Vancomycin Protocol

INTRAVENOUS VANCOMYCIN
For use in severe infections due to Gram positive organisms (e.g. M.R.S.A.) and in certain
situations where there is a history of allergy to beta-lactams as defined in “Penicillin
Allergy” section (http://rbhintranet/policies/antibiotics/penicillin_allergy.pdf.)

DO NOT USE IV VANCOMYCIN for Clostridium difficile infection (CDI)

VANCOMYCIN LOADING DOSE

All patients receive a loading dose of 1g if <70kg and 1.25g if >70 kg in 250ml 0.9% NaCl
over 3 hours. Commence continuous infusion immediately after loading dose.

VANCOMYCIN CONTINUOUS INFUSION

This should always be given as an infusion of Vancomycin in 500ml of NaCl 0.9% over 24
hours by infusion pump (21ml per hour). Use 1.5g Vancomycin unless creatinine is
>120μmol/l when 1.0g Vancomycin should be used.

VANCOMYCIN LEVEL
Clotted blood (red-top bottle) should be collected next day between 0900 and 1300. If the
infusion has just started and been running for LESS THAN 6 HOURS, delay taking the
level until the next morning.

INTERPRETING THE LEVEL:

15 - 25 mg/l - no change required
<15 mg/l - increase the dose by 500mg. Setup a new infusion in which the Vancomycin
dose is increased by 500mg
>25mg/l - decrease the dose by 500mg. Set up a new infusion in which the Vancomycin
dose is decreased by 500mg. (If the patient is only receiving 500mg Vancomycin daily
then decrease the dose by 250mg only).
>30mg/l - STOP the infusion for six hours and then restart, setting up a new infusion in
which the Vancomycin dose is decreased by 500mg.

CONTINUED VANCOMYCIN USE

Patients with normal renal function will require twice-weekly levels once the correct dose
has been determined. Patients with abnormal renal function may require more frequent
monitoring.

MRSA BACTERAEMIAS
Significant MRSA blood stream infections will require a minimum of 14 days of therapy. If
the bacteraemia is line related, removal of the line is a necessity and should be undertaken
as soon as clinically feasible.

RBCH NHS Foundation Trust. AMT Vancomycin and Gentamicin Guidelines. v2011.0)
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 Gentamicin Protocol
Which Dosing Regime Should I Use?

 If you are treating Infective Endocarditis use Protocol A (synergistic dosing)

 For all other clinical indications use Protocol B (extended-interval dosing)

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PROTOCOL A (Synergistic Dosing- INFECTIVE ENDOCARDITIS ONLY)

Dose: 1mg/kg 12 hrly iv (based on ideal body weight (IBW) - see table below)
Round dose to nearest 10mg

Obtain a serum gentamicin level (trough) before the third dose and twice weekly thereafter (more
frequent monitoring may be needed if renal function is fluctuating).

The trough level should be <1mg/L (the Urban & Craig nomogram does NOT apply- DO NOT USE in IE!)

If pre-dose level is >1mg/l increase the interval between doses to once-daily (seek Pharmacy advice).
___________________________________________________________________________________
PROTOCOL B (5mg/kg extended interval dosing- FOR GENERALISED USE IN SEPSIS)
This policy uses a 5mg/kg fixed dose and adjusts the dosing interval according to levels:

1 Is Gentamicin appropriate?
Gentamicin is an antibiotic that is rapidly bactericidal to a wide spectrum of bacteria, with a
predominant activity against Gram negative organisms. Gentamicin should be used in
accordance with the RBCH antimicrobial guidelines.

