Vancomycin intermittent infusion (for patients aged ≥16 years)

This guideline covers:

• Contraindications and cautions
• Calculating and prescribing initial one-off loading dose 
• Calculating and prescribing initial maintenance dose
• Managing unintended delays in vancomycin administration
• Monitoring levels
• Interpreting levels and adjusting vancomycin dose
• Toxicity
• Advice for nursing staff.

Contraindications and cautions 

• Contra-indications: hypersensitivity to vancomycin
• Cautions:
  • Co-administration with potentially neurotoxic and/or nephrotoxic agents (e.g. amphotericin, potent diuretics, NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), aminoglycosides, ACE (Angiotensin Converting Enzyme) 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. 

Intermittent 'Pulsed' Vancomycin infusion - dosing guidance

Prescribing and documentation

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

Vancomycin intermittent infusion should be prescribed on the inpatient HEPMA (Hospital Electronic Prescribing and Medicines Administration) record and on a NHSGGC Adult Vancomycin Intermittent Infusion: Prescription Administration and Monitoring (Vanc-PAM) chart.

A loading dose is required for all patients who are starting 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 continuous infusion guideline see here. 

Step 1: Prescribe vancomycin on HEPMA.

• On the patient's HEPMA record go to "Add drug", select "Vancomycin Intravenous Infusions AS CHARTED" and accept "Intravenous intermittent infusion" as the route.
• Prescribe PRN (as required) on HEPMA. The dose should be left as the pre-populated "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 adjustment.
• 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.
• For further advice on prescribing vancomycin on HEPMA, see here.

Step 2: Calculate the initial dosing regimen and input details on the Vanc-PAM chart

• On the Vanc-PAM chart document the patient’s sex*, age, height, up to date weight and creatinine (if known) and use these to calculate the vancomycin loading dose and initial maintenance dose and dose frequency. 
• The NHSGGC vancomcyin calculator within the GGC Medicines app or via the Staffnet Hub (link only active if connected to NHSGGC network) should be used to calculate the initial vancomcyin dosing regimen.
• If these electronic resources are not available, then use the Loading (Table 1) and Maintenance (Table 2) Infusion tables below. Record the initial vancomycin dosing regimen details in the STEP 2 section of the Vanc-PAM chart.
• 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 Table 1 on the Vanc-PAM chart). Once creatinine available, calculate the initial vancomcyin maintenance dose as above.
• Ensure the Vanc-PAM chart is accessible and near the front of the patient's bedside folder.

*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.

Step 3: Prescribe the one-off loading dose

• Prescribe the loading dose in Box 1 of the Vanc-PAM chart.
• Inform nursing staff that 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 4 at this point (unless a creatinine result is awaited).
• For further information on prescribing / recording administration on the Vanc-PAM chart, refer to the example Vanc-PAM chart here.

Table 1: Vancomycin LOADING infusion

Use only if creatinine not available, otherwise use the vancomycin calculator in the GGC Medicines app or via the Staffnet Hub (link only active if connected to NHSGGC network).

Step 4: Calculate and prescribe the initial maintenance dose

• 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 intermittent infusion maintenance dose. The dose amount and dosage interval are based on estimated creatinine clearance - see here for the equation. Do not use eGFR.
• Prescribe the maintenance dose in Box 2 of the Vanc-PAM chart. The first maintenance dose should be started after the loading dose according to the interval provided by the vancomycin calculator in the GGC Medicines App, Staffnet Hub page (link to page only active if connected to NHSGGC network) or Table 2 below.
• If the maintenance dose is scheduled to be given between the hours of midnight (12am, 00:00) and 05:59, to make vancomycin administration more convenient for the patient (promoting a good night's sleep) and the ward, refer to the section ‘Time window for starting first maintenance dose after the initial loading dose’ in Table 2 below or on the back of the Vanc-PAM, before deciding when to start the first maintenance dose. Example:

A patient is due to be given their vancomycin loading dose at 12pm and from the online calculator their maintenance dose is 1000mg every 12 hours. Instead of starting the first maintenance dose 12 hours after the loading dose at 12am, it could be started earlier (10 hours post-loading dose) at 10pm. The patient would then be on a more convenient 12 hour dosing regimen given at 10pm and 10am as opposed to 12am and 12pm.

• Prescribe maintenance doses in chronological order on the Vanc-PAM chart.
• Select and tick the appropriate target vancomycin trough concentration on the Vanc-PAM chart: Standard: 10-20mg/L or deep-seated/severe infection: 15-20mg/L.

Note: troughs of 15-20mg/L have an increased risk of nephrotoxicity and require close monitoring of renal function.

For further information on prescribing on the Vanc-PAM chart refer to the example Vanc-PAM chart here.

Table 2: Vancomycin maintenance intermittent (pulsed) dosing regimen

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

Step 5: Check creatinine daily and record on the patient's Vanc-PAM chart

Check creatinine daily and record the results on the patient's Vanc-PAM chart and medical notes to ensure any changes impacting on dosing are recognised easily. Review therapy and seek senior or pharmacy advice if reduced urine output or renal function is unstable (e.g. creatinine change of >15-20%). It is important to monitor and record the patient's creatinine daily to identify any potential risk of vancomycin renal toxicity developing. This may require discontinuation of vancomycin therapy.

