TAM (Treatments and Medicines) NHS Highland***DO NOT USE VANCOMYCIN CALCULATOR FOR DIALYSIS PATIENTS***
**Prompt administration within one hour of recognition of sepsis reduces mortality**
Vancomycin in haemodiafiltration (HDF) (Guidelines)
Warning
What's new / Latest updates
04.07.2023
This guidance replaces Management of Vancomycin to pateitns on haemodialysis which currently sits on policies library.
Changes for the update include:
The main difference is that the new policy allows patients to remain on HDF and a level is no longer required immediately prior to giving the next dose. This ensures patients maintain optimal dialysis as previously we switched them to a low flux dialyser, with the risk they may not get switched back. With the old policy it was necessary to take a level at the start of dialysis to check the level was <15mg/L to inform whether a dose of vancomycin should be given before the end of dialysis. This added pressure to nursing staff who often had to chase the results. It also wasn't possible to achieve this for patients in our satellite units, where samples were being taxied to Raigmore and still weren't processed by the end of their dialysis session. The new policy has been adopted nationally, allbeit with slight variations, and I'm not aware of any units now switching their patients to a low flux dialyser to administer vancomycin. A level will now be taken prior to the third dose and is used to inform the fourth dose.
Audience
- HHSCP only
- Secondary Care
- Adults
- Initial dose may be prescribed as a one off on an inpatient drug chart if not being given on dialysis eg if dialysis not due at time of initiation.
- Any initial doses being given on dialysis and all subsequent doses should be prescribed on HERMES (electronic renal prescribing system) by a member of the renal team.
- If an inpatient, an entry should be made on the inpatient drug chart/HEPMA referring to HERMES. A duration or review date should be documented.
- When course complete, ensure vancomycin is STOPPED on both the inpatient chart/HEPMA and HERMES.
| Table 1 Loading dose (first dose: can be given on dialysis or on ward) |
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| Actual body weight | Dose | Volume to be made up to with 0·9% Sodium chloride | Administration time (max rate of 10mg/min) |
| <40kg | 750mg | 250mL | 75 minutes |
| 40 to 59kg | 1000mg | 250mL | 100 minutes |
| 60 to 90 kg | 1500mg | 500mL | 150 minutes |
| >90kg | 2000mg | 500mL | 200 minutes |
| Table 2 Maintenance dose (2nd and 3rd doses given at end of the next two HDF sessions) |
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| Actual bodyweight (dry weight) | Dose | Volume to be made up to with 0·9% sodium chloride | Administration time (max rate of 10mg/min) |
| <40kg | 500mg | 100mL | 50 minutes |
| 40 to 59kg | 750mg | 250mL | 75 minutes |
| 60 to 90kg | 1000mg | 250mL | 100 minutes |
| >90kg | 1250mg | 250mL | 125 minutes |
| Incremental (twice weekly) HDF patients |
| It has been agreed that incremental (2 x week) patients should receive dialysis three times a week for the duration of their vancomycin course. |
| Off unit patients receiving low flux dialysis | |
| Loading dose | Give loading dose as per table 1 |
| Therapeutic drug monitoring | Check a trough level prior to next dialysis session |
| Subsequent doses | Give 1g if vancomycin level <15mg/L (Consultant may specify a level <20mg/L) |
- Take a trough level prior to 3rd dose pre-HDF (dialysis must not have started when level taken).
- Do not delay administration of 3rd dose.
- Use level to guide administration of 4th dose and subsequent doses.
- Thereafter, check trough levels every 3rd dose.
*Caution is required in acutely unwell patients and those receiving HDF more than 3 x week. The frequency of monitoring will need increased. Please refer to Renal Consultant/Renal Pharmacist for advice*
|
Table 3 |
|
| Trough level* | Subsequent dose |
| <10mg/L | Increase dose by 50% |
| 10 to 15mg/L | Increase dose by 25% |
| 15 to 20mg/L | Continue current dose |
| 20 to 25mg/L | Reduce dose by 25% |
| 25 to 30mg/L | Omit next dose and reduce subsequent dose by 50% |
| >30mg/L | Stop until level back to 15 to 20 |
*Use caution when interpreting levels taken prior to first dialysis of the week eg Monday for MWF and Tues for TTS. They may not be representative due to longer interdialytic gap.
- Cimino C, Burnett Y, Vyas N, Norris AH Post. Dialysis Parenteral Antimicrobial Therapy in Patients Receiving Intermittent High‑Flux Hemodialysis. Review Article. Drugs (2021) 81:555–574
- Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Wong-Beringer A, Rotschafer JC, Rodvold KA, Maples HD, Lomaestro BM Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2020;77(11):835.
- Flynn Pharma Ltd. Vancocin Summary of product characteristics (SPC) Vancomycin. Last updated on eMC 17 June 2022. Available at Vancocin Powder for Solution - Summary of Product Characteristics (SmPC) - (emc) (medicines.org.uk) accessed on 16th Nov 2022
- Medusa NHS injectable medicines guide. Vancomycin monograph. Available via Injectable Medicines Guide - Display - Vancomycin - Intravenous - Version 9 - IVGuideDisplayMain.asp (wales.nhs.uk) Accessed on 16th Nov 2022
- Scottish Antimicrobial Prescribing Group. Vancomcyin guidance. Available at Vancomycin (sapg.scot). Accessed on 16th Nov 2022
- Renal Drug Database,Renal Pharmacy Group. Vancomycin monograph last updated 20/10/2022. Available at VANCOMYCIN | The Renal Drug Database accessed on 16th Nov 2022
- Adapted from NHS Tayside vancomycin prescribing on dialysis policy agreed Sept 2020. Available at Vancomycin Prescribing on Dialysis.pdf (scot.nhs.uk). Accessed on 16th Nov 2022