University of Pennsylvania Medical Center Guidelines for Antibiotic Use

VANCOMYCIN GUIDELINES

Vancomycin Resistant Enterococcus Control Guidelines

Vancomycin use requires ID approval (beeper 306-0336) before it will be released by the pharmacy department. If intravenous vancomycin is approved for empiric use, ID approval must be obtained to continue vancomycin > 72 hours.

Pre-operative doses of vancomycin for surgical wound prophylaxis will be released from the OR pharmacy satellite without ID approval. Vancomycin will be released in the same manner as all other restricted antibiotics in the Emergency Department. However, in both instances, vancomycin use should follow the guidelines detailed below.

Vancomycin will only be approved for use in the following situations:

1. The treatment of culture proven serious infections caused by beta-lactam resistant microorganisms (e.g. methicillin resistant Staphylococcus aureus, coagulase negative staphylococcus)

2. The treatment of culture proven infections caused by gram-positive organisms in patients with serious allergies to beta-lactam antimicrobials (anaphylaxis, angioedema, hives) when other agents are not available

3. The treatment of antibiotic-associated colitis that fails to respond to metronidazole or is potentially life threatening (oral vancomycin)

4. Empiric therapy for serious infections in patients who are hemodynamically unstable

5. Empiric therapy in patients who are at risk for gram-positive infections with beta-lactam resistant microorganisms

(For example, vancomycin will be approved for empiric treatment of prosthetic valve endocarditis, endocarditis in intravenous drug users, febrile neutropenic patients with warmth, erythema, or tenderness around an intravenous catheter site.)

6. Empiric therapy for suspected serious invasive infections caused by Streptococcus pneumoniae pending antimicrobial susceptibilities (e.g. endocarditis, meningitis)

7. Surgical prophylaxis for orthopedic procedures (prosthetic joint insertion) or in patients with serious allergies to beta-lactam antimicrobials according to the HUP guidelines (See Guidelines for Surgical Wound Prophylaxis)

8. Prophylaxis for bacterial endocarditis as recommended by the American Heart Association in patients with serious allergies to beta-lactam antimicrobials (See Antimicrobial Prophylaxis for Prevention of Bacterial Endocarditis)

9. Other clinical indications after consultation by an attending physician with Infectious Diseases

 

Criteria for Pharmacokinetic Service Consultation and Monitoring

1.  Patients with stable renal function do not require pharmacokinetic service consultation or serum level determination.

2.  Pharmacokinetic consultation should be obtained and serum levels monitored under the following clinical circumstances:

        a.  Renal dialysis (conventional hemodialysis, peritoneal dialysis, continuous forms of hemofiltration or dialysis)

        b.  Patients with rapidly changing renal function

        c.  Morbidly obese patients (weight > 150 kg)

3.  Pharmacokinetic consultation should be obtained and serum levels monitored if the patient is receiving vancomycin therapy for one of the following infectious diseases/clinical conditions:

        a.  Meningitis

        b.  Osteomyelitis

        c.  Endocarditis

        d.  Liver Transplantation

Vancomycin Dosing Guidelines

The following guidelines base vancomycin dosing on weight and estimated renal function.

Renal Function Estimation

1.  Calculate patient's ideal body weight (IBW):

Male: 50.0 kg + (2.3 X inches over 5ft); Female: 45.5 kg + (2.3 X inches over 5ft)

Ideal Body Weight Table

2. Calculate creatinine clearance (CrCl) using the Cockcroft and Gault equation

Male: (140-age) X IBW (kg)/[72 X Serum Creatinine] Female: 0.85 X CrCl for male 

**If the patient is > 65 years old, use a serum creatinine of 1.0 mg/dL in calculating creatinine clearance when the actual serum creatinine is <1.0 mg/dL.  For patients < 65 years old, use the actual serum creatinine value.

 

Where AGE= age in years

Vancomycin Dosing Nomogram

1.  Actual (total) body weight is used in determining the dosing regimen.  

2.  Only patients with stable renal function should be placed on standing dosing regimens.

3. Patients with pneumococcal meningitis may need higher doses - consult pharmacokinetics and see note below

  Clcr (ml/min)  0 10 20 30 40 50 60 70 80 90 100 > 120
Weight     
30 kg 500 mg  x 1 500 mg q72h 500 mg q 48h 500 mg q48h 750 mg q48h 500 mg q24h 500 mg q24h 750 mg q24h 750 mg q24h 1000 mg q24h 1000 mg q24h 500 mg q12h
40 kg 750 mg  x 1 500 mg q72h 750 mg q48h 750 mg q48h 500 mg q24h 750 mg q24h 750 mg q24h 1000 mg q24h 1000 mg q24h 1250 mg q24h 750 mg q12h 750 mg q12h
50 kg 1000 mg x 1 500 mg q72h 750 mg q48h 500 mg q24h 750 mg q24h 750 mg q24h 1000 mg q24h 1000 mg q24h 1250 mg q24h 750 mg q12h 1000 mg q12h 1000 mg q12h
60 kg 1250 mg x 1 500 mg q48h 750 mg q48h 750 mg q24h 750 mg q24h 1000 mg q24h 1250 mg q24h 1250 mg q24h 750 mg q12h 1000 mg q12h 1000 mg q12h 1250 mg q12h
70 kg 1250 mg x 1 500 mg q48h 500 mg q24h 750 mg q24h 1000 mg q24h 1250 mg q24h 1500 mg q24h 1500 mg q24h 750 mg q12h 1000 mg q12h 1250 mg q12h 1500 mg q12h
80 kg 1500 mg x 1 750 mg q48h 500 mg q24h 750 mg q24h 1000 mg q24h 1250 mg q24h 1500 mg q24h 1000 mg q12h 1000 mg q12h 1250 mg q12h 1250 mg q12h 1500 mg q12h
90 kg 1750 mg x 1 750 mg q48h 500 mg q24h 1000 mg q24h 1250 mg q24h 1500 mg q24h 1750 mg q24h 1000 mg q12h 1250 mg q12h 1250 mg q12h 1500 mg q12h 1750 mg q12h
100 kg 2000 mg x 1 750 mg q48h 750 mg q24h 1000 mg q24h 1250 mg q24h 1500 mg q24h 1000 mg q12h 1000 mg q12h 1250 mg q12h 1500 mg q12h 1500 mg q12h 2000 mg q 12h
> 110 kg 2000 mg x 1 1000 mg q48h 750 mg q24h 1000 mg q24h 1500 mg q24h 1750 mg q24h 1000 mg q12h 1000 mg q12h 1250 mg q12h 1500 mg q12h 1750 mg q12h 2000 mg q12h

Vancomycin dosing for pneumococcal meningitis has not been studied in detail but some authorities recommend the use of 30-45mg/kg/d for meningitis, given 8-12 hourly (10-15 mg/kg/8h) with maximum doses of 2 to 3g/d (700 to 1000 mg q 8h) with normal renal function. Vancomycin should be stopped if the pneumococcus is not penicillin resistant. Consult pharmacokinetics.

Updated 11/21/04 by Paul Edelstein

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