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Applied Clinical Pharmacokinetics, 3e

5: Vancomycin

PROBLEMS
The following problems are intended to emphasize the computation of initial and individualized doses using clinical pharmacokinetic techniques.
Clinicians should always consult the patient’s chart to confirm that antibiotic therapy is appropriate for current microbiologic cultures and
sensitivities. Also, it should be confirmed that the patient is receiving other appropriate concurrent antibiotic therapy, such as aminoglycoside
antibiotics, when necessary to treat the infection.

1. KI is a 75yearold, 62kg (5 ft 9 in) male with S. epidermidis sepsis. His current serum creatinine is 1.3 mg/dL, and it has been stable since
admission. Compute a vancomycin dose for this patient to provide a steadystate peak concentration of 40 μg/mL and a steadystate
trough concentration of 15 μg/mL.

2. Patient KI (see problem 1) was prescribed vancomycin 1000 mg every 36 hours. Steadystate vancomycin concentrations were obtained before and
after the fourth dose, and the peak concentration (obtained ½ hour after a 1hour infusion of vancomycin) was 34 μg/mL while the trough
concentration (obtained immediately before dosage administration) was 2.5 μg/mL. Compute a revised vancomycin dose for this patient to
provide a steadystate peak concentration of 48 μg/mL and a steadystate trough concentration of 17 μg/mL.

3. HT is a 35yearold, 75kg (5 ft 7 in) female with an MRSA wound infection and chronic renal failure. Her current serum creatinine is 3.7 mg/dL, and
it has been stable since admission. Compute a vancomycin dose for this patient to provide a steadystate peak concentration of 45 μg/mL and a
steadystate trough concentration of 15 μg/mL.

4. Patient HT (see problem 3) was prescribed vancomycin 1200 mg every 48 hours. Steadystate vancomycin concentrations were obtained before and
after the fourth dose, and the peak concentration (obtained ½ hour after a 1hour infusion of vancomycin) was 60 μg/mL while the trough
concentration (obtained within ½ hour before dosage administration) was 24 μg/mL. Compute a revised vancomycin dose for this patient to
provide a steadystate peak concentration of 40 μg/mL and a steadystate trough concentration of 20 μg/mL.

5. LK is a 55yearold, 140kg (5 ft 8 in) male with an MSSA wound infection (MIC = 0.5 μg/mL). His current serum creatinine is 0.9 mg/dL, and it has been
stable since admission. Compute a vancomycin dose for this patient to provide a steadystate peak concentration of 45 μg/mL and a steady
state trough concentration of 20 μg/mL.

6. Patient LK (see problem 5) was prescribed vancomycin 1000 mg every 8 hours. Steadystate vancomycin concentrations were obtained before and
after the fourth dose, and the peak concentration (obtained ½ hour after a 1hour infusion of vancomycin) was 42 μg/mL while the trough
concentration (obtained within ½ hour before dosage administration) was 18 μg/mL. Compute a revised vancomycin dose for this patient to
provide a steadystate peak concentration of 40 μg/mL and a steadystate trough concentration of 10 μg/mL.

7. AF is a 45yearold, 140kg (5 ft 2 in) female with a S. viridans endocarditis who is allergic to penicillins and cephalosporins. Her current serum
creatinine is 2.4 mg/dL and is stable. Compute a vancomycin dose for this patient to provide a steadystate peak concentration of 40 μg/mL,
and a steadystate trough concentration of 12 μg/mL.

8. Patient AF (see problem 7) was prescribed 1300 mg every 24 hours. Steadystate vancomycin concentrations were obtained before and after the
fourth dose, and the peak concentration (obtained ½ hour after a 1hour infusion of vancomycin) was 30 μg/mL while the trough concentration
(obtained within ½ hour before dosage administration) was 2.5 μg/mL. Compute a revised vancomycin dose for this patient to provide a
steady state peak concentration of 40 μg/mL and a steadystate trough concentration of 12 μg/mL.

9. DG is a 66yearold, 65kg (5 ft 5 in) female with an MRSA sternal osteomyelitis secondary to coronary artery bypass graft (CABG) surgery. Her current
serum creatinine is 1.4 mg/dL and stable. Compute a vancomycin dose for this patient to provide a steadystate peak concentration of 50
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μg/mL, and a steadystate trough concentration of 20 μg/mL.

