Antimicrobial prescribing: NHS Lothian
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)
Vancomycin
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.
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, sex, height, weight & serum creatinine.
- See here for the Intranet creatinine clearance calculator and further guidance.
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
- 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 |
|
Typically “deep seated” infections
|
- 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.