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Vancomycin Protocol

ST. LUKE’S HOSPITAL/MERCY MEDICAL CENTER


A protocol to guide the dosing and monitoring of vancomycin in adults
Version 2.2 P&T approval date May 2005

General information:
Physicians order "Vancomycin Protocol". This document describes the steps the pharmacy will
take to accomplish the goal of delivering the correct dose, monitoring applicable kinetic
parameters and adjusting the dose accordingly.
Physicians need to specify indications and/or target trough desired.

Input needed:
Name, Date, Account Number, age, weight, initial creatinine, ongoing aminoglycoside treatment,
diagnosis, and follow-up measurements of vancomycin level and creatinine.

Output generated:
Population parameter-based vancomycin dosing regimen
Dose and Interval for vancomycin therapy to be filled out on forms sent to nursing and the
patient chart

Special considerations:
Most conditions require only trough monitoring.
Target Trough (TABLE 1)
Infected Hardware
Diabetic Foot
Osteomyelitis Pneumonia(ventilator-
Endocarditis associated, hospital-
General +
General Pneumonia + AMG acquired, healthcare-
AMG
Severe Infections associated)
Community acquired Meningitis
pneumonia
Leukemia
Target Trough 5 – 15 5 - 10 10 - 15 15 - 20
AMG = Aminoglycoside

The following conditions require individual kinetic modeling:


meningitis, endocarditis, leukemia, and osteomyelitis
patients requiring Q36H or Q48H dosing.
Physicians order vancomycin loading dose and further dosing per pharmacy recommendation –
Pharmacy will implement vancomycin protocol if loading dose is different from dose
calculated by protocol

Exclusions:
Renal failure or rapidly changing renal function (these conditions require physicians to write
custom orders or request assistance for kinetic dosing):
creatinine clearance less than 10
ongoing dialysis treatments
Determination of initial dose:
Initial Dosing (based on actual body weight, round to the nearest 100mg)
Reduce dose by 250mg for weight over 120kg
Reduce dose by 500mg for weight over 200kg
Maximum dose 3000mg
Target trough 5 – 10: Dose = 15 mg/kg
Target trough 10 – 15: Dose = 18 mg/kg
Target trough 15 – 20: Dose = 20 mg/kg
Suspected Meningitis: Initial Dose 30 mg/kg, do 1st dose kinetics to determine subsequent
dose and interval
Set subsequent doses for peak of ~ 40 and trough of ~ 20 (Q8hr interval if needed).

Determination of initial interval


A. Calculate Creatinine Clearance:
•Estimate Ideal Body Weight (IBW) (recorded on log sheet)
Males: 50kg + [2.3kg x (height in inches-60)]
Females: 45.5kg + [2.3kg x (height in inches-60)]

•Estimate Creatinine Clearance (CrCl): for patients with stable renal function ONLY
(recorded on log sheet)
-Males: CrCl (ml/min) = [(140-age)(IBW)]÷ [(serum creatinine) x72]
-Females: CrCl (ml/min) = CrCl (males) x 0.85
-A minimum SCr value of 1mg/dL should be used for elderly or malnourished patients
i.e. if their measured value is < 1mg/dl) to prevent overestimating CrCl.

B. Look up interval based on Creatinine Clearance: (TABLE 2).

CrCl (ml/min) Interval


> 80 Q 12hr
60-79 Q 18hr
40-59 Q 24hr
20-39 Q 36hr
11-20 Q 48hr

***For Q36H, Q48H: one dose only, then 1st dose kinetics ***

Determination of subsequent dosing


Decision Point:
If the patient has meningitis, endocarditis, leukemia, osteomyelitis, or patients requires Q36H
or Q48H then proceed to the "High Intensity" monitoring section.
Otherwise, proceed to "trough only monitoring" on the next page.
Trough only monitoring for subsequent dosing:
A. General information:
- Designed to achieve peak vancomycin levels in the range of 20 - 40 mcg/ml.
- Measurements of peak levels are not needed for this protocol.
- Use table 4 for dose adjustment once the trough level is available

B. Timing for drawing trough levels:


-Obtain trough prior to 3rd dose, within ½ hour before next dose is due. Since
vancomycin kills bacteria in a time-dependent manner, it is important to ensure that the
trough concentration remains above the MIC for the organism being treated.
-Once therapeutic serum level is obtained, continue to monitor trough a minimum of Q 7
days in the absence of any other clinically significant changes in the patient’s renal
function or conditions.

