GENTAMICIN AND VANCOMYCIN D

Type in the data shown in blue and

press <enter>
Creatinine Clearance (ml/min)
Age (years)
Height (cm)
OR Height (feet)
(inches)
Weight (kg)
Sex (m/f)

Creatinine (mmol/L)

Height (cm)

Ideal body weight (kg) #VALUE!

Weight for creatinine

#VALUE!
clearance (kg)

Creatinine CL (ml/min) #VALUE!

Vancomycin loading dose is based on actual body weight, gentamicin dose is based on ac
Devised by Alison Thomson, Pharmacy Dept, Western Infirmary, Glasgow, 0141 211 2022, (52022) 29 July 2009
Developed by Lee Stewart, Pharmacy Dept. Victoria Infirmary, Glasgow 0141 201 5533 (65533)
Checked by Ysobel Gourlay, Pharmacy Dept. Gartnavel General Hospital, Glasgow 0141 301 7963 (57963)
ENTAMICIN AND VANCOMYCIN DOSE CALCULATOR FOR ADULT PATIENTS

Recommended doses and dosage intervals are sho

GENTAMICIN

Dose (mg) #VALUE!

#VALUE!
Infuse over 30 - 60 min

Interval (h) #VALUE!

Take a sample 6 - 14 hours after the first

dose then refer to the gentamicin plot

Review antimicrobial therapy daily. Seek

advice from microbiology if gentamicin
is required empirically for >48 - 72 hours

al body weight, gentamicin dose is based on actual body weight

Glasgow, 0141 211 2022, (52022) 29 July 2009
asgow 0141 201 5533 (65533)
Hospital, Glasgow 0141 301 7963 (57963)
E CALCULATOR FOR ADULT PATIENTS

ed doses and dosage intervals are shown in red

VANCOMYCIN PULSED INFUSION

Loading Dose #VALUE!

Time after loading to start

maintenance pulsed infusion (h)
#VALUE!

Maintenance Dose (mg) #VALUE!

Interval (h) #VALUE!
Infusion rate 500 mg/hour

VANCOMYCIN CONTINUOUS INFUSION

Loading Dose #VALUE!

Start the maintenance infusion immediately after the loading dose

Dose for infusion over 12 hours (mg) #VALUE!

See pulsed or continuous infusion sheets, as appropriate, for

vancomycin monitoring guidelines

ody weight
 Gentamicin Initial Dosage Guidelines
Creat Cl
40 - 49 kg 50 - 59 kg
(ml/min)
< 21 2.5 mg/kg (max 180 mg) then take a sample after

21 - 30 180 mg 48 hourly 200 mg 48 hourly

31 - 40 200 mg 48 hourly 240 mg 48 hourly

41 - 50 240 mg 48 hourly 280 mg 48 hourly

51 - 60 200 mg 24 hourly 240 mg 24 hourly

> 60 240 mg 24 hourly 280 mg 24 hourly

MONITORING OF GENTAMICIN CONCENTRATIONS

·       Make sure all doses are documented with the date and time of administration
·       Take a sample 6 – 14 hours after the start of the first infusion
·       Record the exact time of the dose and sample
·       Plot the concentration measurement on the graph
·       The plot will indicate one of 3 options: (1) continue present dosage regimen, (2) adjust dosage interval
·       Seek advice if you are unsure how to interpret the result
·       Monitor creatinine concentrations daily
·       Take a further sample 6-14 hours post dose every 2 - 3 days.
·       If the concentration is unexpectedly high, or if renal function alters, daily sampling may be necessary.
DO NOT CONTINUE TREATMENT FOR MORE THAN 3 DAYS UNLESS RECOMMENDED BY AN ID PHYS
micin Initial Dosage Guidelines
60 - 69 kg 70 - 80 kg > 80 kg

g (max 180 mg) then take a sample after 24 hours

240 mg 48 hourly 240 mg 48 hourly 260 mg 48 hourly

280 mg 48 hourly 300 mg 48 hourly 320 mg 48 hourly

320 mg 48 hourly 360 mg 48 hourly 400 mg 48 hourly

280 mg 24 hourly 300 mg 24 hourly 320 mg 24 hourly

320 mg 24 hourly 360 mg 24 hourly 400 mg 24 hourly

and time of administration

infusion

resent dosage regimen, (2) adjust dosage interval or (3) withhold and resample after 24 hours
ult

3 days.
unction alters, daily sampling may be necessary.
DAYS UNLESS RECOMMENDED BY AN ID PHYSICIAN OR MICROBIOLOGY
 10.0
Target sampling time
9.5
Concentration (mg/L)

9.0
8.5
8.0
7.5
7.0
6.5
6.0 If the measur
the concentra
5.5
5.0 Give the same dose
every 48 hours
4.5
4.0
3.5
3.0
2.5 If the measured concentration is below this
line, give the same dose every 24 hours
2.0
1.5
1.0
0.5
0.0
4 5 6 7 8 9 10 11 12 13 14 15

Time (hours)
0.5
0.0
4 5 6 7 8 9 10 11 12 13 14 15

Time (hours)
g time

If the measured concentration is above this line, withhold until

the concentration is < 1 mg/L and seek advice

same dose
hours

is below this
24 hours

12 13 14 15 16 17 18 19 20 21 22 23 24

Time (hours)
12 13 14 15 16 17 18 19 20 21 22 23 24

Time (hours)
 MONITORING OF GENTAMICIN CONCENTRATIONS
1. Take a sample 6 – 14 hours after the start of the first infusion
2. Record the exact time of the dose and sample
3. Plot the concentration measurement on the graph
4. The plot will indicate one of 3 options: (1) Continue present dosage regimen, (2)
adjust dosage interval or (3) withhold and resample after 24 hours
5. Seek advice if you are unsure how to interpret the result
6. Monitor creatinine concentrations daily
7. Take a further sample 6-14 hours post dose, every 2 - 3 days.
8. If the concentration is unexpectedly high, or if renal function alters, daily sampling
may be necessary.

