Do not use this guideline if CrCl <10 mL/min or on dialysis

INDICATIONS

  • Serious MRSA infections on advice of consultant microbiologist

DOSAGE

  • As vancomycin has a narrow therapeutic index, accurate dosing is imperative to prevent toxicity
  • If CrCl <10 mL/min or on haemodialysis/peritoneal dialysis, contact renal SpR/consultant for advice on dose

Loading and maintenance doses

Please enter data in all fields:


Age: Patients Height (cm): Patients Weight (kg):
(Actual body weight or estimated if patient unfit to be weighed) Select Sex: Serum Creatinine (micromol/l):

Results

  • Creatinine Clearance (ml/min):

  • Ideal Body Weight (kg):

  • Actual Weight (kg):

    • Vancomycin Infusion - Sodium Chloride 0.9% or glucose 5%:

  • Loading Dose:

  • Loading Dose Infusion Volume of sodium chloride 0.9% or glucose 5%:

  • Loading Dose Duration of infusion:

  • Time after loading to start of maintenance infusion (hours):

  • Maintenance Dose:

  • Maintenance Dose Volume of sodium chloride 0.9% or glucose 5%:

  • Maintenance Dose Infusion Duration:

  • Maintenance Dose Interval (Hours):

MONITORING

  • Monitor creatinine daily

Vancomycin levels

  • Results are meaningless unless dose and sample time are recorded accurately
  • Do not wait for result before giving dose due immediately after taking sample, unless patient has severe renal impairment (CrCl <10 mL/min) or poor urine output (<0.5 mL/kg/hr)

Document on prescription chart

  • Time each infusion started
  • Time sample taken

Record on request form

  • Dose of vancomycin
  • Date and start time of infusion last administered to patient
  • Dose regimen

Timing of samples

  • If CrCl < 10 mL/min or on haemodialysis/peritoneal dialysis, contact renal SpR/consultant for advice on timing
  • If 10 < CrCl < 40 mL/min, take trough concentration immediately before both 1st and 2nd maintenance doses
  • If CrCl ≥ 40 mL/min, take trough concentration immediately before 3rd or 4th maintenance dose, whichever falls before morning dose

ADJUSTMENT OF DOSES

  • Target trough concentration: 10–15 mg/L
    • in some serious infections, the microbiology/ID consultant may advise a target trough concentration up to 20 mg/L
  • Always check dosage history and sampling time are appropriate before interpreting result
  • If necessary, request assistance in interpreting result from pharmacy

Suggested dose change

  • If trough concentration < 10 mg/L, increase dose by approximately 50%; round doses to nearest 250 mg
    • if this increased dose exceeds 1.5 g 12-hrly, seek immediate advice from microbiology
  • If trough concentration between 10-15 mg/L, maintain present dose
    • check renal function daily and if stable re-check trough concentration twice weekly
  • If trough concentration > 15 mg/L, stop until <15 mg/L and seek advice
    • check levels daily unless advised otherwise

Further monitoring

  • If renal function impaired but stable, check trough concentration on alternate days
  • If renal function is changing rapidly (deteriorating or improving), check trough concentration daily to prevent over- or under-treatment
  • If dose has to be changed, take further samples for trough concentration before appropriate dose. See Timing of samples

ADVICE

  • If required, contact ward pharmacist, antimicrobial pharmacist or Medicines information
  • Out-of-hours contact on-call pharmacist or microbiologist

© 2022 The Bedside Clinical Guidelines Partnership.

Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.

Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa