Intravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion

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1 Intravenus Vancmycin Use in Adults Intermittent (Pulsed) Infusin Backgrund This plicy cvers the use f intravenus vancmycin prescribed as an intermittent (pulsed) infusin. This can be used fr treatment r prphylaxis. Vancmycin can als be prescribed as a cntinuus infusin. Cntinuus infusin f vancmycin is preferred, when practical, fr patients with severe r deep-seated infectins (e.g. pneumnia, endcarditis, bne and jint infectins) refer t separate guidance. This plicy des nt apply t the use f vancmycin in patients treated in Renal units r receiving haemdialysis r haemfiltratin. Cntra-indicatins and cautins Cntra-indicatins t vancmycin therapy hypersensitivity Cautins fr vancmycin therapy: T avid the risk f red-neck/red-man syndrme, pain r muscle spasm, ensure that the administratin rate is nt faster than 500 mg per hur. Cncurrent administratin f neurtxic and / r nephrtxic agents increases the risk f vancmycin txicity. Review therapy and cnsider amending r withhlding nephrtxic drugs during treatment with vancmycin. Where pssible, avid c-administratin with the fllwing: amphtericin ptent diuretics aminglycsides NSAIDs ACE inhibitrs The abve list is nt exhaustive cnsult the Summary f Prduct Characteristics espc fr a full list ( Due t ptential ttxicity, vancmycin shuld be avided in patients with previus hearing lss. Prescribing and dcumentatin T ensure cnsistency, reduce risk and imprve the prescribing f vancmycin, standardised charts (agreed natinally) shuld be used t dcument the prescriptin, administratin and mnitring f intermittent vancmycin infusins. These shuld be used in cnjunctin with the existing inpatient prescribing chart (e.g. kardex) and medical / nursing dcumentatin. These charts cntain a step-wise apprach t safe and effective prescribing and key pints f advice n mnitring, interpreting and re-prescribing. SAPG January 2015 Fr review January

2 Intravenus Vancmycin Use in Adults Intermittent (Pulsed) Infusin STEP 1: Prescribe the lading dse and maintenance dsage regimen T reduce the risk f mrtality, cmmence vancmycin administratin within 1 hur f recgnising sepsis. If creatinine is knwn use the nline calculatr (preferred methd). The guidelines (belw) in Table 1 (lading dse) and Table 2 (maintenance dse) can be used if the nline calculatr is nt available. The dse amunt and dsage interval are based n estimated creatinine clearance (Bx 1) and actual bdy weight. If creatinine is nt knwn calculate and prescribe a lading dse based n actual bdy weight (Table 1). Calculate the maintenance dse nce the creatinine is available. Bx 1: Estimatin f creatinine clearance (CrCl) The fllwing Cckcrft Gault equatin can be used t estimate creatinine clearance (CrCl) [140 age (years)] x weight (kg) x 1.23 (male) OR x 1.04 (female) CrCl = (ml/min) serum creatinine (micrml/l) Cautins Use actual bdy weight r maximum bdy weight whichever is lwer. Fr maximum bdy weight table see In patients with lw creatinine (< 60 micrml/l), use 60 micrml/l. Nte: Use f estimated glmerular filtratin rate (egfr) is nt recmmended LOADING DOSE Table 1: Initial vancmycin LOADING dse Actual bdy weight Dse Vlume f sdium chlride (0.9%)* Duratin f infusin < 40 kg 750 mg 250 ml 90 minutes kg 1000 mg 250 ml 2 hurs kg 1500 mg 500 ml 3 hurs > 90 kg 2000 mg 500 ml 4 hurs * Glucse 5% may be used in patients with sdium restrictin. N.B. The lading dse is based n weight nly s des nt take accunt f renal functin. When using the n-line calculatr, n rare ccasins a patient s clearance f vancmycin may be s high that the maintenance dse is higher than the lading dse. In these circumstances, the lading dse shuld be the higher f the lading and maintenance dses i.e. if lading dse is calculated as lwer than maintenance dse then give the maintenance dse as a lading dse instead. SAPG January 2015 Fr review January

