GGC Medicines


Adult Therapeutics Handbook

- Vancomycin intermittent infusion (age 16 and over)

Vancomycin intermittent 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.

Intermittent 'Pulsed' Vancomycin infusion - dosing guidance

For vancomycin continuous infusion guideline see here.

Prescribing and documentation

To reduce the risk of mortality, commence vancomycin administration within 1 hour of recognising sepsis. Vancomycin intermittent infusion should be prescribed on the inpatient kardex and on a GG&C Adult Vancomycin Intermittent Infusion: Prescription Administration and Monitoring (Vanc-PAM) chart.

Step 1: Prescribe vancomycin “as charted” on the kardex.

Do not add a dose / administration time; this causes confusion as times may vary.

Step 2: Documentation on the Vanc-PAM chart

  • On the Vanc-PAM chart document the patient’s sex, age, height, weight and creatinine (if known) and use these to calculate the vancomycin loading dose and initial maintenance dose and dose frequency. Record these details in the STEP 2 section of the Vanc-PAM chart.
  • If creatinine is known - use the vancomycin calculator within the GGC Medicines App or on NHSGGC StaffNet / Clinical Info section. If these electronic resources are not available then use the Loading (Table 1) and Maintenance (Table 2) Infusion tables below.
  • If creatinine is not known – to avoid delaying antibiotic administration, calculate the vancomycin loading dose using the patient’s actual body weight, (see Table 1 below or refer to the table on the Vanc-PAM chart).

Step 3: Prescribe the loading dose

Prescribe the loading dose in Box 1 of the Vanc-PAM chart (inform nursing staff that the dose is due to ensure prompt administration). To avoid delayed maintenance doses it is important to also complete Step 4 at this point (unless a creatinine result is awaited).

Table 1: Vancomycin LOADING infusion

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

Step 4: Prescribe the maintenance dose

  • Prescribe the maintenance dose in Box 2 of the Vanc-PAM chart. The first maintenance dose should be started 12, 24 or 48 hours after the loading dose according to the interval provided by the vancomycin online calculator (or GGC Medicines App).
  • If the maintenance dose is scheduled to be given between the hours of midnight and 6am, to make vancomycin administration more convenient for the patient, refer to the section ‘Time window for starting first maintenance dose post loading dose’ in Table 2 below before deciding when to start the first maintenance dose.
    • Example: the patient is due to be given their vancomycin loading dose at 3pm and from the online calculator their maintenance dose is 1000mg every 12 hours. Instead of starting the first maintenance dose 12 hours post loading dose at 3am, it could be started earlier (7 hours post loading) at 10pm. The patient would then be on a more convenient 12 hour dosing regimen given at 10pm and 10am as opposed to 3am and 3pm.
  • Prescribe maintenance doses in chronological order on the Vanc-PAM chart.

Table 2: Vancomycin maintenance intermittent (pulsed) dosing regimen

CrCl (ml/minute) Dose amount Dose interval Time Window for starting first maintenance dose post loading dose Volume of sodium chloride (0.9%)*
<20 500mg over 1 hour 48 hours 36-48 hours 250ml
20-29 500mg over 1 hour 24 hours 18-24 hours 250ml
30-39 750mg over 1.5 hours 24 hours 18-24 hours 250ml
40-54 500mg over 1 hour 12 hours 6-12 hours 250ml
55-74 750mg over 1.5 hours 12 hours 6-12 hours 250ml
75-89 1000mg over 2 hours 12 hours 6-12 hours 250ml
90-110 1250mg over 2.5 hours 12 hours 6-12 hours 250ml
>110 1500mg over 3 hours 12 hours 6-12 hours

500ml

*Glucose 5% may be used in patients with sodium restriction.

N.B. The daily dose can be split into 3 equal doses and given 8 hourly to produce higher troughs. For example, 1500mg 12 hourly could be prescribed as 1000mg 8 hourly and 750mg 12 hourly as 500mg 8 hourly.

Step 5: Check creatinine daily

Record the results on the Vanc-PAM chart to ensure any changes impacting on dosing are recognised easily. Review therapy and seek advice if renal function is unstable (e.g. creatinine change of >15-20%).

Step 6: Monitoring

Initiate vancomycin monitoring and record the results on the Vanc-PAM chart including the exact sample time. See additional guidance on monitoring below for further details.

