Intravenous Vancomycin Use in A dults - …

1 Intravenous Vancomycin Use in Adu lts - Intermittent Infusion Vanco mycin is a glycopep tide an tibio tic a nd has b actericida l activity against gram positive organisms. I t should routinely be administered in travenously as it is no t absorbed fro m the gu t. I nd ications: - Serious proven or susp ected MR SA or coagu lase nega tive staphyloco cca l in fe ctio ns - Infe ction s due to o ther resistan t gra m positive organisms - Native (with severe sepsis or where MRSA susp ected) or prosthe tic valve endo carditis See Guida nce - Oth e r in fe c tio n s a fter con sulta tion with ID Physician or Microb iolog ist Does your patient have?

2 Severe Burns, Ascite s, Rece ive Dialysis, Pregnan t See k advice fro m phar ma cist or spe cia list area ALTERNATIVE METHOD: Esti m a te CREATININE CLEARANCE ( ml/ min) (a) *or 1g three times daily to achieve higher trough concentrations **f or patients <40kg use 750mg once off loading dose then f ollow <60kg column f or maintenance dose 3. Administration: Dilu tion: Do ses up to in 250 ml sodiu m ch loride. Do ses above up to 2g in 500 ml sodiu m ch loride. Glu cose 5% may be used in pa tien ts w ith so diu m r e s tr ic ti o nInfusion Rate: Do not in fuse fa ster than 500 mg over 60 minu tes (to avoid risk of red neck / red man syndrome, pain or muscle spas m) Always sta te exact time o f sa mp le in re la tion to dose on reque st.

3 Che ck renal function daily. If rena l fun ction is stable, give the n ext do se be fore the trough resu lt is available. I f rena l function is de teriora ting, withh old un til the re sult is available. I f co-prescrib ed w i th gen ta micin mon itor for o to toxicity Trough levels (a t end o f dosag e in terval ju st prior to nex t dose: first me asured with in 48 hour s then every 2-3 days or more frequen tly if renal fun ction is un stab le. Target concentrations: Standard 10-20mg / l Seriously ill (severe or deep sea ted in fections) 15-20 mg/l ( bacterae mia, endo carditis, osteo myelitis, mening itis, and ho spita l acqu ired pneu mon ia) 5.)

4 Delayed Doses: For additional in for ma tion on manag ing missed or delayed dose s see SAPG reco mmenda tion s 6. Adjusting Dosage: Vancomycin concentration Suggested dose change <10mg/L Increase dose by 50% and consider reducing dosage interval or seek advice 10-15mg/L If patient is responding maintain present dosage regimen. 15-20mg/L Maintain present dosage regimen >20mg/L Seek advice If in doubt, take another sample bef ore modifying the dosage regimen and/or contact pharmacy f or advice Actual body weight < 60 kg** Actual body weight 60 90 kg Actual body weight > 90 kg C re at Cl (ml/min) Loading Do se (once off)

5 Start m a i nte n an ce dose after M aintenance Do se Loading Do se Start m a i nte n an ce dose after M aintenance Do se Loading d ose Start m a i nte n an ce dose after M aintenance d ose <20 1g 48 hours 500mg every 48 hours 48 hours 500mg every 48 hours 2g 48 hours 500mg every 48 hours 20-29 1g 24 hours 500mg daily 24 hours 500mg daily 2g 24 hours 500mg daily 30-39 1g 24 hours 750mg daily 24 hours 750mg daily 2g 24 hours 750mg daily 40-54 1g 12 hours 500mg tw ice daily 12 hours 500mg tw ice daily 2g 12 hours 500mg tw ice daily 55-74 1g 12 hours 750mg tw ice daily 12 hours 750mg tw ice daily 2g 12 hours 750mg tw ice daily 75-89 1g 12 hours 1g tw ice daily 12 hours 1g tw ice daily 2g 12 hours 1g tw ice daily 90-110 12 hours tw ice daily 12 hours tw ice daily 2g 12 hours tw ice daily >110 12 hours g tw ice daily* 12 hours g tw ice daily* 2g 12 hours g tw ice daily* 4.

6 Monitoring: (140-age (years)) x weight (Kg)) x (ma les) Creatinine ( micro mol/L) (fe ma les) If Cr <60 micro mo l/L use 60 in calcula tion Use actua l body weigh t or max body weigh t whichever is lower. See table 2. De ter mine L O ADI NG DO SE and MAINTENANCE DOSE from tab le below ( b/c) References: (a) Cockroft Nephron 1976; 16: 31-41 (b)Thomson et al, J Antimicrob Chemother 2009; (c) SAPG Vancomycin guidance 2019 Antimicrobial Managem ent Group Sep 2019 Rev iew S ep 2022 1. PREFERRED METHOD: Loading Dose and main te nance do se can be ca lcu la ted u sing online Vancomycin Calculator (available on NHST antibio tic web site or An timicrobia l Co mpanio n App)