Makindo Medical Notes.com

Pre-dose ('trough') concentration should be 10-15 mg/L (15-20 mg/L for severe infections). Give slowly to avoid 'Red Man Syndrome. Red man syndrome is related to the rate of administration. It is common when vancomycin is administered at a rate of 1g in 2 hrs. The rate of infusion must not exceed 10mg/min. Max dose is 4g/day

About: Always check the BNF link here

• Glycopeptide antibiotics like Teicoplanin
• Gram-positive aerobic and anaerobic infections including MRSA
• Gram positive including MRSA though reports of resistant strains
• Vancomycin is almost completely eliminated unchanged in urine by GFR (>90%)
• Renal function is the most important factor in determining dose and frequency

Action

• Inhibits proper cell wall synthesis in Gram-positive bacteria
• Blocks incorporation of N-acetylmuramic acid and N-acetylglucosamine peptide subunits into the peptidoglycan matrix
• Vancomycin is poorly absorbed after oral administration

Vancomycin is widely used in prophylactic, empirical and targeted therapy settings. Notably, it is used in the targeted treatment of multi-resistant Staphylococcus aureus.

Indications

• Pseudomembranous colitis, Infective endocarditis due to Gram positive cocci
• Catheter associated infections, MRSA, multi-resistant staphylococci.

Administration

• There are two methods of administering intravenous vancomycin, Intermittent IV Infusion or Continuous IV infusion which should ONLY be used in Critical Care or on the Neurosurgical wards.

Dose range: You must check with BNF or drug datasheet

Admin and Monitoring Intermittent dosing

• Loading dose
  • Not for Dialysis patients, children under 16 years, CrCl < 10ml/min, patients allergic to vancomycin or other glycopeptides
  • A loading dose is given based on the patient’s actual body weight. Fluid balance (over or under hydration) is not an important factor in drug distribution. Assuming none of the above contraindications
    • Weight < 60 kg: 1000 mg in 250 ml N-saline over 2 hours
    • Weight 60-90kg: 1500 mg in 500 ml N-saline over 3 hours
    • Weight > 90 kg: 2000 mg in 500 ml N-Saline over 4 hours
    • Either Glucose 5% or Sodium chloride 0.9% (N-Saline) may be used
• Maintenance dose
  • Serum antibiotic levels should be measured in all patients who have treatment with IV vancomycin for longer than 48 hours.
  • The sample should be taken as pr the table below
  • A creatine clearance needs to be calculated. The maintenance dosing and dose interval can be worked out from the table below.
  • A trough (pre-dose) sample only is required. Record time sample is drawn. Record exact time Vancomycin is given.
  • Those with CrCl>30mls/min the next (fourth) dose should be given and the result used to change further doses if necessary.
  • The target range for vancomycin pre-dose concentrations in ALL patients on intermittent vancomycin dosing for severe infection is 15-20mg/L. Some use 10-15 mg/L so follow local guidance.
  • DO NOT WAIT FOR RESULT BEFORE GIVING THE DOSE unless patient has severe renal impairment or poor urine output (<0.5ml/kg/hr).

Maintenance Dosing intervals and doses using creatinine clearance

• Usually given in N-saline but can also use 5% Dextrose
• CRCL < 10: Do not use Vancomycin and contact Microbiology
• CRCL 10-19: 500 mg in 100 ml over 1 hr. Given 48 hrs after loading dose.
• CRCL 20-29: 500 mg in 100 ml over 1 hr. Given 24 hrs after loading dose.
• CRCL 30-39: 750 mg in 250 ml over 2 hr. Given 24 hrs after loading dose.
• CRCL 40-54: 500 mg in 100 ml over 1 hr. Given 12 hrs after loading dose.
• CRCL 55-74: 750 mg in 250 ml over 2 hr. Given 12 hrs after loading dose.
• CRCL 75-89: 1000 mg in 250 ml over 2 hr. Given 12 hrs after loading dose.
• CRCL 90-110: 1250 mg in 250 ml over 3 hr. Given 12 hrs after loading dose.
• CRCL > 110: 1500 mg in 500 ml over 3 hr. Given 12 hrs after loading dose.

Dose Adjustments

• Level < 10 mg/L
  • Increase dose by 50%, round dose to nearest 250 mg.
  • If dose exceeds 1500 mg BD then contact Microbiology
• Level 10-15 mg/L
  • Maintain present dose
  • Daily renal function check
  • Check trough twice weekly if stable
• Level > 15 mg/L (20 mg/L in Severe infection)
  • Stop until level is < 15 mg/L
  • Seek Microbiology advice
  • Check levels daily or as advised

Interactions

• Caution with other ototoxic drugs e.g. Gentamicin and Furosemide
• Caution with Gentamicin, Ciclosporin

Cautions

• Nephrotoxic - monitor levels. Ototoxic
• Avoid rapid infusion as can lead to an anaphylactoid reaction
• Elderly, Stop if tinnitus or hearing loss develops

Contraindications

• Known hypersensitivity

Side effects

• Nephrotoxicity, Ototoxicity - deafness and tinnitus
• Interstitial nephritis, Reduced neutrophils, platelets
• Stevens Johnson syndrome, Toxic epidermal necrolysis
• Hypotension, shock, wheeze
• "Red man" syndrome due to histamine release

Reference

• Dosing Vancomycin
• Vancomycin