The following protocol should be used for patients who are being considered for antimicrobial therapy with vancomycin:

1.  Baseline serum urea and creatinine results must be checked before administering vancomycin.

2.  Dose regimen is as specified in the British National Formulary (BNF).
Consult the Renal Drug Handbook guideline or the West Midlands Medicines Information Service, Ext. 2298 if further information on dosing is required.
 

3.  Routine monitoring ONLY for patients with renal impairment. Other categories of patients that need monitoring are:

  • Patients with altered volumes of distribution, e.g. burns patients, paediatric patients, pregnant patients, i.v. drug abusers and patients with malignancies.
  • Patients receiving prolonged courses of vancomycin i.e. >10 days.
  • Patients receiving higher than usual doses of vancomycin.
  • Patients with endocarditis / meningitis.
    •

 
4.  Initiate drug monitoring 48 hours after administering the first dose.

5.  Only trough levels taken 30 minutes before the next dose should be used for Therapeutic Drug Monitoring (TDM).
     Send 2 – 5 ml of blood in red top tube.
     If a post dose level is considered NECESSARY, it should be done only after liaising with a consultant microbiologist.

6.  The normal trough range is 5 – 20 mg/L. (Previously 5 –10 mg/L)


This is based on both retrospective and prospective studies by Zimmerman et al and Rybak et al respectively, which showed no toxicity with trough values less than 20mg/L. Higher trough levels have also being associated with improved clinical outcomes.

7.  Should the levels be elevated, the measures to be considered are :

  • A dose reduction for subsequent administrations.
  • Omission of the next dose.
  • Extending the dosing interval.

    There is no clear consensus on which is the most appropriate measure, consult a senior colleague, if in doubt.
    •

8.  Vancomycin administration

Add 10ml water for injections to a 500mg vial or 20ml to a 1g vial. [Renal Drugs Handbook 2nd ed] Further dilute before administration with either sodium chloride 0.9% infusion or glucose 5% infusion.

For peripheral line administration dilute each 500mg in 100ml compatible infusion fluid and administer over at least one hour. [Mayne Pharma Plc Vancomycin hydrochloride 500mg and 1g Powder for Concentrate for infusion SPC]

In patients who are fluid-restricted a concentration of 10mg/ml may be used, that is 500mg in 50ml or 1g in 100ml. [Flynn Pharma Ltd Vancomycin CP SPC]

Rapid infusion rates may cause flushing of the upper body (red man syndrome) due to histamine release. Anaphylactoid reactions, including hypotension, wheezing, dyspnoea, urticaria or pruritus may also develop.

Pain and thrombophlebitis, occasionally severe occur in many patients receiving vancomycin. The frequency and severity of thrombophlebitis can be minimized if the drug is administered as a dilute solution (2.5-5mg/ml in the above infusions) and if the sites are changed regularly.

9.  Dosage

The vancomycin dose in normal renal function is 500mg every 6 hours or 1g by IV infusion every 12 hours.
In patients over 65 years, 500mg every 12 hours or 1g once daily. [BNF 50]
Dose in renal impairment is according to Glomerular filtration rate, GFR (ml/min)

GFR 20-50: 500mg every 12-24 hours
GFR 10 - 20: 500mg every 24-48 hours
GFR<10: 500mg every 48-96 hours.

_______________________________________________________________________________

 

 

Authorship & Documentation

Document Status Draft Guideline
Document Ref. Vancomycin Therapeutic Drug Monitoring
Document Version 0.1
Title Hospital guidelines for the therapeutic drug monitoring of Vancomycin
Owners Devadas Pillay (devadas.pillay@goodhope.nhs.uk),
Mohammed Abba (mohammed.abba@goodhope.nhs.uk)
Publication Date 6th February 2006
Target Audience All clinical staff
Circulation list Devadas Pillay (Consultant Microbiologist, GHH)
Papu De (Consultant Microbiologist, GHH)
Tania Caruthers
Evelyn Frost
All Consultants
All staff via Trust Web policies Desktop Icon
Description Evidence based therapeutic drug monitoring of vancomycin
Cross Ref
  1. Therapeutic drug monitoring of glycopeptide antibiotics, BSAC Spring Meeting, MacGowan, Bristol (2005).
  2. Vancomycin therapeutic drug monitoring: is there a consensus view? The results of the UK National External Quality Assessment Scheme (UK NEQAS) for Antibiotic Assays Questionnaire, Journal of Antimicrobial Chemotherapy (2002)
  3. Outcome assessment of minimizing vancomycin monitoring and dosing adjustments, Pharmacotherapy vol.19, Rybak et al (1999)
  4. Laboratory guidelines for monitoring of antimicrobial drugs, NACB symposium, Clinical Chemistry (1998)
  5. Association of vancomycin serum concentrations with outcomes in patients with gram positive bacteraemia, Pharmacotherapy vol.15, Zimmerman et al (1995)

British National Formulary, BNF 50, pages 292 - 293 (2005)

 
Approval Approved by Drugs and Therapeutics Committee on 03/03/2006
Review Date February 2008
Contact Details devadas.pillay@goodhope.nhs.uk, mohammed.abba@goodhope.nhs.uk