Policy

It is the policy of the facility to manage Vancomycin intravenously in accordance with evidence based guidelines and best practice standards. 

It shall be the responsibility of the medical provider to adjust vancomycin orders, order pertinent labs and monitor patient response to the antibiotic.

Purpose

To standardize management of IV vancomycin.

Instructions for a Licensed Nurse

• Notifies the medical provider of lab results and implement orders as per the medical provider with respect to dose.
• Documents the notification and actions in the medical record.

Instructions for Attending Physicians or Nurse Practitioners

1. Indicates that a patient is to receive vancomycin according to this protocol by entering an order for Vancomycin  and documenting the following:
   1. Initial indication: Prophylaxis, empiric or definitive infection.
   2. Suspected infection type
   3. Anticipated duration of therapy
   4. Trough level
      
2. Follows Vancomycin level and consult with pharmacist as needed for appropriate dosing.
   
3. Prior to initiating therapy, obtains a current patient height, weight and serum creatinine.
   
4. Trough levels should be ordered after initiation of therapy and after dose changes. All level should be ordered with a SCr except in the case of dialysis patients.
   
5. After the target trough level is achieved at a steady state, levels should be checked every 3 to 5 days until completion of therapy.
   
6. Trough levels should be checked sooner when clinical indicated i.e. changing in clinical status or renal function.
   
7. Documents the necessary lab and medication orders for vancomycin therapy.

Dosing and Monitoring Guidelines

How to calculate a vancomycin dose: 

• Obtain actual body weight (ABW) 

NOTE: do not calculate based on lean body weight; if morbidly obese use ABW for initial loading dose and monitor trough or consult ID.

Loading Dose (LD): 

• For more severe infections (i.e., Meningitis, endocarditis, pneumonia, etc.) consider a loading dose of 25-30 mg/kg ABW
•  LD = 25-30 mg/kg (Use ACTUAL body weight)

Maintenance dose (MD): 

• Calculate each maintenance dose: MD = 15 mg/kg (Use ACTUAL body weight) 
• Special Populations: Morbid obesity (≥ 130% of IBW) use 30 mg/kg/day divided Q8H as obese often require more frequent dosing intervals (i.e., Q8H)
• Obese patients rarely need doses in excess of 3.5 gm per day. Suggest starting at 1 to 1.25 gm Q8H and adjust upward if necessary. 

Round calculated dose: 

• Doses should be rounded to the nearest 250 mg increment (i.e., 500 mg, 750 mg, 1000 mg, 1250 mg, 1500 mg, etc.)

Estimate patient’s creatinine clearance (CrCl)

Use the Cockcroft-Gault equation. 

Vancomycin Levels

• Vancomycin levels are NOT needed in patients with stable renal function who are on standard doses of vancomycin AND are on therapy for less than 5 days. 

Measure Trough Concentrations if: 

• Patient is receiving vancomycin therapy > 5 days
• Patient has unstable renal function
•  Patient is on an unusual/aggressive dosing regimen
• Patient is morbidly obese (> 130% of IBW)
• Patient has severe or life threatening infection and is receiving concomitant nephrotoxic drugs (i.e., cyclosporine, amphotericin B, aminoglycosides) 

Adjusting a Vancomycin Dose (Recommendations) 

Trough is too low: change the interval, keep the dose

• If the level is < 5 mcg/mL, the dosing INTERVAL should be shortened 

Example: Trough level after 5 days of treatment reported as 3 mcg/mL on a regimen of 1000 mg Q12H, the interval should be shortened to 1000 mg Q8H

Trough is too high: decrease the dose, keep the interval

• If the trough level is >25 mcg/mL, the DOSE should be decreased 50% 

Example: Trough level after 5 days of treatment is reported as 29 mcg/mL on a regimen of 1000 mg Q12H; the dose should be decreased to 500 mg Q12H

Monitoring 

• Baseline weight, BUN, serum creatinine, WBC, temperature, cultures, and sensitivities should be taken every other day in stable patients
• Daily urinary IN’s and OUT’s, CBC, and temperature should be monitored.

Responsibility

The Medical Director shall be responsible to ensure compliance to this policy.