Vancomycin: intermittent infusion only (Paediatric Formulary)

TAM (Treatments and Medicines) NHS Highland

Audience

HHSCP only
Paediatrics only

Indication

Infections due to Gram-positive bacteria including endocarditis, osteomyelitis, septicaemia and soft-tissue infections.

The dosing below is based on recommendations in a report to the Neonatal and Paediatric Pharmacist Group January 2016, on empirical dosing of intermittent intravenous vancomycin in children aged over 1 month, for optimum trough levels. This report showed that in certain age groups, the BNFC dosing did not produce adequate trough levels, AUC24 values, or MICs.

Age	Dose	Frequency	Route
Less than 1 month	See separate vancomycin protocol for neonates
1 month to less than 6 months	12·5mg/kg	8 hourly	Give over at least 60 minutes using an infusion pump. The rate should be below 10mg/minute. Central administration is preferable but concentrations up to 5mg/mL may be given via a large peripheral vein.
6 months to less than 1 year	20mg/kg	8 hourly
1 year to 6 years	25mg/kg	8 hourly
Over 6 years to 16 years	20mg/kg	8 hourly

In renal impairment
GFR 10 to 50mL/min /1.73m²	Give usual starting dose and adjust according to levels	Take a trough level 12 hours after the first dose was given. Give the next dose when the trough is within the target range. If the first level is above the target range, re-check in a further 12 hours.
GFR less than 10mL/min /1.73m²	10mg/kg starting dose (do not repeat dose) Then adjust according to levels	Take trough level 24 hours after the first dose. Give the next dose if the trough is within the target range. If the first level is above the target range, re-check in 12 or 24 hours, depending on how elevated the level is. Seek advice on subsequent dosing.

In renal impairment

GFR 10 to 50mL/min /1.73m²

Give usual starting dose and adjust according to levels

Take a trough level 12 hours after the first dose was given.

Give the next dose when the trough is within the target range.

If the first level is above the target range, re-check in a further 12 hours.

GFR less than 10mL/min /1.73m²

10mg/kg starting dose (do not repeat dose)

Then adjust according to levels

Take trough level 24 hours after the first dose.

Give the next dose if the trough is within the target range.

If the first level is above the target range, re-check in 12 or 24 hours, depending on how elevated the level is.

Seek advice on subsequent dosing.

Levels

Aim: 10 to 20mg/L

Child over 1 year: Estimated glomerular filtration rate (mL/minute/ 1.73 m2) = 40 x height (cm) / serum creatinine (micromol/litre).

Children with low muscle mass, those who have had a bone marrow transplant, or peritoneal dialysis, may need a formal GFR checked by nuclear medicine.

Supply

Vials containing vancomycin (as hydrochloride) powder for reconstitution.
Strengths available: 500mg, 1g.

Preparation

Reconstitute vial with water for injection taking displacement values into consideration.
Average displacement value is 0·2mL for 500mg and 0.4mL for 1g vial as per Medusa.
Reconstitute with water for injections.
- Add 9.8mL to each 500mg vial (giving a concentration of 50mg/mL)
- Add 19·6mL to each 1g vial (giving a concentration of 50mg/mL).
For IV infusion, further dilute with sodium chloride 0·9% or glucose 5% to a concentration of ≤5mg/mL.

The following table can be used as a guide:

Dose	Volume to administer in (mL)
less than 100mg	25mL
100mg to 250mg	50mL
250mg to 500mg	100mL
500mg to 1·25g	250mL
1·25g to 2g	500mL

In fluid restricted patients, maximum concentration is 10mg in 1mL, via CENTRAL LINE ONLY.

Intravenous infusion at rates as per the following table:

Dose	Amount of time to give over
500mg or less	60 minutes
500mg to 900mg	90 minutes
900mg to 1·2g	120 minutes
Greater than 1·2g	Maximum rate of 10mg/minutes

MONITORING

Blood for vancomycin levels should be taken peripherally and not from an existing indwelling venous access device to reduce the risk of falsely elevated results.
Take 1st trough level IMMEDIATELY BEFORE the 4th dose and administer dose without waiting for level results.
The result obtained will determine what to do for the next, ie 5th dose.
Monitor renal function regularly, ie, daily.
If renal function is impaired, eg a change in creatinine of more than 15 to 20%, the trough level should be known before the next dose is administered. See dosing table for monitoring in renal impairment.
If levels are within the therapeutic range, repeat every 3 days.
If levels are sub-therapeutic or are above the therapeutic range, adjust the dose as per tables below AND repeat the level 24 hours after ANY dose adjustment.
Therapeutic range:
- Trough 10 to 20mg/L for, eg, proven infections, bacteraemia, endocarditis.
- Trough levels of 15 to 20mg/L may be recommended by Paediatric Infectious Diseases / Microbiology for severe infections.
Approximate time to steady state: 1 to 2 days.
Note: vancomycin may increase the risk of aminoglycoside induced ototoxicity. Use caution if co-prescribing with other agents that may cause ototoxicity, eg, furosemide, gentamicin, tobramycin.

If the measured concentration is unexpectedly HIGH or LOW, consider the following:

Were the dose and sample times recorded accurately?
Was the correct dose administered?
Was the sample taken from the line used to administer the drug?
Was the sample taken during drug administration?
Has renal function declined or improved?
Does the patient have oedema or ascites?

If in doubt, take another sample before modifying the dosage regimen and/or contact pharmacy for advice.

Level (mg/L)	Suggested dose change
Below 10	Confirm all doses given. If so, and dosage interval 8 hours: change to 6 hourly. Take further level 24 hours after ANY dosage adjustment.
10 to 15	If the patient is responding, maintain the present dosage regimen. If the patient is seriously ill, change an 8 hourly dose to 6 hourly.
15 to 20	Maintain current dosage regimen. Repeat level in 3 days.
Over 20	Confirm trough sample taken appropriately. Stop, reanalyse every 12 hours until level is below 20mg/L and seek advice.

Seek help from pharmacy or microbiology if you need help interpreting the result.

Compatible solutions	sodium chloride 0·9%, glucose 5%, glucose 5% in sodium chloride 0·9%, sodium lactate compound (Hartmann's solution)
Compatible medicine infusions	aciclovir, amiodarone (in glucose 5%), anidulafungin (in glucose 5%), atracurium, calcium gluconate, cisatracurium, clarithromycin (in glucose 5%), dexmedetomidine, glyceryl trinitrate, esmolol, fentanyl, fluconazole, insulin (soluble), labetalol, levofloxacin (in glucose 5%), magnesium sulfate (in glucose 5%), midazolam (in glucose 5%), milrinone, morphine sulfate (in glucose 5%), potassium chloride, remifentanil, tigecycline (in sodium chloride 0.9%)
Incompatible solutions	ampicillin, cefotaxime, ceftazidime, ceftriaxone, cefuroxime, foscarnet, heparin, omeprazole, pantoprazole, piperacillin/tazobactam, dexamethasone sodium phosphate, phenobarbital