10. Patient DG (see problem 9) was prescribed 1200 mg every 36 hours. Steadystate vancomycin concentrations were obtained before and after the
fifth dose, and the peak concentration (obtained ½ hour after a 1hour infusion of vancomycin) was 30 μg/mL while the trough concentration
(obtained within ½ hour before dosage administration) was 12 μg/mL. Compute a revised vancomycin dose for this patient to provide a
steady state trough concentration of 15 μg/mL.

11. GG is a 27yearold, 85kg (6 ft 2 in) male trauma patient with a penicillinresistant enterococcal pneumonia and is currently on a respirator. He
sustained multiple injuries secondary to a motor vehicle accident 2 weeks ago and lost a large amount of blood at the accident site. He
developed acute renal failure due to prolonged hypotension and poor perfusion of his kidneys (current postdialysis serum creatinine is 5.3
mg/dL). He is currently receiving hemodialysis on Mondays, Wednesdays, and Fridays from 0800 to 1200 H, using a lowflux dialysis filter.
Recommend a vancomycin dosage regimen that will achieve peak concentrations of 40 μg/mL and trough concentrations of 20 μg/mL. The first
dose of the regimen will be given immediately after hemodialysis is finished on Wednesday at 1200 H.

12. Patient GG (see problem 11) was prescribed 1600 mg loading dose on Wednesday at 1200 H, and following serum concentrations were obtained:

Date/Time Description Concentration (lg/mL)

Friday at 0800 H Predialysis 20

Monday at 0800 H Predialysis 12.1

Use these serum concentrations to compute the patient’s own pharmacokinetic parameters for vancomycin and a new dosage schedule that will
achieve peak concentrations of 45 μg/mL and trough concentrations of 20 μg/mL.

13. FD is a 67yearold, 60kg (5 ft 2 in) female with a serum creatinine equal to 1.8 mg/dL placed on vancomycin for a postsurgical brain abscess. The
prescribed dose was vancomycin 900 mg every 12 hours (infused over 1 hour), and two doses have been given at 0800 and 2000 hours. A trough
concentration of 20 μg/mL was obtained at 0730 hours the next morning (½ hour before the third dose). Compute the dose to give Cssmax =
40
μg/mL and Cssmin = 15 μg/mL.

14. OI is a 52yearold, 87kg (6 ft 2 in) male with postoperative S. epidermidis septic arthritis. His current serum creatinine is 1.4 mg/dL and stable.
Nine hours after the second dose of vancomycin 1000 mg every 12 hours, a vancomycin serum concentration equal to 20 μg/mL is measured.
Compute a revised vancomycin dose for this patient to provide steadystate peak concentrations equal to 30 μg/mL and steadystate trough
concentrations of 15 μg/mL.

15. HY is a 45yearold, 65kg (5 ft 4 in) female bone marrow transplant recipient who develops MRSA sepsis. Her current serum creatinine is 1.1 mg/dL.
She is administered vancomycin 750 mg every 12 hours. A vancomycin serum concentration was obtained 5 hours after the first dose and equaled
15 μg/mL. Compute a revised vancomycin dose for this patient to provide steadystate peak concentrations equal to 40 μg/mL and steadystate
trough concentrations of 20 μg/mL.

16. OF is a 9dayold, 1550g female premature infant (GA ∼27 weeks) with a wound infection. Her serum creatinine equals 0.7 mg/dL. Compute an
initial vancomycin dose for this patient.

17. Patient OF (see problem 16) was prescribed vancomycin 20 mg every 12 hours. Steadystate vancomycin concentrations were obtained, and the
peak concentration was 20 μg/mL while the trough concentration was 8.6 μg/mL. Compute a revised vancomycin dose for this patient to
provide a steadystate trough concentration of 15 μg/mL.

18. UL is a 7yearold, 24kg (3 ft 11 in) male with MRSA sepsis. His serum creatinine is 0.5 mg/dL, and it has been stable for the last 2 days. Compute an
initial vancomycin dose for this patient.

