From WardWiki - Foundation Doctor Helper
For reasons that escape wardwiki, there are a plethora of vancomycin regimens out there and sadly no two seem to be exactly alike! This is wasteful for the foundation doctor and so wardwiki has reproduced the following published regimen with the proviso that one must follow one's own trust protocol when available. Salford Royal have produced a remarkably user friendly protocol - This protocol has been reviewed to take note of the following:
- Vancomycin prescription is based on actual body weight
- It is based on renal function
- Vancomycin is very toxic if given too rapidly or if levels accumulate
- Continuous infusion is almost always given in specialised circumstances where senior doctors are supervising the administration.
Make sure patient is suitable
Calculate the creatinine clearance.
- If less than 60kg load of 1000mg
- If between 60kg and 90kg load 1500mg
Use local guidelines or BNF for dosing the gentamicin.
Dilute the vancomycin dose in 100mL sodium chloride 0.9% and give by intravenous infusion at no more than 10mg/min. Record on the drug chart the exactstart time of the infusion. This usually takes TWO hours to complete.
Maintenance dose based on creatinine clearance or estimated glomerular filtration rate to be given 12 hours post-loading dose.
|eGFR (ml/min/1.73m2)||Dose (milligrams)||Interval (hours)|
|≤ 29 / dialysis||30 – 39||40 – 54||55 – 74||75 – 89||90 – 110||≥ 111|
Trough level monitoring
Serum antibiotic levels should be measured in all patients who have treatment with intravenous vancomycin for longer than 48 hours. The sample should be taken immediately before the fourth dose or after 48 hours of therapy. A trough (pre-dose) sample only is required. For patients with eGFR >30mls/min the next (fourth) dose should be given and the result used to change further doses if necessary. The target range for vancomycin pre-dose concentrations for most patients is 10-15mg/l. For patients with MRSA or severe/ deep seated infections the target range for vancomycin pre-dose concentrations should be increased to 15-20mg/L. If a dose alteration occurs, trough levels should be measured again, after a further 3 doses have been given.
In most patients vancomycin exhibits linear kinetics. Linear dose, proportional pharmacokinetics can be used to alter doses based on trough levels:
New dose = Target level at steady state x Old dose / Current level at steady state
Ie: a doubling of the dose, should double the serum level.
A. H. Thomson, C. E. Staatz, C. M. Tobin, M. Gall and A. M. Lovering. Journal of Antimicrobial Chemotherapy (2009) 63, 1050–1057 Development and evaluation of vancomycin dosage guidelines designed to achieve new target concentrations