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Aminoglycoside & Vancomycin Dosing & Monitoring (Adults)

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Amikacin Dosing & Monitoring

Amikacin Dosing & Monitoring

  1. Reserve antimicrobial : Effective use of amikacin is complex and should be discussed with Microbiology or Infectious Diseases. The following is provided for guidance.
  2. In general, treatment should be reviewed within 24 hours, and daily thereafter by consultant/specialist registrar. Courses should not usually exceed 3 days. The recommended maximum daily dose is 1.5g; the maximum cumulative dose should not exceed 15g per treatment course.
  3. In multi-drug resistant TB (on Infectious Diseases or Respiratory or Microbiology advice), see IV guideline on MedinfoGalway for dosing and monitoring guidance.
  4. Once daily dosing of amikacin is recommended for most patients. Discuss patients with renal impairment with creatnine clearance less than 30ml/minute with Microbiology or Infectious Diseases
  5. Amikacin is potentially nephrotoxic & ototoxic; monitor amikacin levels closely.
  6. Prolonged duration of treatment and co-administration of nephrotoxins (e.g. diuretics, NSAIDs, vancomycin) increases risk of toxicity and should be avoided where possible.
  7. The responsible clinical team must check reported amikacin levels regularly and adjust dosing if required. The laboratory does NOT alert teams of out of range results. Levels must arrive in the microbiology laboratory by 11am Monday to Friday and by 10am Saturday (not processed on Sunday) to be analysed on the day of receipt.
  8. Do NOT hold dose while waiting for level to be reported, in a patient less than 65 years with good renal function (creatinine clearance greater than 80ml/minute) and with good urine output.
  9. However, in a patient over 65 years, or with abnormal renal function (creatinine clearance less than 80ml/minute), it is generally preferable to await the result of the first amikacin level (i.e. before the second dose) before giving the next dose. If the level is less than 5 mg/L and renal function is stable it is not necessary to routinely hold subsequent doses pending levels.

Table 1: Once Daily Amikacin Dosing Guidelines (Except TB)

Step 1

Cautions/

Discuss with Micro or ID or Pharmacy

Cautions: Age ≥65, renal impairment (CrCl <80ml/min), obesity (use adjusted dosing weight), other nephrotoxins

Patients with severe renal impairment (CrCl <30ml/min) should be discussed with Microbiology or Infectious Diseases

TB: See IV guideline on MedinfoGalway for guidance on dosing & monitoring in TB patients

Step 2

Calculate patient’s ideal body weight (IBW):

Height required

Ideal Body Weight (IBW) (kg) =

Male: 50kg + (2.3 x inches over 5 feet) OR

50kg + (0.9 x cm over 152cm)

Female: 45.5kg + (2.3 x inches over 5 feet) OR

45.5kg + (0.9 x cm over 152cm)

Step 3

Dosing Weight/

Obesity Adjustment:

Weight required

Obesity adjustment :

Obese patient: If actual body weight exceeds IBW by ≥20%, calculate Adjusted Dosing Weight:

Adjusted Dosing Weight (kg)  =

Ideal Body Weight + 0.4 x (Actual Body Weight – Ideal Body Weight)

Non-obese patient: Use actual body weight to dose amikacin.

Step 4

Estimate renal function:

Patient age, weight, height, & serum creatinine required

Must use creatinine clearance ( not eGFR) to dose amikacin.

Calculate the patient’s estimated creatinine clearance using Cockcroft & Gault equation.

Neither creatinine clearance nor eGFR provide a perfect marker of renal function, particularly if rapidly changing renal function.

Step 5

Select a dose based on renal function and weight. If obese use Adjusted Dosing Weight; If non-obese use Actual Body Weight (See Step 3).

CrCl (ml/min)

Dose: round to nearest 50mg

Greater than 80

15mg per kg IV (up to a max of 1.5g)

every 24 hours

60 to 79

12mg per kg IV (up to a max of 1.5g)

every 24 hours

40 to 59

7.5mg per kg IV (up to a max of 1.5g)

every 24 hours

30 to 39

4mg per kg IV (up to a max of 1.5g)

every 24 hours

less than 30

Avoid if possible.