Step 7: Re-prescribe the maintenance dose

  • Re-prescribe the maintenance dose every 3 days (or sooner if the dose or dose times change). For a new maintenance prescription, discontinue the current maintenance prescription box by ticking ‘see box X’ (adding a signature and date) and scoring through. There is no need to alter the kardex, which should state ‘as charted’.
  • To stop therapy on the chart tick the ‘stopped’ box (adding a signature and date) and score through all pages of the chart with the word ‘stop’. Remember to discontinue vancomycin on the kardex and on the prescription chart.

Additional guidance on monitoring intermittent infusion vancomycin therapy

Concentrations are meaningless unless the dose and sample time are recorded accurately
  • Take the initial vancomycin trough (pre-dose) sample between 24-48 hours of commencing therapy. Thereafter, sample every 2-3 days but sample daily if renal function is unstable. Monitor creatinine daily and record the result on the chart. Seek advice from pharmacy if creatinine is unstable (e.g. a change of >15-20%).
  • Record the exact time of all vancomycin samples on the Vanc-PAM chart and ensure that the TrakCare sample request form is printed at the time of sample collection.
  • If renal function is stable, give the next dose before the result is available. If renal function is deteriorating, withhold until the result is available then follow the advice below.
  • Target trough concentration range: 10-20mg/L
  • If the patient is seriously ill (severe or deep-seated infections), the target range is 15-20 mg/L (see table 3 below).
  • If the patient is failing to respond, seek advice from microbiology or an infection specialist.

Adjustment of vancomycin dosage regimen (see table 3, below)

  • 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 too early in therapy (pre-steady state)?
  • Was the sample taken at the correct time i.e. a true trough sample?
  • 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?
  • Is the patient severely underweight or overweight?

Table 3: Adjustment of vancomycin dosage regimen - intermittent 'pulsed' infusion

Vancomycin trough concentration Suggested dose change
<10mg/L Increase the dose by 50% and consider reducing the dosage interval. Always seek advice if you are unsure or if the current dose is >2500mg daily.*
10-15mg/L

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

If the patient is seriously ill, consider increasing the dose amount or reducing the dosage interval to achieve a trough of 15-20 mg/L.

15-20mg/L Maintain the present dosage regimen.
>20mg/L Withhold and seek advice from pharmacy before the next dose is due.
* If daily doses above 4grams are required, please ensure pharmacy have been contacted for advice.
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 in the relevant section of the Vanc-PAM chart. If the dosage regimen needs to be changed, discontinue the present dose and prescribe a new dosage regimen.
  • 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 ototoxicity.

Managing delays in vancomycin dose administration

The guidance below does not apply where the dose has been deliberately withheld (for example due to a high vancomycin trough level or deteriorating renal function). Contact pharmacy for advice in these cases. If you are unsure how to determine if the patient has deteriorating renal function, contact medical or pharmacy staff.

If a patient has stable renal function and a dose of vancomycin has been delayed unintentionally (for example due to loss of intravenous access) then refer to the Table 4a below if ≤50% of the dosing interval has been unintentionally delayed and refer to Table 4b below if >50% of the dosing interval has been unintentionally delayed.

Table 4a: Vancomycin dose - unintended delay of ≤50% of dosing interval

Prescribed dose interval Dose delay Action
12 hourly ≤6 hours
  • Give the delayed dose immediately
  • Record the date and exact time of administration on the chart and kardex with two nurse signatures
  • Give the next dose at originally prescribed time
24 hourly ≤12 hours
48 hourly ≤24 hours

Table 4b: Vancomycin dose - unintended delay >50% of dosing interval

Prescribed dose interval Dose delay Action
12 hourly >6 hours
  • Give the delayed dose as soon as possible
  • Record the date and exact time of administration on the chart and kardex with two nurse signatures
  • Seek advice from pharmacy for further dosing
24 hourly >12 hours
48 hourly >24 hours

Advice for nursing staff on using the GG&C Vanc-PAM chart

  • Before administering check the kardex to ensure vancomycin has not been discontinued there.
  • Check that creatinine and vancomycin levels are being monitored (these are recorded underneath the administration record; discuss with the prescriber promptly if you are unsure if this monitoring is being done).
  • Record the date and exact time of administration on both the Vanc-PAM chart and the kardex with two nurses’ signatures
  • Doses due after a vancomycin sample has been taken should usually be given. Do not wait for the vancomycin result before dosing, unless advised to by medical staff or if renal function is deteriorating (check with a prescriber or pharmacist if unsure).

 

Last updated January 2019