Table 1 Outpatient Infusion Pharmacy Services Managed Protocol

Referring provider

Determine the need for Aminoglycoside therapy, duration of therapy and consult with ID physician if applicable or required at the local medical center.

Authorized Pharmacist Functions:

Gather Patient-Specific Information. Order and evaluate appropriate laboratory work, Initiate aminoglycoside therapy using accepted adult dosing guidelines

Demographics

Age, Gender, Height, and Actual Body Weight (ABW)

Labs

Serum Creatinine (SCr), Blood Urea Nitrogen (BUN), Complete Blood Count (CBC), Cultures & Sensitivities

History

Allergies

Medical and Medication History

Diagnosis/Reason for Vancomycin

Previous aminoglycoside pharmacokinetic data

Order and evaluate appropriate lab work

Baseline SCr

Routine CBC with differential, SCr +/− BUN, and aminoglycoside trough weekly or more frequently based on patient’s age, history, concurrent nephrotoxic or ototoxic medications and clinical judgment.

May order peak level per clinical judgment or patient case.

Trough level should be done prior to 3rd to 5th dose after initiation, change in dosage and at least once a week if creatinine is stable, and more often for changes in creatinine of greater than or equal to 0.5 mg/dL.

If there is a greater than or equal to 0.5 mg/dL change in serum creatinine, a trough and/or repeat random level should be done with the next feasible dose.

Single Daily Dose Aminoglycoside (SDDA)

Gentamicin/Tobramycin 5 mg/kg/dose IV

Amikacin 15 mg/kg/dose IV

Exclusion

i. Pregnant women (no data on fetal pharmacokinetics and toxicity)

ii. Ascites

iii. Endocarditis

iv. Dialysis patients

v. Burn patients

vi. Patients with ESRD or with CrCl < 20 mL/min

vii. Patients who are hemodynamically unstable

viii. Neutropenic or critically ill patients