Vancomycin

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This guidance is for NHS Lothian staff wishing to use Vancomycin for adults.

DO NOT USE UNLESS ONLINE CALCULATOR IS UNAVAILABLE

Document doses and plan in TRAK using \vanc. If possible double-check with ward pharmacist. When online calculator is available, transcribe calculations onto chart. 

Exclusions and contraindicationsDo not use this guidance in the following groups:

  • Patient <16 years old
  • Patients with end stage-renal disease or in those receiving haemodialysis or haemofiltration
  • Critical care patients requiring continuous infusions

Contraindication:

  • Hypersensitivity to glycopeptides (Vancomycin, Teicoplanin, Dalbavancin)

Cautions:

  • To avoid risk of “Red Man Syndrome”, pain or muscle spasm; maximum infusion rate is 500mg/hour
  • To reduce risk of vancomycin toxicity review therapy and amend or withhold nephrotoxic agents. Where possible avoid co-administration with:
    • ACE inhibitors
    • Aminoglycosides (e.g. gentamicin)
    • Amphotericin
    • Diuretics
    • NSAIDs

Required monitoring

  • U+Es daily (if renal function changes significantly, re-calculate creatinine clearance and dose).
  • Vancomycin trough: as indicated below, then every 48-72h. 

Vancomycin toxicity

Nephrotoxicity:

  • Dose-dependent
  • Ensure good hydration
  • Avoid co-prescription of nephrotoxins (e.g. furosemide)

Other:

  • Drug fever
  • Eosinophilia
  • Neutropenia (after cumulative dose of 25g)
  • Tinnitus (discontinue)

Calculate vancomycin dose

1. Calculate Loading dose

This is based on the patient’s actual body weight.

Prescribe as a STAT dose

Actual body weight (kg)

Dose (mg)

Volume of sodium chloride 0.9% (Maximum concentration 5mg/ml)

Duration of infusion

<40

750

250ml

1.5 hours

40–59.9

1000

250ml

2 hours

60–90

1500

500ml

3 hours

>90

2000

500ml

4 hours

2. Calculate the patient's creatinine clearance

  • Calculate using patient's age, height, weight & serum creatinine.
  • Calculator available here (NB: Intranet only)
  • Other online calculators can be used as long as they use the Cockcroft-Gault formula
  • As a last resort calculate manually. 

3. Calculate Maintenance doses

Maintenance dose depends on the patient’s Creatinine Clearance (Cockcroft-Gault)

  • Prescribe doses, record indication & duration/review day.
  • Document when trough levels should be taken

CrCl

(ml/min)

Dose, volume of sodium chloride 0.9%*, duration

Dosing

Interval

Time for 1st

Trough level

<20

500mg in 250ml over 1 hour

48 hours

Before 1st maintenance dose 

20-29

500mg in 250ml over 1 hour

24 hours

Before 2nd maintenance dose 

30-39

750mg in 250ml over 1.5 hours

24 hours

Before 2nd maintenance dose 

40-54

500mg in 250ml over 1 hour

12 hours

Before 3rd maintenance dose 

55-74

750mg in 250ml over 1.5 hours

12 hours

Before 3rd maintenance dose 

75-89

1000mg in 250ml over 2 hours

12 hours

Before 3rd maintenance dose 

90- 110

1250mg in 250ml over 2.5 hours

12 hours

Before 3rd maintenance dose 

>110

1500mg in 500ml over 3 hours

12 hours

Before 3rd maintenance dose 

 

3. Missed/delayed doses

If Dose delayed <1 hour after prescribed time, nursing staff can administer

Length of delay

Recommended action

More than 1 hour;

Less than halfway to next dose

(i.e. <6h if on if on 12h dosing)

Re-prescribe missed dose as once only/STAT.

Give the next vancomycin dose at the ORIGINALLY PRESCRIBED TIME

More than 1 hour;

More than halfway to next dose

(i.e. >6h if on if on 12h dosing)

Re-prescribe missed dose as once only/STAT.

Seek advice from pharmacy for further dosing.

4. Review ongoing need

  • Review daily
  • At 48-72 hours review need for ongoing therapy and available microbiology results
  • Document plan in TRAK using the \antibreview
  • If vancomycin level not therapeutic by 72 hours:
    • Review with ward pharmacist
    • Discuss with microbiology

If vancomycin is to be continued, monitor trough every 48-72 hours or as advised by the pharmacist

Monitoring levels

  • Check U+E daily; if renal function changes significantly, recalculate creatinine clearance and adjust dosing.
  • Monitor trough every 48-72 hours or as advised by the pharmacist

Recommended target trough levels: 

10-15

15-20
  • Skin/soft tissue infection
  • IV cannula infection
  • Wound infection
  • Respiratory tract infection
  • Urinary tract infection

Typically “deep seated” infections

  • Staphylococcus aureus blood stream infection
  • Endocarditis and other intravascular infections
  • Bone and joint infections including prosthetic joint infection
  • Any abscess or collection
  • Infections involving prosthetic material

 

Adjusting the dose based on levels

References

  • Thomson AH, Staatz CE,Tobin CM, Gall M, Lovering AM. Development and evaluation of vancomycin dosage guidelines designed to achieve new target concentrations. Journal of Antimicrobial Chemotherapy. DoI:10.1093/jac/dkp085
  • 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. DoI:10.2146/ajhp080434
  • Scottish Antimicrobial Prescribing Group: Maximum Body Weight Table.