Contact About

Vancomycin continuous infusion (for patients aged ≥16 years)

N.B. In NHSGGC the continuous vancomycin dosing regimen is normally only used in Critical Care wards. Do not use the NHSGGC Adult Vancomycin Intermittent Infusion: Prescribing, Administration and Monitoring (Vanc-PAM) chart for this regimen.

General points

  • This guideline does not apply to patients in Renal Units, on haemodialysis or on haemofiltration.
  • To avoid the risk of an infusion related reaction, pain or muscle spasm, administer no faster than 500mg/hour.
  • Before prescribing, assess the risk of toxicity.

This guideline covers:

Contraindications and cautions 

  • Contra-indications: hypersensitivity
  • Cautions:
    • Co-administration with potentially neurotoxic and/or nephrotoxic agents (amphotericin, potent diuretics, NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), aminoglycosides, ACE inhibitors - this list is not exhaustive, see www.medicines.org.uk) for further information.
    • Vancomycin may increase the risk of aminoglycoside induced ototoxicity - use caution if co-prescribing.
    • Patients with previous hearing loss due to potential ototoxicity. 

Vancomycin continuous infusion - dosing guidance

Prescribing and documentation

To reduce the risk of mortality, commence vancomycin administration within 1 hour of recognising sepsis.

A loading dose is required for all patients who are starting treatment with IV vancomycin. This is followed by a maintenance dose which may be administered either as an intermittent (pulsed) IV infusion or as a continuous IV infusion. For Vancomycin intermittent infusion guideline see here.

Step 1: Calculate, prescribe and administer the loading dose

  • If creatinine is known - use the vancomycin calculator^ within the GGC Medicines app or via the Clinical Info page on the Staffnet Hub (link only active if connected to NHSGGC network) to calculate the loading and maintenance vancomycin dose. On the calculator, ensure continuous is selected for the infusion type.
  • If creatinine is not known or the calculator is unavailable, refer to table 1 below for the loading dose. The loading dose amount is based on actual body weight (ABW). Calculate and prescribe the maintenance dose once creatinine is available.
  • Prescribe the loading dose on Carevue in critical care areas.
  • Contact pharmacy if microbiology request continuous infusion vancomycin for a patient on a ward that does not use Carevue or Carevue unavailable.
  • Inform nursing staff that a vancomycin loading dose has been prescribed and needs to be administered immediately.
  • Prompt administration within 1 hour of recognising sepsis reduces mortality.
  • To avoid delayed maintenance doses, it is important to also complete Step 2 below, at this point (unless a creatinine result is awaited).
  • Contact pharmacy if further advice required.

Table 1: Vancomycin Continuous Infusion LOADING Dose

Actual body weight Dose amount Volume of sodium chloride (0.9%)* Infusion duration
<35kg 25mg/kg 250ml 60 minutes per 500mg+
35-44kg 1000mg 250ml 2 hours+
45-59kg 1500mg 500ml 3 hours+
60-89kg 2000mg 500ml 4 hours+
90-119kg 2500mg 500ml 5 hours+
≥120kg 3000mg~

1000ml

Note: See below for fluid restricted patients#

 6 hours+

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

~Reconstitute each 1000mg vial with 20mls of water for injection. Withdraw contents of 3x1000mg vials and add to one 1000ml sodium chloride 0.9% infusion bag. Dilute the reconstituted solution to a maximum concentration of 5mg/ml.

#Fluid / sodium restricted patients: Reconstitute each 1000mg vial with 20mls water for injection. Withdraw contents of 3x1000mg vials and add to one 500ml sodium chloride 0.9% infusion bag (final concentration approximately 5.4mg/ml)+.

+For more information refer to the NHSGGC Vancomycin Adult Intravenous Medicine Monograph (link only active if connected to NHSGGC network).

IN CRITICAL CARE AREAS a concentration of up to 10mg/ml may be used (administered via a central line); use of higher concentrations may increase the risk of infusion-related events. For further advice refer to NHSGGC Adult Intravenous Monograph (see link above) or the UKCPA Minimum Infusion Volumes for Fluid Restricted Critically Ill Patients Fourth Edition (see here), or contact pharmacy.

Step 2: Calculate, prescribe and administer the vancomycin maintenance continuous infusion regimen

  • Use the vancomycin calculator within the GGC Medicines App or via the Staffnet Hub page (link to page only active if connected to NHSGGC network)  to calculate the maintenance dose and frequency.
  • If the calculator is not available, refer to Table 2 below for the continuous infusion maintenance dose. The dose amount and dosage interval are based on estimated creatinine clearance (CrCl^). See here for the equation to calculate CrCl. Do not use eGFR. 
  • The total daily dose is split into two and administered as a continuous infusion over 12 hours each.
  • Prescribe the vancomycin dose on Carevue in critical care areas. Areas not using Carevue should discuss with pharmacy.
  • Start the continuous infusion immediately after the loading infusion is complete.

^For transgender patients (following ≥ 6 months of hormonal gender affirming therapy or at any time after completion of gender affirming surgery) calculate vancomycin dosing and CrCl and ideal body weight (IBW) according to the patient's gender identity. Use the calculators within the GGC Medicines app or via the Staffnet Hub page (link to page only active if connected to NHSGGC network). If gender affirming therapy does not meet the criteria above, use the patient's sex at birth according to their electronic records. The second last digit of a CHI number informs of a patient's assigned sex at birth - for those assigned male it is odd and for those assigned female it is even.

