Vancomycin intermittent pulsed guideline for adults. Dosing regimens should be tailored based on presumed source of infection, mic data when available, and residual renal function. Avoid if crcl vancomycin dosing guidelines or order vancomycin dosing by pharmacy program. Trough pre levels are taken immediately before a dose within 30 minutes the timing of drug administration and sample collection must be carefully documented do not hold next vancomycin dose while waiting for results of vancomycin levels unless there is a specific reason to do so, e. Microsoft word vancomycin dosing protocol revised 2003. Iv vancomycin dosing and monitoring antibiotic guidelines. You therefore will need to increase the dose by moving 2 levels up the maintenance dose ladder. Intravenous vancomycin in adults wa country health service. In fact, adequate data were not avail able to make recommendations in the original guideline for specific dosing and monitoring for pediatric patients outside of the. Use the following table to guide monitoring of vancomycin based on the patients clinical status. Dose dose new trough trough goal formula can be used if dosing interval stays the same and renal function is stable hemodialysis dose adjustments based on predialysis level 1015 mcgml increase dose by 250 mg 1525 mcgml redose at previous dose 25 mcgml decrease dose by 250 mg or hold. Aug 18, 2020 so per the guidelines, if a loading dose is clinically appropriate, you should use an actual body weightbased dose of 2025 mgkg, but cap the dose at 3000 mg. Vancomycin prescribing and therapeutic drug monitoring. Sbuh vancomycin dosing protocol for adult patients initial.
Vancomycin is a glycopeptides antibiotic that is active against aerobic and anaerobic grampositive cocci. Vancomycin dosing and monitoring in adults clinical guideline. Our new vancomycin dosing protocol proved to be an effective and more convenient initial approach to achieving therapeutic serum concentrations in patients undergoing hd. Increased risk of vancomycin induced nephrotoxicity vd increase not reliably associated with weight increase loading dose 2025mgkg recommended in patients with serious infections 3gm dose cap max daily vancomycin doses of 4. Standarddose vancomycin nomogram michigan medicine. To the editorthe healthcareassociated ventriculitis and meningitis guidelines provide an update to adjusting intraventricular ivt antibiotic doses.
If the estimated renal function crcl is near the border of two dosing intervals, it may be reasonable to begin with the more aggressive interval. Crcl vancomycin is almost exclusively renally cleared and must be renally adjusted. Obtain a vancomycin level and dose per level monitor random levels in patients and re dose when level vancomycin. Protocol i starting regimen all patients who are not already on vancomycin should receive an ideal. Development and evaluation of vancomycin dosage guidelines designed. The use in febrile neutropenia should be in accordance with eviq guidelines. Trough serum vancomycin concentrations in that range should achieve an aucmic of. Dec 18, 2015 therapy in accordance with evidencebased guidelines and best practice standards pharmacist will. Sbuh vancomycin dosing protocol for adult patients continued vancomycin dosing recommendations for patients receiving intermittent hemodialysis adult vancomycin dosing esrd on intermittent hd skin and soft tissue infections first dose subsequent dosing.
Monitor by prehemodialysis level see sbuh vancomycin dosing guidelines for monitoring targets if the same posthemodialysis dose is given for 2 consecutive hemodialysis sessionsin achieving the prehd target, that same dose can be given after each hemodialysis thereafter. We designed a modified vanco mycin dosing protocol that uses a patients serum creatinine scr level, age, and dosage of concurrent gentamicin when. Use guideline based vancomycin dosing and monitoring to maximize treatment success and reduce unnecessary plasma vancomycin levels and needless dosage changes. Consider standard dose for most infections except meningitis, endocarditis. Antibiotic assays for vancomycin and gentamicin are performed by biochemistry. Pharmacy vancomycin dosing guidelines revised 62014 guidelines for dosing and monitoring patients on vancomycin background. Modified vancomycin dosing protocol for treatment of diabetic foot. Sbuh vancomycin dosing protocol for adult patients. However, due to the paucity of data, vancomycin dosing for peritonitis in patients on 52 automated peritoneal dialysis apd is empiric and based on clinical experience rather than evidence. Intravenous formulations are used to treat infections with grampositive bacteria and for surgical prophylaxis in some situations. Monitoring can be extended to once a week or once every 2 weeks. Guidelines for vancomycin dosing and determination of trough.
Vancomycin use, dosing and serum trough concentrations in the. Initial vancomycin dosing regimens and corresponding initial trough levels obtained were evaluated. The vancomycin serum concentration targets of this protocol are 1520 mcgml. The following table aims to target a vancomycin trough level of 1520mgml subsequent doses may be increased incrementally up to a maximum dose of 80mgkgday based on serum trough levels if clinically appropriate e. It is slowly bactericidal with a mechanism of action that consists of binding to peptidoglycan precursors and thus.
Patient is on vancomycin 1g bd and the trough level comes back as 4. Vancomycin dosing for adults university health system. Vancomycin concentration suggested dose change dosing band in the maintenance dose table above in first instance then if still low seek advice 10 15 mgl and nondeep seated infection if the patient is responding, maintain the present dosage regimen. Trough goals of 1520 mcgml are likely to hit auc targets in mrsa with mic 1 mcgml. Since empiric maintenance doses depend on vancomycin clearance, which typically doesnt exceed a certain level in obese patients, its also recommended to stay below 4500 mgday. Calculated vancomycin loading dose for adults with normal renal.