If essential, give 3 to 4mg per kg IV (up to a max of 320mg), one dose only

Check level at 24 hours, discuss need for second dose with Micro/ID

Intermittent haemodialysis: 5mg/kg (up to a max of 400mg) with each dialysis. Give dose post-dialysis.

Table 2: Once Daily Amikacin Administration & Monitoring Guidelines

Administration

  • By IV infusion in 100ml of NaCl 0.9% or Glucose 5% over 30 to 60 minutes. See IV administration guide on MedinfoGalway .

  • Give first dose immediately.

Monitoring

Discuss with pharmacy for advice on monitoring in TB patients. The following applies to indications other than TB:

  • Measure pre-dose (trough) levels only.

  • Post-dose (peak) levels not routinely measured EXCEPT in TB. Ask pharmacy for guidance.

  • The first pre-dose level should be taken within 1 hour before the 2 nd dose is due.

  • Document on request form date and time sample was taken and date and time of last dose.

  • If the level is less than 5mg/L, re-check pre-dose levels twice per week thereafter, or more often if impaired or rapidly changing renal function, haemodynamically unstable, elderly, or on diuretic therapy

  • Note that monitoring of renal function in addition to monitoring of aminoglycoside levels is important as toxicity may occur in patients in whom the aminoglycoside levels have never exceeded the acceptable range.

  • With respect to ototoxicity, vestibular disturbance (vertigo, ataxia) often precedes disturbance of hearing and should not be discounted because the patient has levels within the acceptable range.

Table 3: Interpretation of Pre-dose Levels for Once Daily Amikacin

Target pre-dose (trough) level is <5mg/L

Level

Advice

<5 mg/L

  1. Is amikacin still needed?

  2. Is patient responding clinically?

  3. Continue same dose if renal function stable - but if renal function is changing, recalculate dose with current creatinine

  4. Check level in 3 days ( or more often if impaired or rapidly changing renal function, haemodynamically unstable, elderly, or on diuretic therapy)

≥5 mg/L

  1. Is amikacin still needed?

  2. Is it a true pre-dose (trough) (taken within one hour before dose)?

  3. Where was sample taken from? (falsely high levels can occur if taken from same line used to give amikacin)

  4. Is dose correct for weight & renal function?

  5. Is renal function stable?

  6. Dose adjustment required - contact Microbiology or Infectious Diseases or Pharmacy to discuss on a case-by-case basis.

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Gentamicin Dosing & Monitoring

Gentamicin Dosing & Monitoring​

  1. Effective use of gentamicin is complex and should normally be discussed with Microbiology or Infectious Diseases. The following is provided for guidance.
  2. In general, treatment should be reviewed within 24 hours, and daily thereafter by consultant/specialist registrar. Courses should not usually exceed 3 days.
  3. Once daily dosing of gentamicin is recommended for most patients. Discuss patients with renal impairment with creatinine clearance less than 30ml/minute with Microbiology/Infectious Diseases.
  4. This once daily gentamicin regimen is not recommended for endocarditis, as an alternative dosing regimen is recommended - see Table 4.
  5. Gentamicin is potentially nephrotoxic & ototoxic; monitor gentamicin levels closely.
  6. Prolonged duration of treatment and co-administration of nephrotoxins (e.g. diuretics, NSAIDs, vancomycin) increases risk of toxicity and should be avoided where possible.
  7. The responsible clinical team must check reported gentamicin levels regularly and adjust dosing if required. The laboratory does NOT alert teams of out of range results. Levels are processed once daily and must arrive in the biochemistry laboratory by 11am to be analysed on the day of receipt.
  8. Do NOT hold dose while waiting for level to be reported, in a patient less than 65 years with good renal function (creatinine clearance greater than 80ml/minute) and with good urine output.
  9. However, in a patient over 65 years, or with abnormal renal function (creatinine clearance less than 80ml/minute), it is generally preferable to await the result of the first gentamicin level (i.e. before the second dose) before giving the next dose. If the level is less than 1mg/L and renal function is stable it is not necessary to routinely hold subsequent doses pending levels.

Table 1: Once Daily Gentamicin Dosing Guidelines

Use the Gentamicin Dosing Calculator in the GAPP App to calculate Once Daily Gentamicin dose. Details provided below for background information.The calculator will not produce reliable results in patients who are anuric or in acute renal failure. Advice should be sought from your ward pharmacist or Microbiology or Infectious Diseases.

Do NOT use the calculator for patients with infective endocarditis, as an alternative dosing regimen is recommended -see Table 4

Step 1

Cautions/

Discuss with Micro or ID

  • Cautions: Age ≥65, renal impairment (CrCl <80ml/min), obesity (use adjusted dosing weight), other nephrotoxins.

  • The following should be discussed with Microbiology or Infectious Diseases: Patients with severe renal impairment (CrCl <30ml/min), endocarditis.

  • Once daily gentamicin is not recommended for endocarditis where an alternative dosing regimen is recommended. See Table 4.

Step 2

Calculate patient’s ideal body weight (IBW):

Height required

Ideal Body Weight (IBW) (kg) =

Male: 50kg + (2.3 x inches over 5 feet) OR

50kg + (0.9 x cm over 152cm)

Female: 45.5kg + (2.3 x inches over 5 feet) OR

45.5kg + (0.9 x cm over 152cm)

Step 3

Dosing Weight/

Obesity Adjustment:

Weight required

Obesity adjustment :

  • Obese patient: If actual body weight exceeds IBW by ≥20%, calculate Adjusted Dosing Weight:

Adjusted Dosing Weight (kg) =

Ideal Body Weight + 0.4 x (Actual Body Weight – Ideal Body Weight)

  • Non-obese patient: Use actual body weight to dose gentamicin.

Step 4

Estimate renal function:

Patient age, weight, height, & serum creatinine required

  • Must use creatinine clearance ( not eGFR) to dose gentamicin.

  • Calculate the patient’s estimated creatinine clearance using Cockcroft & Gault equation.

  • Use Gentamicin dosing calculator

  • Neither creatinine clearance nor eGFR provide a perfect marker of renal function, particularly if rapidly changing renal function.

Step 5

Select a dose based on renal function and weight. If obese use Adjusted Dosing Weight; If non-obese use Actual Body Weight (See Step 3)

CrCl (ml/min)

Dose: round to nearest multiple of 40mg

NB: Doses above 400mg once daily rarely needed

Greater than 80

5mg per kg IV (up to a max of 400mg)

every 24 hours

60 to 79

4mg per kg IV (up to a max of 400mg)

every 24 hours

40 to 59

3.5mg per kg IV (up to a max of 400mg)

every 24 hours

30 to 39

2.5mg per kg IV (up to a max of 400mg)

every 24 hours

less than 30

Avoid if possible.

If essential, give 2mg per kg IV (up to a max of 160mg), one dose only

Check level at 24 hours, discuss need for second dose with Micro or ID

Intermittent haemodialysis: See Haemodialysis Dosing Guidelines

Table 2: Once Daily Gentamicin Administration & Monitoring Guidelines

Administration

· By IV infusion in 50 to 100ml of NaCl 0.9% over 30 minutes. See IV administration guide on ward or pharmacy internet http://medinfogalway/ivguides

· Give first dose immediately.

Monitoring

· Measure pre-dose (trough) levels only.

· The first pre-dose level should be taken within 1 hour before the 2nd dose is due.

· Document on request form date and time sample was taken and date and time of last dose.

· If the level is less than 1mg/L, re-check pre-dose levels twice per week thereafter, or more often if impaired or rapidly changing renal function, haemodynamically unstable, elderly, or on diuretic therapy

· Note that monitoring of renal function in addition to monitoring of aminoglycoside levels is important as toxicity may occur in patients in whom the aminoglycoside levels have never exceeded the acceptable range.

· With respect to ototoxicity, vestibular disturbance (vertigo, ataxia) often precedes disturbance of hearing and should not be discounted because the patient has levels within the acceptable range.

Table 3: Interpretation of Pre-dose Levels for Once Daily Gentamicin

Target pre-dose (trough) level is <1mg/L

Level

Advice

<1mg/L

1. Is gentamicin still needed?

2. Is patient responding clinically?

3. Continue same dose if renal function stable but if renal function is changing, recalculate dose with current creatinine

4. Check level in 3 days ( or more often if impaired or rapidly changing renal function, haemodynamically unstable, elderly, or on diuretic therapy)

≥1mg/L

1. Is gentamicin still needed?

2. Is it a true pre-dose trough level (taken within one hour before dose)?

3. Where was sample taken from? (falsely high levels can occur if taken from same line used to give gentamicin).

4. Is dose correct for weight & renal function?

5. Is renal function stable?

6. Dose adjustment required - contact Microbiology or Infectious Diseases or Pharmacy to discuss on a case-by-case basis.

Table 4: Multiple Daily Gentamicin Dosing Guidelines - for Treatment of Endocarditis and Synergy Only

Discussion with Microbiology or Infectious diseases recommended

Other than for endocarditis and synergy, multiple daily dosing of gentamicin is rarely indicated. Once the causative organism has been identified in infective endocarditis, an alternative gentamicin dosing regimen may be indicated on consultation with Microbiology or Infectious Diseases.

Dose

CrCl >70ml/min

Dose – renal impairment

Recommended range for levels

Timing and frequency of levels

1mg/kg (maximum 80mg)

every 8 to 12 hours depending on renal function and age

Contact Microbiology or Infectious Diseases for advice

Pre-dose :

<1mg/L

Post-dose:

3 to 5 mg/L

· Take first pre-dose (trough) level within one hour before 3 rd /4 th dose

· Take first post-dose (peak) level one hour after 3 rd /4 th dose

· Repeat pre-dose (trough) level every 3 days or more often if high risk of accumulation

· Post-dose (peak) levels need only be taken once weekly from week two onwards

· Adjust dose according to levels

· Monitor renal function

· Contact Microbiology or Infectious Diseases for further advice

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Tobramycin Dosing & Monitoring

Tobramycin Dosing & Monitoring

  1. Effective use of tobramycin is complex and should be discussed with Microbiology or Infectious Diseases. The following is provided for guidance.
  2. In general, treatment should be reviewed within 24 hours, and daily thereafter by consultant/specialist registrar. Courses should not usually exceed 3 days, except in cystic fibrosis.
  3. Once daily dosing of tobramycin is recommended for most patients. Discuss patients with renal impairment with creatinine clearance less than 30ml/minute with Microbiology/Infectious Diseases.
  4. Tobramycin is potentially nephrotoxic & ototoxic; monitor tobramycin levels closely.
  5. Prolonged duration of treatment and co-administration of nephrotoxins (e.g. diuretics, NSAIDs, vancomycin) increases risk of toxicity and should be avoided where possible.
  6. The responsible clinical team must check reported tobramycin levels regularly and adjust dosing if required. The laboratory does NOT alert teams of out of range results. Levels must arrive in the microbiology laboratory by 11am Monday to Friday and by 10am Saturday (not processed on Sunday) to be analysed on the day of receipt.
  7. Do NOT hold dose while waiting for level to be reported, in a patient less than 65 years with good renal function (creatinine clearance greater than 80ml/minute) and with good urine output.
  8. However, in a patient over 65 years, or with abnormal renal function (creatinine clearance less than 80ml/minute), it is generally preferable to await the result of the first tobramycin level (i.e. before the second dose) before giving the next dose. If the level is less than 1mg/L and renal function is stable it is not necessary to routinely hold subsequent doses pending levels.

Table 1: Once Daily Tobramycin Dosing Guidelines (Cystic Fibrosis only)

Dose (Cystic Fibrosis only)

· 10mg/kg (if renal function is normal) as a single dose every 24 hours, up to a maximum of 700mg in adults (660mg in children less than 18 years)

Obesity

· If actual body weight exceeds ideal body weight by ≥ 2 0%, an adjusted dosing weight should be used to calculate the dose

Renal Impairment

· Contact Microbiology or Infectious Diseases for advice

Table 2: Once Daily Tobramycin Dosing Guidelines (other than Cystic Fibrosis)

Use the Tobramycin Dosing Calculator in the GAPP App to calculate Once Daily Tobramycin dose in non-CF patients. Details provided below for background information. The calculator will not produce reliable results in patients who are anuric or in acute renal failure. Advice should be sought from your ward pharmacist or Microbiology or Infectious Diseases.