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19. Patient UL (see problem 18) was prescribed vancomycin 250 mg every 6 hours and was expected to achieve steadystate peak and trough

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concentrations equal to 38 μg/mL and 15 μg/mL, respectively. Steadystate peak and trough concentrations were measured and were 25 μg/mL
and 10 μg/mL, respectively. Calculate a new vancomycin dose that would provide a steadystate trough of 15 μg/mL.

20. TK is a 75yearold, 66kg (5 ft 5 in) female with an MRSA pneumonia. Her current serum creatinine is 1.8 mg/dL, and it has been stable over the last 3
days since admission. A vancomycin dose of 1000 mg every 24 hours was prescribed and expected to achieve a steadystate trough concentration
equal to 15 μg/mL. After the third dose, the steadystate trough concentration equaled 25 μg/mL. Calculate a new vancomycin dose that would
provide a steadystate trough of 15 μg/mL.

21. VY is a 48yearold, 170kg (5 ft 7 in) female with septic arthritis due to MRSA. Her current serum creatinine is 1.3 mg/dL and is stable. A vancomycin
dose of 1000 mg every 24 hours was prescribed and expected to achieve a steadystate trough concentration equal to 15 μg/mL. After the third
dose, a steadystate concentration was measured and equaled 8 μg/mL. Calculate a new vancomycin dose that would provide a steadystate
trough of 15 μg/mL.

22. NH is a 75yearold, 62kg (5 ft 9 in) male with MRSA bacteremia. His current serum creatinine is 1.3 mg/dL, and it has been stable since admission. A
vancomycin dose of 1000 mg every 24 hours was prescribed and expected to achieve a steadystate trough concentration equal to 15 μg/mL. After the
third dose, a steadystate concentration was measured and equaled 6 μg/mL. Calculate a new vancomycin dose that would provide a steady
state trough of 15 μg/mL.

23. PA is a 22yearold, 75kg (5 ft 11 in) male with MRSA bacteremia. His initial serum creatinine on admission was 0.8 mg/dL, but his current serum
creatinine is 2.3 mg/dL, and it has been stable for the last 3 days. A vancomycin dose of 1500 mg every 8 hours was prescribed and expected to
achieve a steadystate trough concentration equal to 15 μg/mL. After the sixth dose, a steadystate concentration was measured and equaled
27 μg/mL. Calculate a new vancomycin dose that would provide a steadystate trough of 15 μg/mL.

24. GA is a 55yearold, 78kg (6 ft 1 in) male with an MRSA endocarditis (MIC = 1 μg/mL). His current serum creatinine is 1.5 mg/dL, and it has been stable
over the last 3 days since admission. A vancomycin dose of 1000 mg every 18 hours was prescribed and expected to achieve an AUC24/MIC >
400. After the third dose, the steadystate trough concentration equaled 7 μg/mL. Using the estimated AUC24 ratio method, calculate the AUC24/MIC
ratio for the patient and compute a new vancomycin dose that would provide an AUC24/MIC > 400.

25. RI is a 55yearold, 78kg (6 ft 1 in) male with an MRSA pneumonia (MIC = 1 μg/mL). His current serum creatinine is 1.5 mg/dL, and it has been stable
over the last 3 days since admission. A vancomycin dose of 1000 mg every 12 hours was prescribed and expected to achieve an AUC24/MIC > 400.
After the third dose, the steadystate peak and trough concentrations equaled 25 μg/mL and 7 μg/mL, respectively. The dose was infused over 1
hour with a waiting period of ½ hour before the peak concentration was obtained. Use the steadystate peak and trough concentrations to
calculate the AUC24/MIC ratio for the patient, and compute a new vancomycin dose that would provide an AUC24/MIC > 400.

26. VA is a 55yearold, 78kg (6 ft 1 in) male with an MRSA pneumonia (MIC = 1.5 μg/mL). His current serum creatinine is 1.5 mg/dL, and it has been stable
over the last 3 days since admission. A vancomycin dose of 1000 mg every 24 hours was prescribed and expected to achieve an AUC24/MIC >
400. After the third dose, the steadystate trough concentration equaled 7 μg/mL. The dose was infused over 1 hour with a waiting period of ½ hour
before the peak concentration was obtained. Use a measured AUC24 ratio computed using concentration(s) and a Bayesian pharmacokinetic
computer program to calculate the AUC24/MIC ratio for the patient, and compute a new vancomycin dose that would provide an AUC24/MIC > 400.

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