Empiric therapy for severe communityacquired sepsis. Initial vancomycin maintenance dosing and serum concentration. Vancomycin monitoring and dosing guideline alberta health. Mar 19, 2020 this document is an executive summary of the new vancomycin consensus guidelines for vancomycin dosing and monitoring. Therapeutic monitoring of vancomycin in adult patients. Vancomycin dosing for adults university health system necessary patient information for dosing actual body weight the use of actual body weight is recommend for vancomycin dosing crcl vancomycin is almost exclusively renally cleared and must be renally adjusted o crcl 140age x wt in kg x 0. The researchers concluded that vancomycin dosages of 500 mg every 6 hours or 1 g every 12 hours provide aucmic values of f 100250 and suggested that values around 500 may enhance. Restart vancomycin when level vancomycin infusion this method of vancomycin administration is for use in itu patients only. The potential benefits of weightbased dosing could be further diluted in the clinical setting by the common practice of selecting doses in 250mg increments. Renal dose adjustment guidelines for antimicrobials crrt. Sbuh guidelines for vancomycin serum concentration monitoring.
Troughbased protocol ihd, pd, nocturnal crrt, dose bylevel. Crrt is off, dose as hemodialysis patients or based on any residual renal function. After the target auc or trough level is achieved at steady state, trough levels should be checked every. Doses may vary based on indications, severity, andor patient factors. The pharmacist assumes responsibility of dosing and ordering levels when providers enter a pharmacist onsult. Therapeutic monitoring of vancomycin for serious methicillin. As a guide this is 710 mgkg prior to the second 2 nd. The monitoring of vancomycin to achieve efficacious levels and avoid toxicity is usually done as trough levels. If vancomycin dose is adjusted due to trough out of therapeutic range, the trough must be checked within 1 hour prior to the 4th new dose.
Vancomycin use is limited to the following indications unless use is in. Initial vancomycin dosing protocol to achieve therapeutic. Iv vancomycin dosing and monitoring antibiotic guidelines reference number. Shc antimicrobial dosing guidelines in adults on renal replacement therapies these are general dosing guidelines for reference only. Shc antimicrobial dosing guidelines in adults on renal. Initial vancomycin maintenance dosing and initialrepeat monitoring i. Establish patient age, weight, and serum creatinine. All results will be available on the computer as soon as the test is complete. Informal copy when printed vancomycin dosing and monitoring in adults clinical guideline page4 of 14 public i4a2. Initial vancomycin dosing protocol to achieve therapeutic serum. Pharmacy vancomycin dosing guideline summary revised 72014. Intravenous vancomycin use adult inpatientambulatory. Check a vancomycin level at 2448 hours post dose or with am labs on the day of the next hemodialysis session if applicable to obtain an estimated steady state level a high flux filters in hd will remove 2040% of the vancomycin dose during dialysis.
Patients should have vancomycin troughs and serum creatinine drawn on a weekly basis while on therapy. Administration of vancomycin by continuous infusion. Cerebrospinal fluid vancomycin dosing and monitoring. In patients with renal impairment, vancomycin trough will be ordered sooner than the 4th dose and subsequent dosage adjustments will be made based on renal function and serum concentration by pharmacy. The maximum recommended dose for adult or pediatric patients is 100mgkgday or 6 gramsday. Vancomycin dosing, administration and monitoring guidelines for. All adult patients requiring antimicrobial therapy with intravenous vancomycin with the following exclusions.
Vancomycin empiric dosing for severe or deepseated infections. Continuous infusion protocol introduction vancomycin has traditionally been dosed as intermittent boluses. If this increase will exceed 1500mg bd, seek immediate advice from microbiology. In adult patients, cefazolin 2 g if vancomycin 1 g if dosing is based on weight. Vancomycin dosing and monitoring for pediatric patients. The guidelines recommend trough concentrations are 1020 times the minimum inhibitory concentration mic of the isolated pathogen in addition to incorporating empiric vancomycin adjustments based on ventricle size, volume, and external. A loading dose should be given to all patients starting on vancomycin. Rate of infusion in mgmin target concentration in mgl x 0. The recommendations below should be used as a guideto aid in antibiotic dosing while on crrt.
Idsa vancomycin dosing guidelines concerning troughs of 1520 mcgml. It was developed by the american society of healthsystem pharmacists, the infectious diseases society of america, the pediatric infectious diseases society, and the society of infectious diseases pharmacists vancomycin consensus guidelines committee. Vancomycin regional guideline september 27, 2011 9 appendix 2 dosing recommendations for children and pregnant women for pediatric patients, the childrens and womens hospital of british columbia dosing guidelines recommend routine empiric vancomycin doses of 4060 mgkgday, divided every 8 hours. Vancomycin empiric dosing guidelines october 2018, 4th edition for more information, please contact pharmacy or visit. Current recommended dosing of vancomycin for children with. Please contact pharm with questionsconcerns consider adequate loading doses to ensure prompt attainment of steady state drug levels. There have been a number of logistical and medical problems with the safe dosing and monitoring of vancomycin. Guidelines for the dosing and monitoring of gentamicin, vancomycin and teicoplanin general points. Vancomycin dosing for pediatrics university health system. Weightbased dosing is recommended for all antibiotics in patients jul 03, 2001 aminoglycoside dosing in patients with cystic fibrosis 12 vancomycin overview and pharmacokinetic calculations 15 clinical pearls 21 dialysis aminoglycosides and vancomycin 21 tnmc nephrology protocol for vancomycin dosing 21 clinical pharmacokinetic consult service 23.
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