Do NOT use the calculator for patients with Cystic Fibrosis, as an alternative dosing regimen is recommended - see Table 1 above

Step 1

Cautions/

Discuss with Micro or ID

  • Cautions: Age ≥65, renal impairment (CrCl <80ml/min), obesity (use adjusted dosing weight), other nephrotoxins.

  • Patients with severe renal impairment (CrCl <30ml/min) should be discussed with Microbiology or Infectious Diseases.

Step 2

Calculate patient’s ideal body weight (IBW):

Height required

Ideal Body Weight (IBW) (kg) =

Male: 50kg + (2.3 x inches over 5 feet) OR

50kg + (0.9 x cm over 152cm)

Female: 45.5kg + (2.3 x inches over 5 feet) OR

45.5kg + (0.9 x cm over 152cm)

Step 3

Dosing Weight/

Obesity Adjustment:

Weight required

Obesity adjustment :

  • Obese patient: If actual body weight exceeds IBW by ≥20%, calculate Adjusted Dosing Weight:

Adjusted Dosing Weight (kg) =

Ideal Body Weight + 0.4 x (Actual Body Weight – Ideal Body Weight)

  • Non-obese patient: Use actual body weight to dose tobramycin.

Step 4

Estimate renal function:

Patient age, weight, height, & serum creatinine required

  • Must use creatinine clearance ( not eGFR) to dose tobramycin.

  • Calculate the patient’s estimated creatinine clearance using Cockcroft & Gault equation.

  • Use Tobramycin dosing calculator

  • Neither creatinine clearance nor eGFR provide a perfect marker of renal function, particularly if rapidly changing renal function.

Step 5

Select a dose based on renal function and weight. If obese use Adjusted Dosing Weight; If non-obese use Actual Body Weight (See Step 3).

Do NOT use this table for patients with Cystic Fibrosis

CrCl (ml/min)

Dose: round to nearest multiple of 40mg

NB: Doses above 400 mg once daily rarely needed

Greater than 80

5mg per kg IV (up to a max of 400mg)

every 24 hours

60 to 79

4mg per kg IV (up to a max of 400mg)

every 24 hours

40 to 59

3.5mg per kg IV (up to a max of 400mg)

every 24 hours

30 to 39 2.5mg per kg IV (up to a max of 400mg) every 24 hours

less than 30

Avoid if possible.

If essential, give 2mg per kg IV (up to a max of 160mg), one dose only

Check level at 24 hours, discuss need for second dose with Micro or ID

Intermittent haemodialysis: 1mg/kg (up to a maximum of 80mg) with each dialysis. Give dose post-dialysis.

Table 3: Once Daily Tobramycin Administration & Monitoring Guidelines

Administration

· By IV infusion in 50 to 100ml of NaCl 0.9% or Glucose 5% over 20 to 60 minutes. See IV administration guide on ward or pharmacy internet http://medinfogalway.ie/ivguides

· Give first dose immediately.

Monitoring

· Measure pre-dose (trough) levels only.

· The first pre-dose level should be taken within 1 hour before the 2 nd dose is due.

· Document on request form date and time sample was taken and date and time of last dose.

· If the level isless than 1mg/L, re-check pre-dose levels twice per week thereafter (once weekly in cystic fibrosis patients), or more often if impaired or rapidly changing renal function, haemodynamically unstable, elderly, or on diuretic therapy

· Note that monitoring of renal function in addition to monitoring of aminoglycoside levels is important as toxicity may occur in patients in whom the aminoglycoside levels have never exceeded the acceptable range.

· With respect to ototoxicity, vestibular disturbance (vertigo, ataxia) often precedes disturbance of hearing and should not be discounted because the patient has levels within the acceptable range.

