Download Vancomycin dosing

Clinical Guidelines for Use of Antibiotics
VANCOMYCIN (Adult)
Please always prescribe VANCOMYCIN in the Variable Dose Antibiotic section of the EPMA
SUPPLEMENTARY drug chart (and add a ‘placeholder’ on the electronic drug chart).
1 Background
Vancomycin is a glycopeptide antibiotic that is active against gram positive organisms,
including methicillin resistant Staph. aureus (MRSA).
The risk of renal toxicity (and ototoxicity) is increased when prescribed with other nephrotoxic
drugs, such as gentamicin.1,2
2 Intravenous dose of VANCOMYCIN (intermittent bolus dosing)
VANCOMYCIN requires determination and prescribing of both of the following:
INITIAL LOADING DOSE
ONGOING MAINTENANCE DOSE
2.1 BEFORE PRESCRIBING
1. Determine patient ACTUAL BODY WEIGHT
2. Determine patient Creatinine Clearance (see below)
Creatinine Clearance (ml/min should be calculated manually using the Cockgroft Gault
equation (below)or the online calculator function here. DO NOT use the eGFR.
Cockcroft Gault equation:
Notes for Cockcroft Gault equation:
Age (years)
Weight (kg)
Serum Creatinine (micromols/litre)
F = 1.23 in MEN
F = 1.04 in WOMEN
Compliance with these guidelines will be reviewed regularly by the Trust Prescribing Committee Please check the intranet to ensure you have the latest version.
Note: This document is electronically controlled. The master copy is maintained by the owner department. If this document is printed it becomes uncontrolled.
Contact Numbers: Microbiology Ext 4800;
Antibiotics Pharmacist Ext 5033;
4PHA-GDL-031 Version 4
Adopted as Trust Policy: May 2015 Review Date: May 2017
Medicines Information Ext 5029
Page 1 of 8
Clinical Guidelines for Use of Antibiotics
2.2 PRESCRIBING INITIAL LOADING DOSE : Use Table 1 below to determine the
loading dose: Use patient’s ACTUAL BODY WEIGHT1,6
Table 1: VANCOMYCIN LOADING DOSE
Actual Body Weight (kg)
Loading dose
<60kg
60-90kg
>90kg
1000mg
1500mg
2000mg
(1g)
(1.5g)
(2g)
Adapted from Thomson, AH et al, March 20096
2.3 MAINTENANCE DOSE: Based on CALCULATED Creatinine Clearance as indicator of
RENAL FUNCTION using Cockcroft Gault equation: see here for online Cockcroft Gault
calculator (via medicinescomplete). DO NOT use the eGFR.
USE the calculated creatinine clearance for the patient in Table 2 below to determine the
maintenance dose and dose interval for VANCOMYCIN
The first maintenance dose should be given the same number of hours AFTER the
LOADING DOSE as the ongoing dosing interval.
Table 2: VANCOMYCIN MAINTENANCE DOSE SCALE
Creatinine
Clearance (mL/min)
Dose (mg)
Dosing Interval
(hours)
Dose point 8
>110
1500mg*see below
12
Dose point 7
90-110
1250mg
12
Dose point 6
75-89
1000mg
12
Dose point 5
55-74
750mg
12
Dose point 4
40-54
500mg
12
Dose point 3
30-39
750mg
24
Dose point 2
20-29
500mg
24
Dose point 1
<20
500mg
48
Adapted from Thomson, AH et al, March 20096
*UNLESS body weight <45kg: then use MAXIMUM dose of 1.25g (1250mg) until
levels have been checked
Compliance with these guidelines will be reviewed regularly by the Trust Prescribing Committee Please check the intranet to ensure you have the latest version.
Note: This document is electronically controlled. The master copy is maintained by the owner department. If this document is printed it becomes uncontrolled.
Contact Numbers: Microbiology Ext 4800;
Antibiotics Pharmacist Ext 5033;
4PHA-GDL-031 Version 4
Adopted as Trust Policy: May 2015 Review Date: May 2017
Medicines Information Ext 5029
Page 2 of 8
3 Administration
Clinical Guidelines for Use of Antibiotics
The maximum concentration of vancomycin when prepared for infusion is 5mg/ml.3,4
Infusions should be given at a rate no greater than 10 mg/min is recommended.3,4
Rapid infusion may cause severe hypotension (including shock and cardiac arrest), wheezing,
dyspnoea, urticaria, pruritus, flushing of the upper body (‘red man' syndrome), pain and
muscle spasm of back and chest. Stop the infusion if they occur. A longer infusion time or
premedication with an antihistamine may limit the reaction.3
4 VANCOMYCIN LEVEL MONITORING
4.1 Target VANCOMYCIN levels
Standard dosing PRE-DOSE LEVELS
 Target range: 10-15mg/L1
High dose PRE-DOSE LEVELS for complicated infections
 Target range: 15-20mg/L 1,5,6,7
Complicated infections include:
 Bacteraemia (confirmed blood-stream infection)
 Endocarditis
 Osteomyelitis
 Meningitis
 HAP (Hospital acquired pneumonia)
 VAP (Ventilator associated pneumonia)
 Other infections caused by resistant organisms (microbiology will advise).
4.2 Timing of level
Levels should be taken within one hour before next dose is due (PRE-DOSE or
‘TROUGH’ levels)1
4.3 The intial PRE-DOSE level should be taken:
TWICE DAILY (12 hourly) dosing:
JUST BEFORE THE FOURTH DOSE
ONCE DAILY (24 hourly) dosing:
JUST BEFORE THE THIRD DOSE
ALTERNATE DAY (48 hourly) dosing: JUST BEFORE THE SECOND DOSE
Compliance with these guidelines will be reviewed regularly by the Trust Prescribing Committee Please check the intranet to ensure you have the latest version.
Note: This document is electronically controlled. The master copy is maintained by the owner department. If this document is printed it becomes uncontrolled.
Contact Numbers: Microbiology Ext 4800;
Antibiotics Pharmacist Ext 5033;
4PHA-GDL-031 Version 4
Adopted as Trust Policy: May 2015 Review Date: May 2017
Medicines Information Ext 5029
Page 3 of 8
Clinical Guidelines for Use of Antibiotics
4.4 Do I wait for the level to give the dose or not?
Do not wait for the results of the pre-dose (trough) levels before giving the next
dose
4.5 How often to repeat blood samples for drug levels
TWICE a week if VANCOMYCIN levels are within range and urine output and renal
function are STABLE
If the dosage has been adjusted, then recheck levels after 2 days:



TWICE DAILY (12 hourly) dosing:
FOUR DOSES
ONCE DAILY (24 hourly)dosing:
TWO DOSES
ALTERNATE DAY (48 hourly) dosing: ONE DOSE
4.6 Practicalities of taking blood samples for drug levels
Send 3.5mL blood in a yellow top (SST) tube
Ensure that the following are recorded on the blood form:
Time the sample was taken
Current dose of VANCOMYCIN
Time level taken/hours post last dose.
Indication for treatment
4.7 Interpretation of levels:
The trough (pre dose) level should be between 10–15mg/L or 15-20mg/L depending
on the indication (see section 4.1)
If level is outside the desired range, FIRST check for technical explanations; for
example:
LEVEL taken at INCORRECT TIME
INCORRECT timing of DOSAGE
Use Table 3 below for guidance on how to adjust VANCOMYCIN dose according to
measured pre-dose levels.
Compliance with these guidelines will be reviewed regularly by the Trust Prescribing Committee Please check the intranet to ensure you have the latest version.
Note: This document is electronically controlled. The master copy is maintained by the owner department. If this document is printed it becomes uncontrolled.
Contact Numbers: Microbiology Ext 4800;
Antibiotics Pharmacist Ext 5033;
4PHA-GDL-031 Version 4
Adopted as Trust Policy: May 2015 Review Date: May 2017
Medicines Information Ext 5029
Page 4 of 8
Clinical Guidelines for Use of Antibiotics
Table 3: VANCOMYCIN trough level interpretation and maintenance dose adjustment
Pre-dose (trough
level)
Maintenance dose adjustments (Refer to maintenance dose
ladder above)
< 5 mg/L
Move up 2 DOSE POINTS on maintenance dose scale (Table 2)
5 to 10 mg/L
Move up 1 DOSE POINT on maintenance dose scale (Table 2)
For HIGH DOSING of COMPLICATED INFECTIONS (see section
4.1) move up one step on maintenance dose ladder
10 to 15 mg/L
For STANDARD DOSING indications stay at current dose
15 to 20 mg/L
Stay at current dose
20 to 25 mg/L
Move down 1 DOSE POINT on maintenance dose scale (Table
2) without omitting any doses
More than 25 mg/L
Omit next dose and decrease by 2 DOSE POINTS
on maintenance dose scale (Table 2)
> 30 mg/L
HOLD VANCOMYCIN DOSING
Seek advice from microbiology or an antimicrobial pharmacist
Adapted from Vancomycin Prescribing Guidance for: Musgorve Park Hospital (Taunton) and Leeds
Teaching Hospitals.
Compliance with these guidelines will be reviewed regularly by the Trust Prescribing Committee Please check the intranet to ensure you have the latest version.
Note: This document is electronically controlled. The master copy is maintained by the owner department. If this document is printed it becomes uncontrolled.
Contact Numbers: Microbiology Ext 4800;
Antibiotics Pharmacist Ext 5033;
4PHA-GDL-031 Version 4
Adopted as Trust Policy: May 2015 Review Date: May 2017
Medicines Information Ext 5029
Page 5 of 8
Clinical Guidelines for Use of Antibiotics
5 When to refer to the antibiotic team:
Stable therapeutic levels cannot be achieved
Patient has severe renal impairment or is on dialysis
Patient is not clinically improving
6. Additional Monitoring
6.1 Renal function
There is some evidence that high dose vancomycin is associated with a greater risk of renal
toxicity.6,8
For patients with a high trough concentration target (15-20mg/L) renal function MUST
be monitored a minimum of twice a week.
Patients with new acute kidney injury (AKI) should be referred to the antibiotic team
and/or Microbiology for review and/or advice.
