GL/PTC/05.

R2-2016

CHANGI GENERAL HOSPITAL

GUIDELINES ON USE OF
INTRAVENOUS VANCOMYCIN
These guidelines were approved by the Pharmacy & Therapeutics Committee
with effect from 4 May 2016 and supersede the previous version (GL/PTC/05.R1-2011)

Drug class
Antibiotic; glycopeptide

Mechanism of Action
Inhibition of bacterial cell wall synthesis by blocking glycopeptide polymerisation through tight
binding to D-alanyl-D-alanine portion of cell wall precursor

Appropriate or Acceptable Indications

Treatment of serious infections caused by -lactam-resistant gram-positive microorganisms
Treatment of infections caused by gram-positive microorganisms in patients who have severe
allergies to -lactam antimicrobials
Prophylaxis for endocarditis following certain procedures in patients at high risk for endocarditis.

Contraindications
Hypersensitivity to vancomycin or any component of the formulation
Hypersensitivity to other glycopeptides (e.g., teicoplanin)

Precautions
Patients with previous severe hearing loss vancomycin is best avoided
Patients with renal impairment (especially elderly)
Patients receiving other nephrotoxic or ototoxic drugs

Drug Interactions
Increased risk of toxicity with other ototoxic or nephrotoxic drugs
Increased risk of neuromuscular blockade with neuromuscular blocking agents

Pregnancy Risk
FDA Category C
Adverse events have not been observed in animal reproduction studies.
Vancomycin crosses the placenta and can be detected in foetal serum, amniotic fluid, and cord
blood. Adverse foetal effects, including sensorineural hearing loss or nephrotoxicity, have not been
reported following maternal use during the second or third trimesters of pregnancy.
The pharmacokinetics of vancomycin may be altered during pregnancy and pregnant patients may
need a higher dose of vancomycin due to changes in volume of distribution and total plasma
clearance.

Lactation
Enters breast milk use with caution

Adverse Drug Reactions

Parenteral >10% : Hypotension associated with flushing, erythematous rash on face
and upper body (Red Man syndrome - usually associated with a
rapid rate of infusion)
1 - 10% : Chills, drug fever, eosinophilia, reversible neutropenia, rash, phlebitis
<1% : DRESS, thrombocytopenia, ototoxicity, renal failure, vasculitis

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Initiating Vancomycin Therapy
Dose based on renal function and actual body weight
Estimate renal function based on creatinine clearance (CrCL) and urine output
Calculate CrCL using the Cockcroft-Gault equation:

140 age (years) x [IBW / Adj BW / Actual BW] (kg) x 88.4

CrCL(mL/min) = -------------------------------------------------------------------------------- (x 0.85 for females)
72 x Serum Creatinine [SCr] (mcmol/L)

IBW (Ideal body weight), may be calculated as:

o For males: 50 + (0.91 x [height(cm) -152.4 cm])
o For females: 45 + (0.91 x [height(cm) - 152.4 cm])
Actual body weight should be used when patients weight is below IBW
AdjBW (Adjusted body weight) should be used for obese or overweight patients >120% IBW, and
may be calculated as:
o IBW + 0.4 (Actual body weight IBW)

Recommended Dose Based on Renal Function in Adults

Maximum recommended dose = 2g/dose (and/or 6g/day)

Loading doses of 25 - 30 mg/kg/dose may be considered for severely ill patients

o To facilitate rapid attainment of target serum trough vancomycin levels
o Maximum recommended loading dose of 2g

Obese/overweight patients
o Dose and/or frequency may have to be adjusted to achieve target serum trough
concentrations
o Earlier or more frequent monitoring may be required to avoid toxicity

Note that there are situations where SCr does not reflect vancomycin clearance or where volume of
distribution (Vd) are altered (listed under Special Populations).

Renal Function Recommended Dose and Dosing Interval

15 mg/kg/dose every 8 to 12-hourly
CrCL >50 mL/min More frequent dosing is recommended in young patients with good renal
function
CrCL 20 - 50 mL/min 15 mg/kg/dose every 24-hourly
15 mg/kg/dose
Requires longer dosing intervals or lower doses, adjust based on
CrCL <20 mL/min timed random vancomycin serum concentrations
Redose when serum concentrations<20 mg/L
o Note that subsequent doses may be lower
Loading dose: 15 - 25 mg/kg on Day 1
Redose based on pre-HD concentrations (mg/L)
o <10 : 1000 mg after HD
Haemodialysis (HD)
o 10 - 25 : 500 - 750 mg after HD
>25 : Hold vancomycin and obtain vancomycin
concentrations prior to next HD session
Continuous Loading dose: 15 - 25 mg/kg on Day 1
ambulatory Requires longer dosing intervals or lower doses, adjust based on
peritoneal timed random vancomycin serum concentrations
dialysis Redose when serum concentrations<20 mg/L
(CAPD) o 500 1000 mg every 48 to 72-hourly

