Vancomycin is started on suspicion and continued on inertia. The commonest failure is not the initial decision, which is usually reasonable, but the absence of anything that forces the decision to be revisited once the cultures are back.
So write the review date at the moment you write the prescription: 48 to 72 hours, when blood cultures and susceptibilities will have declared themselves. At that review there are only three honest outcomes - stop, because nothing gram-positive grew and the patient has improved; narrow, because a susceptible organism was identified and a beta-lactam will do better; or continue with a documented reason and a planned duration. Anything else is drift.
The second half of the habit is monitoring. Dose to an area-under-the-curve target where your laboratory can calculate one, rather than chasing a trough, and check renal function at least twice weekly in anyone on a prolonged course or on other nephrotoxins. The patients who come to harm are rarely the ones who needed vancomycin; they are the ones who stayed on it.
- Record a 48 to 72 hour review date with every vancomycin start.
- At review, choose explicitly: stop, narrow, or continue with a documented reason and end date.
- De-escalate to a beta-lactam for susceptible staphylococci - it outperforms vancomycin, and this is not a downgrade.
- Dose to an AUC target where the laboratory supports it rather than to a trough alone.
- Check creatinine at least twice weekly on prolonged courses, and more often with concurrent nephrotoxins.
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