Pharmacokinetic Dosing Consult Note (Vancomycin/Aminoglycoside)

Note Type: [Initial PK Consult / PK Follow-Up]

Drug: [Vancomycin / Gentamicin / Tobramycin / Amikacin]

Consult Request: [Ordering service]; [Consult date/time]; [Reason: initial dosing / AUC or level interpretation / renal function change / dialysis dosing / supratherapeutic level / subtherapeutic level / other]

Pharmacist: [Pharmacist name, credentials]

Reason for Consult

[Medication and monitoring paradigm] for [indication and infection site]. [Time-critical issues if applicable]. (For vancomycin, specify AUC-guided vs trough-only. For aminoglycosides, specify conventional peak/trough vs extended-interval vs synergy dosing. Include urgent considerations such as acute kidney injury, mistimed level, or pre-operative timing only if explicitly stated.)

Clinical Context

[Brief infectious disease context: suspected/confirmed pathogen, culture sites, susceptibilities if available]. MIC: [value, method, and source if known; otherwise state "not available"]. [Infection severity features impacting targets: bacteremia, endocarditis, meningitis, osteomyelitis, pneumonia, sepsis, ICU status]. Therapy start date: [date]; Day of therapy: [number]. (Keep concise. Do not infer organisms or MIC from historical data unless explicitly linked to the current episode.)

Patient-Specific PK Inputs

Anthropometrics: Height: [value]. Actual body weight: [value] (measured [date/time]). IBW: [value]. Adjusted body weight: [value, if applicable]. Dosing weight used: [actual / IBW / adjusted] with rationale. (If no recent measured weight exists, explicitly state this limitation and recommend obtaining an accurate weight.)

Renal Function: Serum creatinine: [current value, date/time]; prior: [value(s), date/time]. Creatinine clearance: [value] ([Cockcroft-Gault / other formula]; weight used: [actual / IBW / adjusted]). Urine output: [status, if relevant]. Renal trajectory: [stable / improving / deteriorating]. (If SCr is missing, outdated, or rapidly changing, explicitly state that PK predictions are low confidence.)

Dialysis Status: [HD: schedule, last session end time, next session] / [CRRT: modality and effluent rate] / [PD: regimen details]. (Include only if patient is on renal replacement therapy; omit entirely if not applicable.)

Dosing History

Current regimen: [Dose], [route], [frequency], [infusion duration], started [date/time].

Recent administrations (24–72 hours): [Doses with administration timestamps and infusion durations]. (If MAR timing is uncertain, state this and note that level interpretation may be limited.)

Concomitant nephrotoxins/ototoxins: [Relevant agents]. (Omit if none.)

Drug Levels

(Include only when levels have been drawn.)

• [Trough / Peak / Random]: [Value with units]; drawn [date/time]; associated dose: [dose, route, infusion duration, date/time]; [hours] post-infusion; timing: [appropriate / inappropriate]; [interpretable / non-interpretable for PK adjustment].

AUC Analysis (if applicable): Method: [Bayesian software / first-order equations / two-level trapezoidal]. Levels used: [number and types]. MIC assumption: [value and source, or "not available"]. Estimated AUC24: [value]. (Always label AUC as estimated, not measured.)

Targets

Vancomycin

AUC24 target: [range]. Target attainment timing: [goal]. (If using trough-only monitoring, label as surrogate and state numeric goal. Acknowledge when extrapolating AUC targets to non-serious or non-MRSA indications.)

Aminoglycosides

Dosing strategy: [conventional peak/trough / extended-interval / synergy dosing]. Targets: [peak/trough goals or Cmax:MIC ratio appropriate to strategy]. Level timing: [specific timing relative to dosing]. Safety threshold: [trough minimization goal]. (If single-dose with no monitoring planned, state this and omit detailed targets.)

(Include only the applicable drug section above.)

Assessment

[Synthesis of PK/PD status and clinical context.]

• Exposure status: [At target / above target / below target] with rationale.
• Renal safety: [SCr trend and AKI concern].
• Ototoxicity (aminoglycosides): [Denied / reported tinnitus or vertigo / unable to assess]. (Omit for vancomycin.)
• Confidence/limitations: [Data gaps or uncertainties affecting reliability of assessment].

Recommendations

1. Dosing: [Dose], [route], [frequency], [infusion duration]. Start: [immediately / next scheduled dose / after level obtained]. [Loading dose if indicated with rationale]. [Hold criteria and re-dose trigger if applicable]. (Provide executable instructions without requiring additional calculations.)
2. Monitoring: Next level: [type] to be drawn [exact timing relative to dosing]. Renal labs: [frequency with rationale]. Clinical monitoring: [fever, WBC, hemodynamics]. Toxicity monitoring: [urine output, ototoxic symptoms, audiology if prolonged aminoglycoside]. [Orders to obtain missing data: weight, BMP, MAR clarification].
3. Follow-Up: Pharmacy reassessment: [after next level / within 24 hours / after HD]. Earlier review triggers: [AKI, unexpected level, dialysis change, clinical deterioration].
4. Communication: [Recommendation communicated to team: yes/no]. [Orders entered per protocol by pharmacist / provider to enter orders].