C. Correcting dose for changing renal function:


-Check serum creatinine (SCr) prior to start of therapy and twice weekly thereafter.
Check more frequently if on concomitant nephrotoxins, such as aminoglycosides,
unstable renal function, or goal trough > 15.
-Initial Scr ≤ 2 mg/dL: if Scr changes by ≥ 0.5mg/dL from the start of therapy, then draw
vancomycin trough level 30minutes prior to the next scheduled dose.
-Initial Scr > 2 mg/dL: if Scr changes by ≥ 1 mg/dL from the start of therapy, then draw
vancomycin trough level 30minutes prior to next scheduled dose.
Use table 4 to make necessary dose adjustments.

D. Administration guideline (Table 3):


Dose Infuse over
1 g or less 60 minutes
1.1-1.5 g 90 minutes
1.6-2 g 120 minutes
> 2g approximately 1g/hr
**may infuse more rapidly if tolerated in some instances

E. How to use table 4 for dose adjustment by trough level:


- Example: if patient is currently receiving every 12 hour regimen, and trough level came
back 1 to 5 mcg/ml less than goal, increase dose by 250mg ( if current regimen is 1 gram
every 12 hours, change to 1250mg every 12 hours). If trough level came back in the goal
range, no change is needed, etc.
High intensity monitoring for subsequent dosing:
1st dose kinetics:
- Dosing interval Q12H, Q18H, Q24H: check peak 1 hour after initial dose being infused
and trough 30 minutes before 2nd dose is due.
- Dosing interval Q36H, Q48H: check peak 1 hour after initial dose being infused and
trough 2 hours before proposed 2nd dose, make adjustments prior to 2nd dose.
Use pharmacokinetic modeling software to determine dose and interval.

A A. Determination of subsequent dosing:


B 1. Use pharmacokinetic modeling software to determine subsequent dose and
interval.
2. Timing for drawing subsequent levels:
-Obtain trough 30minutes prior to 4th dose, obtain conditional peak if trough is not in
goal range and 4-8 x MIC. Use pharmacokinetic modeling software to determine
subsequent dose and interval
--Once therapeutic serum level is obtained, continue to monitor trough a minimum of
Q 7 days in the absence of any other clinically significant changes in the patient’s
renal function or conditions.

B. Correcting dose for changing renal function:


-Check serum creatinine (SCr) prior to start of therapy and twice weekly thereafter.
Check more frequently if on concomitant nephrotoxins, such as aminoglycosides or if
unstable renal function or goal trough > 15.
-Initial Scr ≤ 2 mg/dL: if Scr changes by ≥ 0.5mg/dL from the start of therapy, then draw
vancomycin trough level 30minutes prior to the next scheduled dose.
-Initial Scr > 2 mg/dL: if Scr changes by ≥ 1 mg/dL from the start of therpay, then draw
vancomycin trough level 30minutes prior to next scheduled dose.
Use pharmacokinetic modeling software to make any dosing adjustment necessary as
above.
Dose Adjustment (TABLE 4)

Trough > 5 below 1-5 below At Goal 1-5 above 6-10 above > 10 above goal
goal goal goal goal
Q12H Dose Dose No ∆ Interval to ∆ Interval to Hold further dosing,
500mg 250mg change Q18H Q24H redraw level at 24
hours
Q18H ∆ interval ∆ Interval No ∆ Interval to ∆ Interval to Hold further dosing,
to Q12H to Q12H change Q24 Q36- Obtain redraw level at 36
and dose trough before hours
250mg 2nd dose
Q24H ∆ interval ∆ Interval No ∆ Interval to ∆ Interval to Hold further dosing,
to Q12H to Q18H change Q36 –Obtain Q48 – Obtain redraw level at 48
trough before trough before hours
2nd dose 2nd dose
Q36H ∆ interval ∆ Interval No ∆ Interval to Hold further Dose by levels,
to Q18H to Q24H change Q48 –Obtain dosing, inform MD
before 2nd Redraw level
dose at 72 hours
Q48H ∆ interval ∆ Interval No Decrease Dose by Dose by levels,
to Q24H to Q36H change dose 250mg levels, inform inform MD
MD

*** If trough < 4 –8 x MIC use kinetic software to target trough in the range of 4 –8 x MIC ***