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Section 1: Vancomycin Trough Monitoring & Kinetics
Question 1: Extended Multiple Choice (EMC)
Clinical Scenario:
*65-year-old male, weight 72 kg, SCr 1.9 mg/dL. Admitted for MRSA
pneumonia. Vancomycin 1,500 mg IV q12h started. Pre-dose 4 trough = 26
mcg/mL (target: 15–20 mcg/mL).*
Question:
What is the priority action?
• A) Administer next dose as scheduled
• B) Increase dose to 1,750 mg q12h
• C) Hold next dose, extend interval to 24h, recheck trough
• D) Switch to daptomycin
Rationale:
CJMM Steps:
1. Recognize Cues: Trough (26 mcg/mL) > target + renal impairment (CrCl
≈40 mL/min).
2. Analyze Cues: High troughs increase nephrotoxicity risk (IDSA 2020).
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3. Prioritize Action: Holding and interval extension reduces accumulation.
Distractor Alert: "Switch to daptomycin" (D) is premature without
assessing reversibility.
Question 2: Bowtie (BT)
Clinical Scenario:
Risk factors for vancomycin nephrotoxicity.
Structure:
• Left (Risks): Trough >20 mcg/mL, Concurrent piperacillin-tazobactam,
Hypovolemia
• Right (Mitigations): Hydration (1.5 L/day), AUC monitoring, Avoid
NSAIDs
• Center: Nephrotoxicity Prevention
Question:
Drag factors to correct side. Which mitigation directly counters "Hypovolemia"?
Answer: Hydration
Rationale:
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Hypovolemia reduces renal perfusion → tubular injury. Hydration preserves
glomerular filtration (ASHP 2022). Concurrent nephrotoxins (pip-tazo)
compound risk.
Question 3: Extended Drag & Drop (EDD)
Clinical Scenario:
Order steps for trough monitoring in a new hemodialysis patient.
Actions to Sequence:
1. Calculate CrCl pre-dialysis
2. Draw trough 12–24h post-infusion (not post-dialysis)
3. Administer dose after dialysis session
4. Adjust dose based on trough
Correct Order:
3→1→2→4
Rationale:
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Section 1: Vancomycin Trough Monitoring & Kinetics
Question 1: Extended Multiple Choice (EMC)
Clinical Scenario:
*65-year-old male, weight 72 kg, SCr 1.9 mg/dL. Admitted for MRSA
pneumonia. Vancomycin 1,500 mg IV q12h started. Pre-dose 4 trough = 26
mcg/mL (target: 15–20 mcg/mL).*
Question:
What is the priority action?
• A) Administer next dose as scheduled
• B) Increase dose to 1,750 mg q12h
• C) Hold next dose, extend interval to 24h, recheck trough
• D) Switch to daptomycin
Rationale:
CJMM Steps:
1. Recognize Cues: Trough (26 mcg/mL) > target + renal impairment (CrCl
≈40 mL/min).
2. Analyze Cues: High troughs increase nephrotoxicity risk (IDSA 2020).
, 3
3. Prioritize Action: Holding and interval extension reduces accumulation.
Distractor Alert: "Switch to daptomycin" (D) is premature without
assessing reversibility.
Question 2: Bowtie (BT)
Clinical Scenario:
Risk factors for vancomycin nephrotoxicity.
Structure:
• Left (Risks): Trough >20 mcg/mL, Concurrent piperacillin-tazobactam,
Hypovolemia
• Right (Mitigations): Hydration (1.5 L/day), AUC monitoring, Avoid
NSAIDs
• Center: Nephrotoxicity Prevention
Question:
Drag factors to correct side. Which mitigation directly counters "Hypovolemia"?
Answer: Hydration
Rationale:
, 4
Hypovolemia reduces renal perfusion → tubular injury. Hydration preserves
glomerular filtration (ASHP 2022). Concurrent nephrotoxins (pip-tazo)
compound risk.
Question 3: Extended Drag & Drop (EDD)
Clinical Scenario:
Order steps for trough monitoring in a new hemodialysis patient.
Actions to Sequence:
1. Calculate CrCl pre-dialysis
2. Draw trough 12–24h post-infusion (not post-dialysis)
3. Administer dose after dialysis session
4. Adjust dose based on trough
Correct Order:
3→1→2→4
Rationale:
