Download vancomycin dosage and monitoring guidelines

VANCOMYCIN DOSAGE AND MONITORING GUIDELINES
This dosing guideline applies to all adult patients on Vancomycin except renal patients.
STEP 1 - IDEAL BODY WEIGHT CALCULATION
• Obtain patients weight (kg) and height (feet & inches).
• Calculate Ideal Body Weight (IBW)
• IBW = (males: 50 kg, females: 45.5 kg) + 2.3 kg for every inch > 5 feet
• Use ideal body weight (IBW) if the patient is obese and actual body weight if underweight.
STEP 2 - CREATININE CLEARANCE ESTIMATION
• Check U + E’s and obtain serum creatinine (micromol/L)
• DO NOT USE eGFR
• Calculate creatinine clearance using equation below or refer to online calculator.
CAUTIONS
If the creatinine concentration is <60 micromol/L use 60 micromol/L for creatinine clearance calculation. This equation may overestimate creatinine
clearance in elderly or severely underweight patients.
CREATININE CLEARANCE ESTIMATION
(140 - age (years)) x IBW (kg)
Creatinine CL = --------------------------------------------------- x 1.23 (males) OR
(ml/min)
Serum Creatinine (micromol/L)
1.04 (females)
Cockcroft & Gault, Nephron 16: 31-41, 1976
STEP 3 - INITIAL VANCOMYCIN DOSAGE REGIMEN
• Based on patients ideal body weight and creatinine clearance, look up vancomycin dose in table below.
Creatinine Clearance (ml/min)
Ideal Body Weight <60kg
Ideal Body Weight >60kg
<20
1000mg then sample after 24 hours
1000mg then sample after 24 hours
20 - 29
1000mg every 48hrs
1000mg every 48hrs
30 - 49
750mg every 24hrs
750mg every 24hrs
50 - 59
1000mg every 24hrs
1000mg every 24hrs
60 - 69
500mg every 12 hrs
1000mg every 24hrs
70 - 79
750mg every 12 hrs
750mg every 12hrs
80 - 100
750mg every 12 hrs
1000mg every 12hrs
>100
1250mg every 12 hrs
1250mg every 12hrs
STEP 4 - VANCOMYCIN PREPARATION AND ADMINISTRATION
• Reconstitute vancomycin with the required volume of water for injection
(10mls water for injection for a 500mg vial & 20ml water for injection for a 1gram vial)
• Vancomycin must be diluted before administration - Further dilute the vancomycin by adding it to
an Intravenous bag of sodium chloride 0.9% or glucose 5%.
Maximum concentration for infusion 5mg/ml (eg 1gram given in a minimum of 200ml NaCI 0.9%) see table
Vancomycin Dose
Volume of diluent
Sodium Chloride 0.9% or Glucose 5%
Administration Time
500mg
100ml
50-60 minutes
750mg
250ml
75 minutes
1000mg
250ml
100 -120 minutes
1250mg
250ml
120 - 125 minutes
* Vancomycin must be administered by intravenous infusion at a rate no greater than 10mg/minute.
Failure to do so can result in anaphylaxis, shock and Redman syndrome.
STEP 5 - MONITORING OF VANCOMYCIN CONCENTRATIONS
• These are initial dosage guidelines. The handling of vancomycin is highly variable and early analysis of the trough concentration is required to optimise therapy.
• Record the exact times of all doses administered below
• Check U+E’s daily
• Check trough concentration immediately before the fourth dose (within 48 hours) or sooner if renal function is impaired or deteriorating.
• Ongoing monitoring check trough (pre dose) level every 72 hours or sooner if renal function deteriorates.
Target trough concentration 10 - 15 mg / L
Advice on administration, therapeutic drug monitoring / dosage adjustment and sampling available from clinical pharmacist or microbiology
Produced by Lanarkshire Area Infection Group (LAIG)
Approved By: Clinical Board
Date August 2007
Review Date August 2009
MPR.VANCOM.1380.W