See also

Key points

1. Administer vancomycin intravenously (IV) over at least 1 hour. Rapid infusion may cause red man syndrome (see Adverse Effects section below)
2. Vancomycin levels are required to ensure that the target therapeutic range is achieved (see Therapeutic Drug Monitoring section below) 
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

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 

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 20–30 mg/kg is given over 1 hour followed by a continuous infusion.
The usual starting dose is 60 mg/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 18-30 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)

Eg 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

Infants 0-90 days old

* >60 to the upper limit of normal (ULN) for serum creatinine. For children with moderate to severe renal impairment, seek specialist advice for dosing

Infants and children >90 days of age

Usual starting dose: 15 mg/kg/dose (maximum 750 mg) every 6 hours

• In children with severe sepsis, consider a loading dose of 30 mg/kg (maximum 1500 mg). 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
• For children with moderate to severe renal impairment, seek specialist advice for initial dosing

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

• Trough level samples are to be taken approximately 30 minutes before the dose is due.
• Inpatients 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

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 section below).

Adverse Effects

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

Rapid infusion may cause vancomycin infusion reaction (previously referred to as red man syndrome):

• 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 vancomycin infusion reaction 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

• Child 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