo, A. M. Peterson,V.Wilbur, & J. A. Reinhold (Eds.),
Pharmacotherapeutics for advanced practice: A practical approach (pp. 181-195). Philadelphia, PA:Wolters Kluwer
• 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