Vancomycin in haemodiafiltration (HDF) (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • HHSCP only
  • Secondary Care
  • Adults

DO NOT USE VANCOMYCIN CALCULATOR FOR DIALYSIS PATIENTS

Prompt administration within one hour of recognition of sepsis reduces mortality

Prescribing

  • Initial dose may be prescribed as a one off on an inpatient drug chart if not being given on dialysis, eg, if dialysis not due at time of initiation.  
  • Any initial doses being given on dialysis and all subsequent doses should be prescribed on HERMES (electronic renal prescribing system) by a member of the renal team. 
  • If an inpatient, an entry should be made on the inpatient drug chart/HEPMA referring to HERMES.  A duration or review date should be documented. 
  • When course complete, ensure vancomycin is STOPPED on both the inpatient chart/HEPMA and HERMES.

LOADING DOSE

FIRST DOSE: can be given on dialysis or on ward
Actual body weight Dose Volume to be made up to with 0·9% Sodium chloride Administration time (max rate of 10mg/min)
<40kg 750mg 250mL 75 minutes
40 to 59kg 1000mg 250mL 100 minutes
60 to 90 kg 1500mg 500mL 150 minutes
>90kg 2000mg 500mL 200 minutes

MAINTENANCE DOSE

SECOND & THIRD DOSE: given at end of the next two HDF sessions
Actual bodyweight (dry weight) Dose Volume to be made up to with 0·9% sodium chloride Administration time (max rate of 10mg/min)
<40kg 500mg 100mL 50 minutes
40 to 59kg 750mg 250mL 75 minutes
60 to 90kg 1000mg 250mL 100 minutes
>90kg 1250mg 250mL 125 minutes

 

THERAPEUTIC DRUG MONITORING AND MAINTENANCE DOSE

FOURTH DOSE onwards
  • Take a trough level prior to 3rd dose pre-HDF (dialysis must not have started when level taken).
  • DO NOT delay administration of 3rd dose.
  • Use level to guide administration of 4th dose and subsequent doses.
  • Thereafter, check trough levels every 3rd dose.
Trough level* Subsequent dose (round to nearest 250mg)
<10mg/L Increase dose by 50%
10 to 15mg/L Increase dose by 25%
15 to 20mg/L Continue current dose
20 to 25mg/L Reduce dose by 25%
25 to 30mg/L Omit next dose and reduce subsequent dose by 50%
>30mg/L Stop until level back to 15 to 20
Caution is required in acutely unwell patients and those receiving HDF more than 3 x week.
The frequency of monitoring will need to be increased.
Please refer to Renal Consultant/Renal Pharmacist for advice.
Use caution when interpreting levels taken PRIOR to first dialysis of the week. Eg: Monday for MWF and Tuesday for TTS. They may not be representative, due to longer interdialytic gap.

Incremental (twice weekly) HDF patients

These patients should receive dialysis three times a week for the duration of their vancomycin course.

Off unit patients receiving low flux dialysis

  • Loading dose: Give loading dose as per table 1
  • Therapeutic drug monitoring: Check a trough level prior to next dialysis session
  • Subsequent doses: Give 1g if vancomycin level <15mg/L (Consultant may specify a level <20mg/L)

References

  • Cimino C, Burnett Y, Vyas N, Norris AH Post. Dialysis Parenteral Antimicrobial Therapy in Patients Receiving Intermittent High‑Flux Hemodialysis. Review Article.  Drugs (2021) 81:555–574
  • Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Wong-Beringer A, Rotschafer JC, Rodvold KA, Maples HD, Lomaestro BM Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists.  Am J Health Syst Pharm. 2020;77(11):835.
  • Flynn Pharma Ltd.  Vancocin Summary of product characteristics (SPC) Vancomycin.  Last updated on eMC  17 June 2022. Available at Vancocin Powder for Solution - Summary of Product Characteristics (SmPC) - (emc) (medicines.org.uk) accessed on 16th Nov 2022
  • Medusa NHS injectable medicines guide.  Vancomycin monograph.  Available via Injectable Medicines Guide - Display - Vancomycin - Intravenous - Version 9 - IVGuideDisplayMain.asp (wales.nhs.uk) Accessed on 16th Nov 2022
  • Scottish Antimicrobial Prescribing Group.  Vancomcyin guidance.  Available at Vancomycin (sapg.scot).  Accessed on 16th Nov 2022
  • Renal Drug Database,Renal Pharmacy Group.  Vancomycin monograph last updated 20/10/2022.  Available at VANCOMYCIN | The Renal Drug Database accessed on 16th Nov 2022
  • Adapted from NHS Tayside vancomycin prescribing on dialysis policy agreed Sept 2020.  Available at Vancomycin Prescribing on Dialysis.pdf (scot.nhs.uk).  Accessed on 16th Nov 2022

Editorial Information

Last reviewed: 27/04/2023

Next review date: 30/04/2026

Author(s): Renal Department.

Version: 2.2

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Kirsten McCulloch, Renal Pharmacist, , Dr Stewart Lambie, Renal Consultant, , Stuart Ross, Specialist Renal Nurse.

Document Id: TAM565