Table 2: Vancomycin continuous infusion maintenance regimen

CrCl (ml/minute) Total Daily dose Dose for continuous infusion over 12 hours Volume of sodium chloride 0.9%* for 12-hour infusion~
<20 Use intermittent (pulsed) infusion or follow Renal Unit guidelines
20-25 500mg 250mg 250ml
26-34 750mg 375mg 250ml
35-49 1000mg 500mg 250ml
50-69 1500mg 750mg 250ml
70-89 2000mg 1000mg 250ml
90-119 2500mg 1250mg 250ml
120-180 3000mg 1500mg 500ml
>180 3750mg 1875mg 500ml

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

~Dilute doses up to 1250mg in 250ml sodium chloride (0.9%) and doses between 1250mg and 2000mg in 500ml sodium chloride 0.9%. For more information refer to the NHSGGC Vancomycin Adult Intravenous Medicine Monograph (link only active if connected to NHSGGC network).

FLUID RESTRICTED PATIENTS IN CRITICAL CARE AREAS- refer to the UKCPA Minimum Infusion Volumes For Fluid Restricted Critically Ill Patients Fourth Edition (see here).

The final administration concentration should not exceed 5mg/ml for peripheral administration or 10mg/ml for central administration.

To avoid the risk of an infusion-related reaction, pain or muscle spasm, administration should be no faster than 500mg/hour unless via a central line in critical care.

Step 3: Monitoring continuous infusion vancomycin

Concentrations are meaningless unless the dose and sample time are recorded accurately

Monitor creatinine daily. Seek advice if creatinine is unstable (e.g. a change in creatinine of >15-20%).

Take a sample 12-24 hours after starting the continuous infusion then every day with the routine bloods, or as advised by the pharmacist. 

Blood sampling for therapeutic drug monitoring (TDM) is not recommended from a vascular access device (VAD) that is being used to deliver medications, as this will affect the results. Established Peripheral Venous Cannulas (PVCs) and below antecubital fossa midlines should not be used for blood sampling. If a TDM sample is taken from a VAD used to administer the medication, ensure this is documented on the request and in the medical notes so this can be considered by laboratory and clinical staff when interpreting results. See Vascular access devices (VADs), care and maintenance guideline for further information.

Record the exact time of all vancomycin samples in the medical notes and ensure the Trakcare sample request form is printed at the time the sample is collected. Both are important to ensure accurate interpretation of vancomycin blood levels. The sample times reported on TrakCare and Clinical Portal are not always accurate. 

The 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. Close monitoring of renal function is essential due to increased nephrotoxicity risk with this higher target range.

If the patient is failing to respond, seek advice from microbiology or an infection specialist.

Step 4: Interpretation of vancomycin level and adjustment of vancomycin continuous infusion regimen

Always check that the dosage history and sampling time are appropriate before interpreting the result. Refer to Tables 3 and 4 below and adjust dose accordingly, if required. Seek advice from pharmacy or microbiology if you need help to interpret the result.

Table 3: Considerations for high or low vancomycin levels

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 4: Adjustment of vancomycin dosage regimen - continuous infusion

N.B. Always seek advice if you are unsure or if the current dose is >4000mg daily.

Vancomycin concentration Suggested dose change
<10mg/L Investigate reasons for low concentration, e.g. interruption to infusion, incorrect rate, change in renal function. See table 3. Consider discussing with pharmacy.
10-<15mg/L Increase the 12hourly dose by 250mg.
15-25mg/L

If the patient is responding to treatment, 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.

Close monitoring of renal function essential due to increased nephrotoxicity risk with this higher target range.

If the patient is not responding, discuss with microbiology or infectious diseases.
26-30mg/L Decrease the 12hourly dose by 250mg*.
>30mg/L Stop until <25mg/L then restart at a lower dose.

*If the patient is only receiving 500mg/day, reduce the 12hourly dose to 125mg.
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 medical notes. 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.
  • Review the need for vancomycin on a daily basis.

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.

Patients transferring out of critical care wards

  • Before a patient is transferred out of critical care to another ward area, vancomycin continuous infusion should be switched to vancomycin intermittent infusion.
  • Stop the continuous infusion just before the patient leaves critical care.
  • Prescribe intermittent vancomycin on the patient's HEPMA (Hospital Electronic Prescribing and Medicines Administration) record - go to "Add drug" and select "Vancomycin Intravenous Infusions AS CHARTED."
  • Choose "Intravenous intermittent infusion" as the route.
  • Prescribe PRN as required in HEPMA. The dose should be left as the prepopulated "1 dose" and no frequency / administration time should be added to HEPMA. This is to allow for flexibility if the dose or dosage time requires to be altered.
  • To minimise the risk of missed doses, consider adding a HEPMA "order note" stating "Please note this patient is on IV vancomycin." Remember to tick the "Suppress on Order stop / discontinue" option, so that when the drug is discontinued, the note will be removed.
  • Prescribe on a Vanc-PAM chart.
  • Do not prescribe a loading dose.
  • The intermittent vancomycin dose should be based on the vancomycin levels and the current continuous infusion daily dose. If the levels are in range, then prescribe the intermittent dose as the continuous infusion daily dose split into 2 equal doses and given 12 hourly e.g. continuous infusion 2g over 24 hours, should be changed to intermittent infusion 1g every 12 hours. Seek advice from pharmacy if levels are out-with target range.
  • If the patient's levels are within the target range, administer the first intermittent dose within 2-4 hours of stopping the continuous vancomycin infusion. Try to ensure the 12 hourly intermittent dose is prescribed at suitable times for the ward and patient.
  • For further advice refer to the NHSGGC Vancomycin Intermittent Infusion guideline , or discuss with pharmacy.

Guideline reviewed: July 2024

Page updated: August 2024