24
24
 50ml/min 20ml/min/48
Time /24 h h
1.75 12.6 11.3
3 10.5 10.3
4 9.0 9.6
5 7.8 8.9
6 6.7 8.3
7 5.8 7.7
8 5.0 7.1
9 4.3 6.6
10 3.7 6.1
11 3.2 5.7

12 2.7 5.3
13 2.4 4.9
14 2.0 4.6
15 1.7 4.3
16 1.5 3.9
17 1.3 3.7
18 1.1 3.4
19 1.0 3.2
20 0.8 2.9
24 0.5 2.2
 Vancomycin Loading Dose
Actual body weight

< 40 kg

40 - 59 kg

60 - 90 kg

>90 kg

Vancomycin Maintenance Pulsed Infusion

CrCL (ml/min)

< 20

20 - 29

30 - 39

40 - 54

55 - 74

75 - 89

90 - 110

> 110
 Vancomycin Loading Dose Monitoring
Dose
Target concentration (trough at the end

750 mg in 250 ml saline over 1.5 hours Standard:

1000 mg in 250 ml saline over 2 hours Severe or deep-seated infections:

1.
1500 mg in 500 ml saline over 3 hours

2000 mg in 500 ml saline over 4 hours 2.

3.

4.
ancomycin Maintenance Pulsed Infusion
Dose and dosage interval

500 mg over 1 h every 48 hours

500 mg over 1 h every 24 hours

750 mg over 1.5 h 24 hourly

500 mg over 1 h 12 hourly

750 mg over 1.5 h 12 hourly

1000 mg over 2 h 12 hourly

1250 mg over 2.5 h 12 hourly

1500 mg over 3 h 12 hourly

 Monitoring of Vancomycin Concentrations

Target concentration (trough at the end of the dosage interval)

Standard: 10 – 20 mg/L

Severe or deep-seated infections: 15 - 20 mg/L

Take a trough sample at the end of the dosage interval after 24 – 48 hours of therapy then every 2
3 days or daily if the patient has unstable renal function.
Use the NHS GGC monitoring form to record dosage and sampling detail
Record the times of the last dose and the blood sample on the request form and the sample time
on the sample tube.
Seek advice from pharmacy or microbiology if you need help to interpret the result.

Adjustment of vancomycin pulsed infusion doses

Vancomycin concentration Suggested dose change

< 10 mg/L Increase the dose by 50% or seek advice

10 - 20 mg/L Maintain the present dose

> 20 mg/L Stop until <20 mg/L then seek advice

entrations

4 – 48 hours of therapy then every 2 -

e request form and the sample time

to interpret the result.

d infusion doses

seek advice

k advice
 Vancomycin Loading Dose

Actual body weight Dose

< 40 kg 750 mg in 250 ml saline over 1.5 hours

40 - 59 kg 1000 mg in 250 ml saline over 2 hours

60 - 90 kg 1500 mg in 500 ml saline over 3 hours

>90 kg 2000 mg in 500 ml saline over 4 hours

Vancomycin Maintenance Continuous Infusion

CrCL (ml/min) Daily dose

< 20 Used pulsed infusion or follow Renal Unit guidelines

20 - 29 500 mg

30 - 39 750 mg

40 - 54 1000 mg

55 - 74 1500 mg

75 - 89 2000 mg

90 - 110 2500 mg

> 110 3000 mg

 Loading Dose Monitoring of Vanco

Dose
Target concentratio
g in 250 ml saline over 1.5 hours

1. Take a sample 12 - 24 hours after starting t

mg in 250 ml saline over 2 hours
daily of the patient has unstable renal func

mg in 500 ml saline over 3 hours 2. Use the NHS GGC monitoring form to recor

mg in 500 ml saline over 4 hours 3. Record the times of the blood sample on th

4. Seek advice from pharmacy or microbiolog

nce Continuous Infusion

Dose for continuous infusion over

12 hours
Adjustment of vancomyc

infusion or follow Renal Unit guidelines Vancomycin concentration

250 mg < 15 mg/L

375 mg 15 - 25 mg/L

500 mg >25 - 30 mg/L

750 mg > 30 mg/L

1000 mg

1250 mg

1500 mg
onitoring of Vancomycin Concentrations

Target concentration range: 15 - 25 mg/L

4 hours after starting the continuous infusion then every 2 - 3 days or

as unstable renal function.

onitoring form to record dosage and sampling details.

he blood sample on the request form and the sample tube.

armacy or microbiology if you need help to interpret the result.

tment of vancomycin continuous infusion doses

Suggested dose change

Increase the 12 hourly dose by 250 mg

No change

Decrease the 12 hourly dose by 250 mg

Stop until < 25 mg/L then restart at a lower dose