Table 4: Interpretation of Pre-dose Levels for Once Daily Tobramycin

Target pre-dose (trough) level is <1mg/L

Level

Advice

<1 mg/L

1. Is tobramycin still needed?

2. Is patient responding clinically?

3. Continue same dose if renal function stable -but if renal function changing, recalculate dose with current creatinine

4. Check level in 3 days ( or more often if impaired or rapidly changing renal function, haemodynamically unstable, elderly, or on diuretic therapy)

≥1 mg/L

1. Is tobramycin still needed?

2. Is it a true pre-dose (trough) (taken within one hour before dose)?

3. Where was sample taken from? (falsely high levels can occur if taken from same line used to give tobramycin).

4. Is dose correct for weight & renal function?

5. Is renal function stable?

6. Dose adjustment required - contact Microbiology or Infectious Diseases or Pharmacy to discuss on a case-by-case basis.

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Intravenous Vancomycin Dosing & Monitoring

Intravenous Vancomycin Dosing & Monitoring

1. Effective use of Vancomycin is complex and should normally be discussed with Microbiology or Infectious Diseases. In particular, discuss patients with renal impairment with creatinine clearance less than 30ml/minute – or those on prolonged courses. The following is provided for guidance.

2. Review empiric treatment every 24 hours.

3. The responsible clinical team must check reported Vancomycin levels and renal function regularly and adjust dosing if required. The laboratory does NOT alert teams of out of range results. Levels are available daily from 8am to 8pm.

4. Do not hold doses pending levels unless specifically requested to do so or toxicity suspected. This practice frequently results in sub-therapeutic levels.

Table 1: Vancomycin Dosing Guidelines

Use the IV Vancomycin Dosing Calculator in the GAPP App to calculate the initial dose of vancomycin.

The calculator is suitable for patients with stable renal function – and will not produce reliable results in patients who are anuric or in acute renal failure. Advice should be sought from your ward pharmacist or Microbiology or Infectious Diseases.

Details provided below for background information.

Step 1

Estimate renal function:

Patient age, weight, height & creatinine required

· Must use creatinine clearance ( not eGFR) to dose vancomycin.

· Calculate the patient’s estimated creatinine clearance using Cockcroft & Gault equation. Use Vancomycin Dosing Calculator

· Neither creatinine clearance nor eGFR provide a perfect marker of renal function, particularly if rapidly changing renal function.

Step 2

Does the patient need a loading dose?

· Initial loading dose of 25mg/kg (maximum 2g) by IV infusion recommended for critical care patients, haematology/oncology patients, complicated infections e.g. endocarditis, osteomyelitis, bloodstream infection, meningitis, or MRSA pneumonia, and if recommended by Microbiology or Infectious Diseses.

· Use actual body weight to calculate the dose.

· Round dose to nearest multiple of 250mg.

Step 3

Select an initial maintenance dose based on renal function and actual body weight

Creatinine Clearance: (ml/minute)

Dose:

Round to nearest multiple of 250mg

Frequency:

Greater than 50

15mg per kg IV (max 2g)

Every 12 hours

20 to 50

15mg per kg IV (max 2g)

Every 24 hours

less than 20

15mg per kg IV (max 2g)

Re-dose based on levels, generally every 3 to 7 days; discuss with Microbiology or Infectious Diseases or Pharmacy

Intermittent haemodialysis: See Haemodialysis Dosing Guidelines

Table 2: Vancomycin Administration and Monitoring Guidelines

Administration

  • Must be given by IV Infusion, maximum rate 10mg/min (otherwise risk of anaphylactoid reactions, thrombophlebitis and red man syndrome). See IV administration guide on ward or pharmacy internet http://medinfogalway.ie/ivguides

  • Do not delay administration of the first dose.

  • Consider giving subsequent doses at 10am and 10pm for twice daily dosing.

  • Do not hold doses pending levels or if levels have not been sent, unless specifically requested or toxicity suspected.

Monitoring

  • The first pre-dose (trough) level should be taken on Day 3 of treatment -and no later than before the 4 th or 5 th dose . Take sample within the hour before dose is due.

  • Dosing and monitoring for patients with renal impairment with creatinine clearance less than 30ml/minute should be discussed with Microbiology/Infectious Diseases on a case-by-case basis.

  • Monitor creatinine and renal function daily and review dose if necessary. Use Vancomycin dosing calculator .

  • Complete the laboratory request form for vancomycin level when prescribing the first dose.

  • Document on request form date and time sample was taken, date and time of last vancomycin dose.