2 What are the Contra-indications?

a. Severe renal impairment: avoid Gentamicin when your patient has a known calculated
creatinine clearance of <21ml/min or known severe renal impairment. Use the online
creatinine clearance calculator to derive this http://rbhintranet/creatinine/index.php
In this instance discuss with your seniors who may wish to discuss alternatives with the
duty Consultant Microbiologist.
b. Myasthenia gravis (may impair neuro-muscular transmission)
c. Known / documented hypersensitivity
d. Pregnancy- whilst not an absolute contra-indication, please discuss with your seniors
who may wish to discuss safer alternatives with the duty Consultant Microbiologist

3 Calculate a Dose Based on Ideal Body Weight (IBW)

Use the attached table to obtain your patient’s ideal body weight (IBW).
Calculate a 5mg/kg dose based on ideal body weight (NOT their actual weight) up to a
maximum dose of 450mg.
Round the calculated dose to the nearest 10mg (e.g. calculated: 347mg = actual dose: 350mg)

Female Ideal Body Weight (IBW) Table IBW (female) = [(height (cm) – 154) x 0.9] + 45.5
Height 4’11 5’ 5’1 5’2 5’3 5’4 5’5 5’6 5’7 5’8 5’9 5’10 5’11 6’ 6’1 6’2 6’3
(feet)
Height 150 152 155 158 160 163 165 168 170 173 175 178 180 183 185 188 191
(cm)
IBW 41.9 43.7 46.4 49.1 50.9 53.6 55.4 58.1 59.9 62.6 64.4 67.1 68.9 71.6 73.4 76.1 78.8
(kg)

Male Ideal Body Weight (IBW) Table IBW (male) = [(height (cm) – 154) x 0.9] + 50
Height 5’ 5’1 5’2 5’3 5’4 5’5 5’6 5’7 5’8 5’9 5’10 5’11 6’ 6’1 6’2 6’3 6’4
(feet)
Height 152 155 158 160 163 165 168 170 173 175 178 180 183 185 188 191 193
(cm)
IBW 48.2 50.9 53.6 55.4 58.1 59.9 62.6 64.4 67.1 68.9 71.6 73.4 76.1 77.9 80.6 83.3 85.1
(kg)
RBCH NHS Foundation Trust. AMT Vancomycin and Gentamicin Guidelines. v2011.0)
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4 Administer the Dose
Infuse 5mg/kg in 100ml Normal Saline over 30 minutes. Make a note of the time the infusion
starts in the case notes and on the prescription chart.

5 Obtain a Gentamicin serum level 6-14 hrs after the start of the infusion
It is the responsibility of the prescribing clinician to ensure a serum sample (clotted blood (red top
bottle)) is taken between SIX TO FOURTEEN (6-14) HOURS after the start of the infusion.
You MUST document A) time the infusion commenced and B) time the level was taken in the
case notes, on the specimen request form and on the drug chart so that the Urban & Craig
nomogram below can be used to accurately decide on the interval between doses.

6 Further Doses
Use the Nomogram below (Urban & Craig, 1997) to interpret the Gentamicin level to decide on
an appropriate interval between doses. The Nomogram is divided into different areas with
corresponding frequency of dosing = 12hrly (rarely applicable), 24hrly, 36hrly or 48hrly.
If the level is on the dividing line between 2 areas, choose the longer dosing interval.

URBAN & CRAIG NOMOGRAM (1997)

If your patients calculated Creatinine Clearance is <21ml/min or if their Gentamicin level falls
above the uppermost line then NO further Gentamicin doses should be given.
Discuss antibiotic alternatives with a Microbiologist. If there are no other alternatives, obtain a
repeat serum Gentamicin level at 24hr intervals and only re-dose, if still clinically indicated, when
the level falls <1mg/l.

7 Course Duration

Gentamicin treatment is rarely required for longer than 3 days.

PROLONGED GENTAMICIN THERAPY INCREASES THE RISKS OF PERMANENT RENAL

OR AUDIO-VESTIBULAR DAMAGE- COURSES LASTING >3 DAYS NEED DISCUSSION
WITH SENIOR PHYSICIAN AND APPROVAL FROM A CONSULTANT MICROBIOLOGIST.

In patients with normal renal function requiring courses >3 days measure levels twice weekly.

In patients with pre-existing renal impairment a level may be required 6-14 hours after each
Gentamicin dose.
RBCH NHS Foundation Trust. AMT Vancomycin and Gentamicin Guidelines. v2011.0)
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