3 Intravenus Vancmycin Use in Adults Intermittent (Pulsed) Infusin STEP 1: Prescribe the lading dse and maintenance dsage regimen MAINTENANCE DOSAGE REGIMEN Give the first maintenance infusin 12, 24 r 48 hurs after the lading infusin accrding t dse interval prvided by the nline calculatr r Table 2 (belw). CrCl (ml/min) Table 2: Vancmycin MAINTENANCE dsage regimen VANCOMYCIN PULSED INFUSION - INITIAL MAINTENANCE DOSAGE GUIDELINES Dse amunt Vlume f sdium chlride (0.9%)* Dse Interval < mg ver 1 hur 250 ml 48 hurs mg ver 1 hur 250 ml 24 hurs mg ver 1.5 hurs 250 ml 24 hurs mg ver 1 hur 250 ml 12 hurs mg ver 1.5 hurs 250 ml 12 hurs mg ver 2 hurs 250 ml 12 hurs mg ver 2.5 hurs 250 ml 12 hurs > mg ver 3 hurs 500 ml 12 hurs * Glucse 5% may be used in patients with sdium restrictin. Dses up t 2000 mg can be diluted in 500 ml fluid. The daily dse can be split int 3 equal dses and given 8 hurly. This apprach is especially useful fr patients wh require high dses as it prduces higher trugh cncentratins. Fr example, 1500 mg 12 hurly (3000 mg per day) culd be prescribed as 1000 mg 8 hurly and 750 mg 12 hurly (1500 mg per day) as 500 mg 8 hurly. Mnitr the vancmycin cncentratin and reassess the dsage regimen Cncentratins are meaningless unless the dse & sample times are recrded accurately Due t wide variability in the handling f vancmycin, early analysis f a vancmycin cncentratin is required t ensure that the dsage regimen is apprpriate. Take a trugh sample (pre-dse) within 48 hurs f starting therapy then every 2-3 days, r daily if the patient has unstable renal functin. Mnitr creatinine daily. Recrd the exact time f all vancmycin samples n the vancmycin prescribing chart AND n the sample request frm. If renal functin is stable, give the next dse befre the trugh result is available. If renal functin is deterirating, withhld until the result is available then fllw the advice in Table 3. SAPG January 2015 Fr review January

4 Intravenus Vancmycin Use in Adults Intermittent (Pulsed) Infusin Mnitr the vancmycin cncentratin and reassess the dsage regimen Target vancmycin cncentratins Target trugh cncentratin range: mg/l If the patient is seriusly ill (severe r deep-seated infectins), the target range is mg/l. If the measured cncentratin is < 15 mg/l, cnsider increasing the dse amunt r reducing the dsage interval (see 8 hurly dsing abve). If the patient is failing t respnd, seek advice frm micrbilgy r an infectin specialist. Adjustment f the vancmycin dsage regimen Always check that the dsage histry and sampling time are apprpriate befre interpreting the result. Seek advice frm pharmacy r micrbilgy if yu need help t interpret the result. If the measured cncentratin is unexpectedly HIGH r LOW, cnsider the fllwing: Were the dse and sample times recrded accurately? Was the crrect dse administered? Was the sample taken frm the line used t administer the drug? Was the sample taken during drug administratin? Has renal functin declined r imprved? Des the patient have edema r ascites? Table 3: Adjustment f Vancmycin Dsage Regimen Vancmycin cncentratin <10 mg/l Suggested dse change Increase the dse by 50% and cnsider reducing the dsage interval r seek advice If the patient is respnding, maintain the present dsage regimen mg/l If the patient is seriusly ill, cnsider increasing the dse amunt r reducing the dsage interval t achieve a trugh level f mg/l mg/l Maintain the present dsage regimen >20 mg/l Stp until <20 mg/l then seek advice If in dubt, take anther sample befre mdifying the dsage regimen and / r cntact pharmacy fr advice Apprved by SAPG January 2013 Fr review January

5 Intravenus Vancmycin Use in Adults Intermittent (Pulsed) Infusin Mnitr the vancmycin cncentratin and reassess the dsage regimen General pints Recrd the exact times f all measured cncentratins n the vancmycin prescriptin chart. Undertake pre-prescribing checks (Bx 2) t assess the risk f txicity Reassess the dse and cntinue r prescribe a dsage change Dcument the actin taken in the medical ntes Review the need fr vancmycin daily. Bx 2: Txicity Mnitr creatinine daily. Seek advice if renal functin is unstable (e.g. a change in creatinine f > 15-20%) Signs f renal txicity include increase in creatinine r decrease in urine utput / liguria Cnsider an alternative agent if creatinine is rising r the patient becmes liguric. Vancmycin may increase the risk f aminglycside induced ttxicity use cautin if c-prescribing. Apprved by SAPG January 2013 Fr review January