6.3 Hearing and balance
Where patients are prescribing vancomycin alongside other nephrotoxic drugs (especially
aminoglycosides such as GENTAMICIN or AMIKACIN) consider monitoring for signs of
ototoxicity (changes to or loss of hearing, changes in balance).1
6.4 Full blood count
Blood dyscrasias have been reported due to VANCOMYCIN therapy, including neutropenia and
thrombocytopenia.4 It is recommended that the FULL BLOOD COUNT is monitored weekly for
patients on vancomycin therapy where the duration of the course is greater than 1 week.
Compliance with these guidelines will be reviewed regularly by the Trust Prescribing Committee Please check the intranet to ensure you have the latest version.
Note: This document is electronically controlled. The master copy is maintained by the owner department. If this document is printed it becomes uncontrolled.
Contact Numbers: Microbiology Ext 4800;
Antibiotics Pharmacist Ext 5033;
4PHA-GDL-031 Version 4
Adopted as Trust Policy: May 2015 Review Date: May 2017
Medicines Information Ext 5029
Page 6 of 8
Clinical Guidelines for Use of Antibiotics
7. Dialysis patients
Please liaise with the Dialysis Unit (5286) for all cases when drugs are administered on
dialysis.
For Haemodialysis (HD) patients usual dosing is a 1g IV loading dose then a single 500mg IV
dose after every dialysis unless the previous level is above 20mg/L. Due to logistics trough
vancomycin levels are used from the previous dialysis to decide if the next dose is given. Only
in this circumstance is there no need to await the level from the current day before
administering the dose. If a trough vancomycin level is above 20mg/L, omit further doses and
wait until subsequent trough level is below 20mg/L. Vancomycin will be administered, in the
usual case, on the dialysis unit and not on the ward. Supplies of vancomycin will be provided
by the ward.
Infuse a 1g vancomycin dose over 100 minutes.
Type of dialysis
Haemodialysis (HD) patients
Vancomycin dose
1g IV loading dose and then 500mg IV
stat after each HD unless previous level at
dialysis is above 20mg/L. The level is
recorded from the previous dialysis before
each dose is given.
On peritoneal dialysis or acute
haemodialysis
1g IV loading dose monitor levels every 24
hours. When level is 20mg/L or under give
another 1g IV dose.
For patients with PD peritonitis, the
treatment protocol involves administration
of intraperitoneal vancomycin. Please seek
advice from the Renal PD Nurses (Ext
5288 / 5286 / 7346).
Compliance with these guidelines will be reviewed regularly by the Trust Prescribing Committee Please check the intranet to ensure you have the latest version.
Note: This document is electronically controlled. The master copy is maintained by the owner department. If this document is printed it becomes uncontrolled.
Contact Numbers: Microbiology Ext 4800;
Antibiotics Pharmacist Ext 5033;
4PHA-GDL-031 Version 4
Adopted as Trust Policy: May 2015 Review Date: May 2017
Medicines Information Ext 5029
Page 7 of 8
8 References
Clinical Guidelines for Use of Antibiotics
1. Rybak et al. Therapeutic monitoring of vancomycin in adult patients: A consensus
review of the American Society of Health-System Pharmacists, the Infectious Diseases
Society of America, and the Society of Infectious Diseases Pharmacists. Am J HealthSyst Pharm 2009; 66: 82-88
2. Rybak et al. Nephrotoxicity of vancomyrin , alone and with an aminoglycoside. Journal
of Antimicrobial Chemotherapy 1990; 25: 679-687
3. ‘Medusa’ IV monograph for VANCOMYCIN IV. Accessed via
http://medusa.wales.nhs.uk/IVGuideDisplay.asp (Feb 2015).
4. Summary of Product Characteristic: Vancocin®, date of last revision of the text 23
October 2008 (Flynn). Accessed via http://www.medicines.org.uk/emc/medicine/21291
(Feb 2015).
5. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the
management of adults with hospital-acquired, ventilator-associated, and healthcareassociated pneumonia. Am J Respir Crit Care Med 2005; 171: 388–416
6. Thomson et al. Development and evaluation of vancomycin dosage guidelines
designed to achieve new target concentrations. Journal of Antimicrobial Chemotherapy
2009; 63: 1050-1057.
7. Tunkel AR, Hartman BJ, Kaplan SL et al. Practice guidelines for the management of
bacterial meningitis. Clin Infect Dis 2004; 39:1267–84.
8. Jeffres MN, Isakow W, Doherty JA et al. A retrospective analysis of possible renal
toxicity associated with vancomycin in patients with healthcare-associated methicillinresistant Staphylococcus aureus pneumonia. Clin Ther 2007; 29: 1107–15.
Compliance with these guidelines will be reviewed regularly by the Trust Prescribing Committee Please check the intranet to ensure you have the latest version.
Note: This document is electronically controlled. The master copy is maintained by the owner department. If this document is printed it becomes uncontrolled.
Contact Numbers: Microbiology Ext 4800;
Antibiotics Pharmacist Ext 5033;
4PHA-GDL-031 Version 4
Adopted as Trust Policy: May 2015 Review Date: May 2017
Medicines Information Ext 5029
Page 8 of 8