Step 6: Monitoring vancomycin blood concentrations (levels)

• Ensure a plan is in place for initial and ongoing vancomycin blood level monitoring. This plan should be documented in the patient's medical notes.
• The prescriber should indicate when a vancomycin trough (level) is due by ticking the 'level due' box on the Vanc-PAM and arrange for a level to be taken.
• Print the TrakCare sample requests for the vancomycin trough (level) at the time of sample collection. The sample times reported on TrakCare and Clinical Portal are not always accurate.
• Record the date and exact times of all vancomcyin levels on the Vanc-PAM chart.
• Take the first vancomycin trough (pre-dose) level as per Table 3 below
• Thereafter, check a vancomycin level every 2-3 days but sample daily if the renal function is unstable (e.g. change of >15-20%).
• Avoid taking blood samples for vancomycin monitoring from lines, vascular access device (VAD) as results are often inaccurate. Additional guidance on monitoring vancomycin intermittent infusion can be found below. Also refer to the Vascular access devices (VADs), care and maintenance guideline for further information.
• Target vancomycin trough concentration: standard 10-20mg/L or deep-seated / severe infection: 15-20mg/L. Troughs of 15-20mg/L have an increased risk of nephrotoxicity and require close monitoring of renal function.
• Record the results on the Vanc-PAM chart including the exact sample time. Add action / comments, based on the result, and initials and staff grade to the Vanc-PAM chart. 
• For further information see 'Additional guidance on monitoring intermittent infusion vancomycin therapy' below.

Table 3: Timing of first (initial) vancomycin trough (pre-dose) level

Step 7: Review / Re-prescribe / Amend / Stop the vancomycin maintenance dose

Review the need for vancomycin on a daily basis.

Re-prescribe the maintenance dose every 3 days (or sooner if the dose or dose times change) on the Vanc-PAM chart. 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 HEPMA, the PRN prescription should state '1 dose' and no frequency.

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 and in the Action / Comments box on the Vanc-PAM chart. 

To stop therapy on the Vanc-PAM 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 HEPMA and on Vanc-PAM chart.

Additional guidance on monitoring intermittent infusion vancomycin therapy

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 Cannula (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 form and 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.

If the 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 in Table 4 - Adjustment of vancomycin dosage regimen.

In some patients with MSSA or MRSA bacteraemia, microbiology may request an AUC 24 calculation. These requests should be referred to an Antimicrobial Pharmacist. This service is only available during normal working hours. Out with these hours, trough level monitoring should continue until an Antimicrobial Pharmacist is available.

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

Interpreting vancomycin results and re-prescribing

• Always check for errors and that the dosage history and sampling time are appropriate before interpreting the result or making any adjustments.
• Refer to the dose adjustment Table 4 below.
• Seek advice from pharmacy or microbiology if you need help to interpret the result or in patients with changing renal function.
• Record the vancomycin concentration on the Vanc- PAM chart with the action taken. Also document your initials and staff grade. Prescribe the new dosage regimen if required.

Table 4: Adjustment of vancomycin dosage regimen - intermittent 'pulsed' infusion

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

Managing unintended delays in intermittent 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 if necessary. 

If a patient has stable renal function (if you are unsure how to determine if the patient has deteriorating renal function, contact medical or pharmacy staff) and a dose of vancomycin has been delayed unintentionally (for example due to loss of intravenous access) then refer to:

• Table 5a below if ≤50% of the dosing interval has been unintentionally delayed.
• Table 5b below if >50% of the dosing interval has been unintentionally delayed.

Table 5a: Vancomycin dose - unintended delay of ≤50% of dosing interval

Table 5b: Vancomycin dose - unintended delay >50% of dosing interval

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

• For further information on prescribing / completing / recording administration of vancomycin on the Vanc-PAM and HEPMA refer to example Vanc-PAM chart here and the FAQs document.
• Vancomycin should be prescribed on the Vanc-PAM and on HEPMA under the PRN section.
• Before administering, check both the patient’s HEPMA and Vanc-PAM to ensure vancomycin has not been discontinued in either place.
• Not all clinical areas use HEPMA. If the patient has recently transferred from another area e.g. Emergency Department, ITUs, renal dialysis check ALL available documentation to clarify if and when any previous doses have been given.
• Transition between clinical areas increases the risk of dosing errors – extra vigilance is required.
• Check “Discontinued Rx” section in the patients HEPMA to ensure that a dose has not already been given, e.g. in theatre, another ward, etc.
• Check that creatinine and vancomycin levels are being monitored and documented (these are recorded underneath the administration record on the Vanc-PAM chart). If these are not documented, please discuss with the prescriber promptly and clarify the ongoing plan.
• If the ‘level due’ box is ticked, confirm a level has been taken before giving dose. Do not wait for the result before dosing, unless advised to by the medical staff or if renal function is deteriorating (check with a prescriber / pharmacist if unsure).
• If a dose has been delayed unintentionally see section above ‘Managing unintended delays in vancomycin dose administration’ for advice on how to proceed.
• Record the date and exact time of administration on both the Vanc-PAM chart and HEPMA with two qualified nurses’ signatures.
• Promoting a good night’s sleep: doses prescribed between midnight (00:00) and 05:59 should be given at the prescribed time, but the timing of future doses discussed with the prescriber / pharmacy, as it may be possible to adjust to more patient friendly times.
• Ensure Vanc-PAM chart is accessible and near the front of the patient’s bed side folder.
• For more details on administration refer to the NHSGGC Vancomycin Adult Intravenous Medicine Monograph (link only active if connected to NHSGGC network).

Guideline reviewed: August 2024

Page last updated: August 2024