Vancomycin

  • See also

    Antibiotics

    Key Points

    1. Administer vancomycin intravenously (IV) over at least 1 hour. Rapid infusion may cause red man syndrome (see Adverse Effects).
    2. Vancomycin levels are required to ensure that the target therapeutic range is achieved (see Therapeutic Drug Monitoring).
    3. Continuous infusions of vancomycin in infants aged 0 to 90 days are associated with earlier and improved attainment of target concentrations compared with intermittent dosing.

    Dose

    Patient age

    Dosing regimen

    0 – 90 days

    Continuous infusion recommended.

    ˃ 90 days

    Intermittent dosing preferred. Consider continuous infusion in critically ill patients or when unable to achieve therapeutic vancomycin levels with intermittent dosing – seek specialist advice.  

    Continuous infusion


    Infants 0 to 90 days of age
    Loading dose 15 mg/kg/dose IV (over 1 hour) followed by a continuous infusion according to the table below.


    Serum creatinine (micromol/L)

    Corrected Gestational Age (CGA)

    Continuous infusion dose

    < 40

    ≥ 40 weeks

    50 mg/kg/day

    < 40

    < 40 weeks

    40 mg/kg/day

    40 – 60

    All

    30 mg/kg/day

    >60

    All

    20 mg/kg/day

    Infants and children > 90 days of age
    Seek specialist advice
    Switching from intermittent vancomycin dosing to a continuous infusion:

    Commence at the dose equivalent to the total daily dose administered in the previous 24 hour period

    • the continuous infusion can be commenced immediately after the last intermittent dose is given
    • a loading dose is not required

    Initiating vancomycin treatment with a continuous infusion:
    Loading dose 20 – 30mg/kg is given over 1 hour followed by a continuous infusion.
    The usual starting dose is 60mg/kg/day.

    Therapeutic drug monitoring
    Target steady state level: 15 – 25 mg/L young infants (0 – 90 days of age)
    20 - 25 mg/L children (>90 days of age)

    • Collect sample for steady state vancomycin level approximately 18 to 30 hours after the start of the infusion (with routine bloods where possible).
    • If the steady state level is within target range, continue vancomycin infusion and repeat steady state level 18 – 30 hours after the first level. 

    Dose adjustment
    If the steady state level is outside of the therapeutic range, adjust the dose according to the following formula:

    Adjusted dose (mg/day) = last maintenance dose (mg/day) x (target level/last vancomycin level)

    E.g. if a 3 kg infant is prescribed 50 mg/kg/day and has a vancomycin level of 13 mg/L, the adjusted dose = 150 mg x (20/13) = 230 mg/day

    Intermittent dosing

    Neonates: 15 mg/kg/dose intravenously (IV) at a frequency according to the table below:


    CGA

    Dosing frequency

    < 29 weeks

    24 hourly

    29 to 35 weeks

    12 hourly

    36 to 44 weeks

    8 hourly

    > 44 weeks

    6 hourly

    Infants and children
    Usual starting dose: 15 mg/kg/dose (maximum 750mg) every 6 hours.
    In children with severe sepsis, consider a loading dose of 30 mg/kg (maximum 1500mg). The next dose is then given 6 hours after the loading dose. 
    Use actual body weight for dose calculations, including obese patients, up to the maximum recommended doses.

    Therapeutic drug monitoring
    Target trough level: 10 – 15 mg/L (15 – 20 mg/mL for severe infections) 

    Dosing frequency

    Timing of initial vancomycin trough levels

    6 hourly

    Before the 5th dose

    8 hourly

    Before the 4th dose

    12 hourly

    Before the 3rd dose

    18 hourly

    Before the 2nd dose

    24 hourly

    Before the 2nd dose

    Renal impairment

    Take a trough level before the 2nd dose is due and withhold the dose until the result is known. Seek specialist advice for subsequent dosing

    • Trough level samples are to be taken approximately 30 minutes before the dose is due.
    • In patients with normal renal function, the next dose of vancomycin should be given at the scheduled time before the level is known.

    Vancomycin levels should be repeated until there are two consecutive levels within target range. After this, vancomycin levels can be repeated every 3 days or whenever there is a significant change in bodyweight, serum creatinine or if the dose has been adjusted. 

    Dose adjustment


    Trough plasma concentration

    Suggested dosage adjustment

    <10mg/mL

    Increase the dose or dosing frequency.

    >20mg/L

    Reduce the dose or dosing frequency or withhold the dose. Monitor for nephrotoxicity.

    Administration

    Dilute to 5 mg/mL or weaker and infuse over at least 60 minutes (maximum rate
    10 mg/minute).

    Concentrations up to 10 mg/mL may be administered via a central line if necessary, the risk of infusion reactions is increased with higher concentrations (see Adverse Effects).

    Adverse Effects
    Vancomycin is potentially nephrotoxic and ototoxic especially when used in combination with other nephrotoxic or ototoxic agents (e.g. aminoglycosides) and in renal impairment.

    Rapid infusion may cause red man syndrome
    Features:

    • flushing or rash on the upper body and neck
    • muscle spasm of the chest and back
    • fever
    • hypotension
    • itch

    These features develop quickly and usually subside within an hour but may persist for several hours in some cases.

    If symptoms of red man syndrome occur:

    • Cease the infusion
    • Check the dose and infusion rate
    • Wait for symptoms to resolve
    • Further dilute the infusion if possible
    • Resume the infusion at a reduced rate
    • Document the adverse reaction in the patient notes and update their Allergies and Adverse Drug Reaction details
    • Infuse subsequent doses over 90 – 120 minutes and consider administration of an antihistamine before future doses

    Consider consultation with local paediatric team when:

    • Children with renal impairment
    • Unable to achieve vancomycin levels within the target range

    Consider transfer when:
    Child requiring care beyond the level of comfort of the local hospital.

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

     

    Last Updated November, 2019

  • Reference List

    1. Antibiotic Therapeutic Guidelines. https://tgldcdp.tg.org.au.acs.hcn.com.au  (viewed March 2019).
    2. Australian Medicines Handbook Children’s Dosing Companion. https://childrens.amh.net.au/  (viewed March 2019).
    3. British National Formulary for Children. https://www.medicinescomplete.com.acs.hcn.com.au (viewed March 2019).
    4. Gwee, A. et al. Continuous Versus Intermittent Vancomycin Infusions in Infants: A Randomized Controlled Trial. Pediatrics. 2019. 143(2):e20182179.
    5. Lilley, L et al. Paediatric Injectable Guidelines. 5th ed. 2016. The Royal Children’s Hospital. Flemington, Victoria.
    6. Wolters and Kluwer Clinical Drug Information, INC. Lexicomp Online http://online.lexi.com.acs.hcn.com.au/lco/action/home/switch?acc=36265# (viewed March 2019).