Therapeutic Handbook - GGC Prescribing

Vancomycin dosing guidelines (For patients aged > 16 years)General points• Continuous infusion of vancomycin is preferred for patients with severe or deep-seated infections(e.g. pneumonia, endocarditis, bone and joint infections).• These guidelines do not apply to patients in Renal Units, on haemodialysis or on haemofiltration.• Contra-indications: hypersensitivity• Cautions: Co-administration with potentially nephrotoxic agents (amphotericin, potent diuretics,NSAIDs, aminoglycosides, ACE inhibitors – see www.medicines.org.uk). Avoid in patientswith previous hearing loss. To avoid the risk of “red-neck / red-man syndrome”, pain or musclespasm, administer no faster than 500 mg/hour.A. Intermittent ‘Pulsed’ infusion (if continuous infusion is not practical)InfectionsPrescribing and documentationRefer to hospital site policy regarding how to prescribe vancomycin and where to record doses andconcentration measurements.Step 1: Prescribe the loading dose and maintenance dosage regimen• To reduce the risk of mortality, commence vancomycin administration within 1 hour of recognisingsepsis.• If creatinine is known – use the online calculator on StaffNet, Clinical Info section. If it is notavailable, use the Loading and Maintenance Infusion tables below. The dose amount anddosage interval are based on estimated CrCl (see page 260) and actual body weight (ABW). Donot use eGFR.• If creatinine is not known – calculate the single loading infusion dose using actual body weight,prescribe and administer. Calculate the maintenance dose once creatinine is available.Table 1: Vancomycin LOADING infusionActual body weight Dose amountVolume of sodium chloride(0.9%) *Duration of infusion< 40 kg 750 mg 250 ml 90 minutes40 – 59 kg 1000 mg 250 ml 2 hours60 – 90 kg 1500 mg 500 ml 3 hours> 90 kg 2000 mg 500 ml 4 hours* Glucose 5% may be used in patients with sodium restriction.Table 2: Vancomycin maintenance intermittent (pulsed) infusion continued on next pagePage 266