  • If the level is acceptable check a pre-dose level within the hour before dose is due twice per week thereafter, or more often if impaired renal function, haemodynamically unstable, elderly, or if there has been difficulty in maintaining sufficiently high levels.

  • Post-dose (peak) levels are rarely indicated and should only be checked when recommended by Microbiology or Infectious Diseases.

Table 3: Interpretation of Vancomycin Levels

  • Target pre-dose (trough) level is 10 to 15mg/L, but a higher target pre-dose level of 15 to 20mg/L is recommended for critical care patients, haematology/oncology patients, for complicated infections e.g. endocarditis, osteomyelitis, bloodstream infection, meningitis, or MRSA pneumonia and if recommended by Microbiology or Infectious Diseases.

If target level is 10 to 15mg/L

If target level is 15 to 20mg/L

Level

Advice

Level

Advice

< 10mg/L

Low

  1. Is vancomycin still needed?

  2. Is it a true pre-dose trough level (taken within one hour before dose)?

  3. Is dose correct for weight & renal function?

  4. Are doses being held/have recent doses been given on time?

  5. An increase in dose is likely to be needed - discuss with Microbiology or Infectious Diseases or Pharmacy.

  6. If a dose increase is recommended, re-check level pre 4 th dose at new regimen.

< 15mg/L

Low

  1. Is vancomycin still needed?

  2. Is it a true pre-dose trough level (taken within one hour before dose)?

  3. Is dose correct for weight & renal function?

  4. Are doses being held/have recent doses been given on time?

  5. An increase in dose is likely to be needed - discuss with Microbiology or Infectious Diseases or Pharmacy.

  6. If a dose increase is recommended, re-check level pre 4 th dose at new regimen.

10 to 15

Target Range

  1. Is vancomycin still needed?

  2. Is patient responding clinically?

  3. Continue same dose if renal function stable.

  4. Check level in 3 days.

15 to 20

Target Range

  1. Is vancomycin still needed?

  2. Is patient responding clinically?

  3. Continue same dose if renal function stable.

  4. Check level in 3 days.

>15mg/L

High

  1. Is vancomycin still needed?

  2. Is it a true pre-dose trough level (taken within one hour before dose)?

  3. Where was sample taken from? (falsely high levels can occur if taken from same line used to give vancomycin).

  4. Is dose correct for weight & renal function?

  5. Is renal function stable?

  6. Dose adjustment required - discuss with Microbiology or Infectious Diseases. Do not administer a further dose without discussion with Microbiology or Infectious Diseases.

  7. If the patient is to continue on vancomycin at a reduced dose re-check level as advised.

>20mg/L

High

  1. Is vancomycin still needed?

  2. Is it a true pre-dose trough level (taken within one hour before dose)?

  3. Where was sample taken from? (falsely high levels can occur if taken from same line used to give vancomycin).

  4. Is dose correct for weight & renal function?

  5. Is renal function stable?

  6. Dose adjustment required - discuss with Microbiology or Infectious Diseases. Do not administer a further dose without discussion with Microbiology or Infectious Diseases.

  7. If the patient is to continue on vancomycin at a reduced dose re-check level as advised.

References

1. The Renal Drug Database www.renaldrugdatabase.com [accessed February 2024]

2. The Sanford Guide to Antimicrobial Therapy Digital Update May 2024

3. Rybak et al Vancomycin Therapeutic Guidelines: A Summary of Consensus Recommendations from IDSA/ASHP/SIDP Clin Infect Dis 2009 49;325-327.

4. Thomson et al Development and evaluation of vancomycin dosage guidelines designed to achieve new target concentrations JAC 2009;63:1050-1057.

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Cockcroft and Gault Equation

Cockcroft and Gault Equation

Creatinine Clearance (CrCl) (ml/min)

1.Calculate Ideal Body Weight (IBW) in kg (see below)

2. If actual body weight < IBW,  use actual body weight in this equation

1. N = 1.23 males & 1.04 females

Ideal Body Weight (IBW) (kg) =

Male:

50kg + (2.3 x inches over 5 feet) OR 50kg + (0.9 x cm over 152cm)

Female:

45.5kg + (2.3 x inches over 5 feet) OR 45.5kg + (0.9 x cm over 152cm)