Vancomycin

  • See also

    Background and adverse effects

    Glycopeptide antibiotic, active against gram positive bacteria. Usually reserved for treatment of methicillin-resistent staph aureus (MRSA).

    Potentially nephrotoxic, ototoxic.

    Can cause red man syndrome - flushing or rash on the upper body and neck; muscle spasm of the neck and back. This is dose and infusion related. Vancomycin should be infused over a minimum of 60 minutes, and over 120 minutes for doses greater than 500mg, patients with previous reactions, and neonates.

    Dose

    The dose chosen needs to be guided by the clinical picture and age of patient, and adjusted according to trough levels.

    Neonates

    IV: Loading dose of 15 mg/kg then

    Preterm: 10 mg/kg/dose 24 hrly
    Term: Week 1 of life: 10 mg/kg/dose 12 hrly
    Week 2-4 of life: 10 mg/kg/dose 8 hrly

    Severe infections: 15 mg/kg/dose

    Nb: There is limited evidence behind dosing in preterm infants, and other centres use alternative dosing protocols based on weight.

    Infants and children

    IV: usual start dose 15mg/kg 6 hourly

    Maximum recommended 2g/dose

    Adjust according to trough levels. Range of dosing 10-20 mg/kg 6-8 hourly.

    Patients in Intensive Care: Consider loading dose 20-30mg/kg, and earlier monitoring of trough levels.

    Monitoring - trough levels

    Start

    Sample

    Repeat (For maintenance, assuming normal renal function)

    Therapeutic Range

    3rd to 5th dose

    Earlier if renal impairment or load given.

    Trough

    (immediately before dose is due)

    Every 3-5 days if dose unchanged.

    10-15 mg/L

    Cellulitis

    15-20mg/L

    Severe infection: bacteraemia, endocarditis, pneumonia, osteomyelitis. meningitis, known high MIC

    Note: If trough levels are out of range, adjust either the dose or dosing interval. Recheck trough level in 24 hours.

    Adjusting dose

    Adjust according to trough levels. Usual range of dosing 10-20 mg/kg/dose 6-8 hourly.

    General principles - Adjust one thing at a time.

    Low trough levels: Increase dose and/or reduce interval (ie: give more frequently).

    High trough levels: Increase interval (give less frequently) first, and/or reduce dose.

    Consider starting with the following: (All levels are mg/L)

    Level <5 increase dose by 50-100% (eg 10 to 20 mg/kg/dose).

    Level 5-10 increase dose by 20%

    Level >20 increase dose interval (eg from 6 to 8 hourly). Recheck level prior to next dose and administer if within target range.

    Consider discussing changes with local pharmacist/pharmacology team.

    Additional information:

    Recommended trough levels have recently increased.

    Trough levels of <10 may promote bacterial resistance.


    Trough levels of 15-20 are thought to be most efficacious in the treatment of severe infection; however there are no data on the safety of longer courses of vancomycin at doses that achieve these levels. If a longer course of treatment is required, monitor renal function closely, especially if on concomitant nephrotoxic medications.

    Links: (RCH Intranet)

    Paediatric injectable guidelines

    Last updated April 2012