Continuous Renal 10 - 15 mg/kg/dose 12 to 24-hourly

Replacement Timed random vancomycin serum concentrations should be obtained
Therapy (e.g., within 12 to 24 hours after initial dose
CVVHD) Redose when serum concentrations<20 mg/L
o Note that subsequent doses may be lower

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Monitoring Parameters

Renal function
Serum creatinine (SCr) levels should be monitored at least once every 3 days
Monitor SCr more frequently if patients have acutely changing SCr, or if there is an increased risk
for nephrotoxicity
Monitor urine output, especially in situations where SCr may not reflect vancomycin
clearance

Vancomycin Serum Concentrations

Usually NOT needed if Vancomycin is to be given for less than 3 days

Trough Concentrations
th
Obtain concentrations at steady state, i.e., usually between 2 - 5 days (or before the 4 or
th
5 dose) after the start of therapy for patients with CrCL> 20mL/min
Take within 30 minutes prior to the next scheduled dose. For patients with stable renal
function, administer the next dose as scheduled unless concerned for toxicity
More frequent trough concentrations are recommended for patients :
o With unstable renal and hemodynamic function
o Who require higher vancomycin trough concentrations
o Who require more aggressive dosing to achieve target trough concentrations
o Are obese/overweight
o With altered volume of distribution
o Whose serum creatinine do not reflect vancomycin clearance
After an appropriate dosing regimen is obtained, trough concentrations can be monitored weekly in
patients with stable renal and hemodynamic function
Target Trough
Infections
Concentration

Urinary tract infections, mild-moderate skin and soft tissue infections 10-15 mg/L
Bacteraemia, endocarditis, meningitis, pneumonia, osteomyelitis/ septic
arthritis, severe skin and soft tissue infections (e.g., necrotising fasciitis), 15 - 20 mg/L
febrile neutropenia

Peak concentrations
Not routinely required unless required for pharmacokinetic calculations
Peak levels should be drawn 60 minutes after the end of the infusion

Timed Random concentrations

May be needed in acute renal failure or rapidly changing SCr, and/or when patient
experience significant fluid status changes

After concentrations are available

Review patients current renal function and fluid status
Review timings of administered vancomycin doses, and when serum concentrations were
obtained
Thereafter, adjust doses and dosing intervals if needed. Consider the target concentration,
the time concentrations were obtained, the patients renal function and fluid status before
establishing a new dosing regimen.
Vancomycin generally exhibit linear pharmacokinetics in patients with stable renal function
and fluid status

Reconstitution and Administration (Intravenous)

Reconstitute each 500 mg vial using 10 mL of sterile water for injection, swirl vial to ensure
complete dissolution
Draw the required dose and dilute to a concentration not exceeding 5 mg/mL (usual volume 100-
500 mL) with sodium chloride 0.9% or dextrose 5%
Vancomycin should be administered as an intravenous infusion over at least 120 minutes
For patients on intermittent haemodialysis, infuse vancomycin over 60 minutes during the final
hour of haemodialysis
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Special Populations
Situations when serum creatinine may not reflect vancomycin clearance
o Acutely changing renal function
o Critically ill/septic shock
o Amputees
o Low muscle mass: cerebral palsy, muscular dystrophy, para-or quadriplegics,
elderly/immobile patients
o Ventricular assisted device patients/congestive heart failure, cardiogenic shock
o Diabetes mellitus
o Cirrhosis
o Cystic fibrosis
Patients with altered volume of distributions where doses may not be based on actual body weight
o Burns patients
o Critically ill/septic shock
o Overweight/Obese patients
o Pregnancy
o Ventricular assisted device patients/severe congestive heart failure, cardiogenic shock
o Fluid overload
o Cirrhosis
o ESRD

References
Vancomycin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Hudson, OH. Available at:
http://online.lexi.com. Accessed February 24, 2016
Rybak M, Lomaestro B, Rotschafer J. Therapeutic monitoring of vancomycin in adult
patients: A consensus review of the American Society of Health-System Pharmacists, the
Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists.
Am J Health-Syst Pharm. 2009; 66:82-98.

For further advice on vancomycin dosing and monitoring, contact:

Ward/Team pharmacist
IPAS Pharmacy (Ext. 1915/1917)
Drug Information Centre (Ext. 1885)

Contributing authors/reviewers
Original document (May 2005) : Dr Helen Oh
Senior Consultant, Medicine (Infectious Diseases)

Mr Ian Wee
Senior Pharmacist, Pharmacy

Current revision (February 2016) : Mr Ian Wee

Principal Clinical Pharmacist, Pharmacy

Dr Jonathan Seah
Senior Clinical Pharmacist, Pharmacy

Dr Loh Soak Yee

Pharmacist, Pharmacy

Mr Michael Widjaya
Pharmacist, Pharmacy

Date of next revision : February 2019