Vancomycin continuous infusion (for patients aged ≥16 years)

General points

  • These guidelines do not apply to patients in Renal Units, on haemodialysis or on haemofiltration.
  • Contra-indications: hypersensitivity
  • Cautions: Co-administration with potentially nephrotoxic agents (amphotericin, potent diuretics, NSAIDs, aminoglycosides, ACE inhibitors - see www.medicines.org.uk). Avoid in patients with previous hearing loss. To avoid the risk of "red-neck / red-man syndrome", pain or muscle spasm, administer no faster than 500mg/hour.

Vancomycin continuous infusion - dosing guidance

For Vancomycin intermittent infusion guideline see here.

Step 1: Prescribe the loading dose and maintenance dosage regimen

  • To reduce the risk of mortality, commence vancomycin administration within 1 hour of recognising sepsis.
  • If creatinine is known - use the vancomycin calculator within the GGC Medicines App or on NHSGGC StaffNet / Clinical Info section. If these are not available then use the Loading and Maintenance Infusion tables below. The dose amount and dosage interval are based on estimated creatinine clearance (CrCl, see here for the equation) and actual body weight (ABW). Do not use eGFR.
  • If creatinine is not known - calculate the single loading infusion dose using ABW, prescribe and administer. Calculate the maintenance dose once creatinine is available.

Table 4: Vancomycin LOADING infusion

Actual body weight Dose amount Volume of sodium chloride (0.9%)* Infusion duration
<40 kg 750mg 250ml 90 minutes
40-59 kg 1000mg 250ml 2 hours
60-90 kg 1500mg 500ml 3 hours
>90 kg 2000mg 500ml 4 hours
*Glucose 5% may be used in patients with sodium restriction.
Vancomycin maintenance continuous infusion regimen

Start the continuous infusion immediately after the loading infusion is complete.

Table 5: Vancomycin maintenance continuous dosing regimen

CrCl (mL/minute) Daily dose Dose for continuous infusion over 12 hours
<20 Use pulsed infusion or follow Renal Unit guidelines
20-29 500mg 250mg
30-39 750mg 375mg
40-54 1000mg 500mg
55-74 1500mg 750mg
75-89 2000mg 1000mg
90-110 2500mg 1250mg
>110 3000mg 1500mg
Dilute doses up to 1250mg in 250ml sodium chloride (0.9%) and doses above 1250mg and up to 2000mg in 500ml sodium chloride 0.9%. Glucose 5% may be used in patients with sodium restriction.

Step 2: Monitor vancomycin concentration and reassess the continuous infusion dose

Concentrations are meaningless unless the dose and sample time are recorded accurately
  • Take a sample 12-24 hours after starting the continuous infusion then every 1-2 days or daily if the patient has unstable renal function. Monitor creatinine daily.
  • Record the exact time of all vancomycin samples on the vancomycin prescription chart.
  • Target steady state concentration range: 15-25mg/L. If the patient is seriously ill (severe or deep-seated infections), the target range is 20–25mg/L.
  • If the patient is failing to respond, seek advice from microbiology or an infection specialist.
Adjustment of vancomycin continuous infusion regimen
  • Always check that the dosage history and sampling time are appropriate before interpreting the result.
  • Seek advice from pharmacy or microbiology if you need help to interpret the result.

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

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

Table 6: Adjustment of vancomycin dosage regimen - continuous infusion

Vancomycin concentration Suggested dose change
<15mg/L Increase the 12 hourly dose by 250mg.
15-25mg/L

If the patient is responding, maintain the present dosage regimen.

If the patient is seriously ill, consider increasing the dose amount to achieve a steady state level of 20-25mg/L.

26-30mg/L Decrease the 12 hourly dose by 250mg.
>30mg/L Stop until <25mg/L then restart at a lower dose.
If in doubt, take another sample before modifying the dosage regimen and/or contact pharmacy for advice
General points
  • Record the exact times of all measured concentrations on the vancomycin prescription chart. If the dosage regimen needs to be changed, discontinue the present dose and prescribe a new dose.
  • Document the action taken in the medical notes.
  • Undertake pre-prescribing checks (see below) to assess the risk of toxicity.
  • Review the need for vancomycin daily.

Toxicity

  • Monitor creatinine daily. Seek advice if renal function is unstable (e.g. a change in creatinine of >15-20%).
  • Signs of renal toxicity include an increase in creatinine or decrease in urine output / oliguria.
  • Consider an alternative agent if creatinine is rising or the patient becomes oliguric.
  • Vancomycin may increase the risk of aminoglycoside-induced toxicity.

 

Last reviewed February 2018