Vancomycin

Our patients are frequently on Vancomycin, due to the increasing incidence of ORSA in both hospital-acquired infections, and community-acquired infections. ORSA can cause a variety of infections, and we commonly follow patients with ORSA pneumonia, cellulitis, deep soft tissue infections, abscesses, osteomyelitis, bacteremia and endocarditis. Vancomycin does also cover other gram-positives, but is the treatment of choice for ORSA infections. It is the treatment of choice in PCN-allergic patients with gram positive infections. There are several important things to remember when treating a patient with Vancomycin:

1. Weight and renal function (measured by GFR or creatinine clearance). Both will influence the therapeutic dosing of Vancomycin. Generally, Vancomycin is dosed 15-20 mg/kg, and given q12h hours in patients with normal renal function.

2. Vancomycin is not absorbed systemically when given orally. Therefore, po Vancomycin is only approved as second-line treatment of C. difficile colitis. Otherwise, it should ALWAYS be given intravenously.

3. Weekly labs. When on Vancomycin, weekly labwork should be checked and should include: CBC with differential, BUN and creatinine, and Vancomycin trough.

4. Goal troughs. Vancomycin is monitored via the collection of troughs, which should be drawn ~30 minutes prior to the next scheduled dose. In general, peak testing is unnecessary. The goal trough will depend on the site of infection (keeping in mind that these goals have been extrapolated from other data, and have yet to be verified in clinical studies):

1. Goal trough of 15-20 mcg/ml is reserved for Pneumonia, Endocarditis, Meningitis, and Osteomyelitis.


2. Goal trough of 10-15 mcg/ml is used for skin and soft tissue infections and Bacteremia.

5. Adverse Reactions.

1. "Red Man Syndrome." A systemic response to the infusion, that includes flushing and sweating. Is not dangerous, and is not an allergy. It can usually be remedied by slowing the infusion rate, and/or diluting the Vancomycin in a larger volume of solute.


2. Ototoxicity. Generally not reversible, and occurs at high levels.


3. Renal failure. Uncommon, except when Vancomycin is given concomitantly with other nephrotoxic agents. If a patient develops ARF while on Vancomycin, you can generally continue Vancomycin, making dose adjustments, while the cause of the ARF is being worked up.

***In terms of when we follow Vancomycin levels, we should follow Vancomycin levels on patients on which we recommended the use of IV Vancomycin when seen as an inpatient AND will follow up with you in ID Clinic. In cases where we do not plan to see the patient in follow up, the team should make arrangements for that patient's outpatient provider to follow labwork. You may volunteer to follow labwork on these patients if they have no provider to do so. BUT, you should NEVER follow Vancomycin levels or labs on patients whom you have not seen. We have been called to follow labs on patients being discharged from various services who are going home or to a SNIF on Vancomycin. The answer to this request should be a firm NO. It becomes a legal liability when following labwork on a patient you don't know and have never seen, and in whom you did not recommend Vancomycin in the first place. What if they develop an adverse drug reaction??? Who is responsible? On paper, you would be, as the ordering physician. So, keep that in mind. Most services have no staff in place assigned to follow labwork on patients on IV antibiotics, and remember, NEITHER DO WE. It is our responsibility as fellows to follow it on our patients only. We should not volunteer to do it as a service for the entire hospital. Just imagine how many labs we would be following if we monitored labs on every patient discharged on Vancomycin from UNC?!?! Please make requesting services aware of this.***

Yvonne Carter, MD

Hospital Follow Ups

When on the inpatient consult service, we are frequently consulted on patients who will need further ID assistance...with continued monitoring, antibiotics management, assessments for cure or improvement, etc. If there is ever a patient who you think may need further ID input after discharge, it is usually best for the patient for them to be scheduled with you in the ID Clinic as an outpatient (particularly if they are on a non-medical service as an inpatient). Use your and your attending's judgement on which patients should be followed as an outpatient.

• In general, if a patient is discharged on antibiotics, and the duration of treatment is not determined prior to discharge, you should see that patient to determine when it is safe to discontinue antibiotics.


• If a patient is discharged on IV or oral antibiotics for an illness where there is a way of determining clinical response to therapy (for example, abscesses and osteomyelitis can be evaluated using imaging), you should see that patient in follow up to assess for improvement or cure.


• If a patient will require long-term suppressive or prophylactic antibiotics (particularly in immunosuppressed patients), you should see that patient in follow up, at least for a few visits, until they are stable on therapy and their PCP can take over.

Remember, once you are responsible for a consult as an inpatient, that patient is YOURS to follow as an outpatient. If you are unable to arrange for follow up with you, and you schedule the patient to be seen by another provider, you MUST communicate this to the provider who will see the patient. If you see a patient in consult who already belongs to an ID provider, you should have that patient follow up with their primary ID provider after discharge (and also communicate this to that provider).

Yvonne Carter, MD

Setting up outpatient consults

When on the inpatient consult team, you receive many calls from outside providers, and from other services, sometimes requesting that their outpatients be seen in the ID Clinic. In terms of triaging these patients, it is best to first discuss the case and question with the ID Attending, to determine if he/she thinks the patient should be seen right away versus scheduling with the next available appointment.

When scheduling outpatient consults, the best days and times will vary, depending on the schedule of the attending, the other fellow, and yourself. Typically, if the attending is available, you should schedule an outpatient to be seen on any morning when you or the fellow you are working with DOES NOT have a regularly scheduled clinic session. After you are called, it is reasonable for the patient to expect to be seen in the next 2-3 days if urgent, and in the next week if you are awaiting any records or data prior to seeing the patient, and it is not urgent.

Of course, most outpatient consults should be scheduled for patients in which seeing an ID specialist will make a difference in thier course or outcome. Outpatient consults should NOT be performed on patients who:

• are under age 18,
• will be admitted to UNC within the next 24 hours,
• are our own HIV patients (as they can be seen in our Walk-In Clinic),
• are being referred for Lyme Disease or Chronic Lyme Disease,
• are being referred for recurrent MRSA abscesses without active disease (as they can be scheduled for a "next available" appointment).

Some examples reasonable referrals for Outpatient Consults have been:

• FUO in a patient with active, ongoing fever with a documented workup
• New diagnosis of HIV (these sometimes can be punted to next available, but typically, it is better to see them quickly to get them set up into care, especially if an opportunistic infection is suspected)
• Acute HIV (talk to Cindy Gay about having these patients seen ASAP)
• Infectious complications in pregnant women
• Fever in returning travelers

Keep in mind, however, that each case should be reviewed on a case-by-case basis. Let your attending know about each case, so that it is "discussed," in case the referring physician wants to go "over your head" to have the patient seen sooner.

The consult can be scheduled by Paul Behe, by sending a phone message (if the pt is a UNC patient), or by providing Paul with the Name, DOB, and reason for visit. Note, that on the billing form at the end of the visit, you should bill the patient for a "Consultation" visit, by checking one of the consultation boxes on the upper right hand side of the form.

Same-Day Consults called from a UNC Outpatient Clinic:

One other part of outpatient consults that comes up is if there is a patient in another clinic at UNC, who the provider wants to send over to the ID Clinic or for you to come see right away. First, remember, that the patient is an outpatient, and therefore not ill enough (yet) to warrant an emergent evaluation. First, determine what exactly the question is. If there is time, and the question is simple, sometimes it is okay to swing by to see these types of consults while on rounds, when the entire team is together. If there is not time, and the attending is agreeable, it is also okay to have the pt brought in the next day for a scheduled appointment. Again, this should be discussed with the attending, and the question from the referring team/physician should be clear.

Consults Referred by Dr.Cohen, Dr.Weber, or other Division Attendings:

When you are asked to see a patient by Dr.Cohen or Dr.Weber, do it immediately. Typically, they will ask you to see a patient whom they've been asked to see from another highly regarded physician at UNC. They ask us to see these patients quickly to maintain good working relationships between the ID Department and other departments at UNC. Sometimes, however, it may be a favor for a friend. Either way, they will usually call you directly, or "cc" you on an email regarding the patient, or sometimes have thier secretary call you. Whenever this is the case, you should, of course, ask about any clinically relevant history, and inquire what the question to be addressed is. If you are ever called directly by a patient or another doctor, who uses their name to have a patient seen, verify this with them prior to scheduling the patient (yes, I've been had by scheduling a demanding patient who claimed to have been referred by Dr.Cohen, who knew nothing about the patient). As for the other Division Attendings, the same principles apply. In general, Dr.Cohen just wants the patient to be seen, and he may not ask for any follow up information regarding the patient. Dr.Weber, however, should probably be called if you are seeing a patient he asked you to see, even if you are staffing it with another attending. If not called, you should email him an update on what you found and what you did.

There has sometimes been a breakdown in communication in why we are asked to see some patients. Therefore, it is of high importance that you find out why we are seeing them prior to scheduling them.

Also, each encounter with any patient, even if it is a patient being sent over to the clinic to casually answer an ID-related question, should be (a) staffed with an attending, and (b) documented in the patient's medical record.

Yvonne Carter, MD