Vancomycin Prescribing Guidance in Paediatrics ( 1 month - 16 years )

Publication: 06/03/2014  
Last review: 05/10/2017  
Next review: 01/10/2020  
Clinical Guideline
CURRENT 
ID: 3743 
Approved By: LTHT Drugs and Therapeutics Committee [DTC] 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Vancomycin Prescribing Guidance in Paediatrics (1 month - 16 years)

Drug information
    Introduction
    Antimicrobial activity
    Dose/Routes of administration
    Therapeutic Drug Monitoring (checking levels)
    Pharmacokinetics
    Allergy advice
    Key interactions (include BNF black dot)
    Side effects and monitoring required
Drug indications
    Prophylaxis indications in LTHT
    Treatment indications in LTHT
        For patients over 50kg
        For patients under 50kg
    Prescribing restriction

This document provides guidelines for healthcare professionals involved in paediatric care regarding the situations in which it would be appropriate to consider the use of Vancomycin electronic Medicines Compendium information on Vancomycin.

The use of Vancomycin electronic Medicines Compendium information on Vancomycin can be considered within its currently approved LTHT Drugs and Therapeutics Committee [DTC] application; other indications will require chairman’s action.

There are separate neonatal vancomycin guidelines and prescription chart.

DRUG INFORMATION
Introduction

The British National Formulary for Children (BNFC) recommends an initial dosing regimen of 15mg/kg three times a day (tds) with a maximum daily dose of 2g1. The dose is then adjusted according to the Vancomycin electronic Medicines Compendium information on Vancomycin trough levels to reach the desired plasma concentration of 10-15mg/L or 15mg-20mg/L1.2.

Recent reports have suggested that the current recommended dosing regimen frequently results in sub-therapeutic trough levels2, 3. The increase in the number of invasive MRSA infection in children and reports of strains with reduced Vancomycin electronic Medicines Compendium information on Vancomycin susceptibility highlights the need to provide optimal Vancomycin electronic Medicines Compendium information on Vancomycin dosing3.

An audit of Vancomycin electronic Medicines Compendium information on Vancomycin levels in paediatric medical and oncology patients was undertaken at Leeds Teaching Hospitals between January 2010 and December 2011. 29 (94%) intravenous vancomycin prescriptions complied with the current BNFC dosing of 15mg/kg tds, however only 2 (7%) of these courses achieved the therapeutic plasma concentration2.

The study by Frymoyer3 reported that a hospital wide increase in Vancomycin electronic Medicines Compendium information on Vancomycin dosing in paediatrics from 15mg/kg tds to 15mg/kg four times a day (qds) for the treatment of invasive MRSA infection resulted in more than a 50% decrease in the proportion of children with an initial Vancomycin electronic Medicines Compendium information on Vancomycin trough level less than 5mg/L. The proportion of children with a trough level greater than 20mg/L did not change.

In light of the recent reports Leeds Teaching Hospitals will now use the initial dosing regimen of 15mg/kg qds (maximum initial dose 750mg every 6 hours). See prescribing guidance below for further information

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Antimicrobial activity

Vancomycin electronic Medicines Compendium information on Vancomycin is a glycopeptide antibiotic derived from Nocardia orientalis, which has bactericidal activity against aerobic and anaerobic Gram-positive bacteria including multi-resistant staphylococci. There are reports of glycopeptide-resistant Enterococci and staphylococcus aureus with reduced susceptibility to glycopeptides4, 5.

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Dose/Routes of administration

PAEDIATRIC DOSES
Treatment indications below

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Therapeutic Drug Monitoring (checking levels)

Treatment indications below

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Pharmacokinetics

Vancomycin electronic Medicines Compendium information on Vancomycin is a concentration independent antibiotic which has complex pharmacokinetics characterised by a two or three compartment model6,7

It is a glycopeptide antibiotic, which is not well absorbed orally. 80% to 90% of Vancomycin electronic Medicines Compendium information on Vancomycin is excreted unchanged by the kidneys within 24 hours after an administration of a single dose8, 7.

The half-life of Vancomycin electronic Medicines Compendium information on Vancomycin ranges from 2 to 10 hours depending on age9.

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Allergy advice

Vancomycin electronic Medicines Compendium information on Vancomycin is contraindicated in patients with known hypersensitivity to this drug 5,10.

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Key interactions (include BNF black dot)

There is an increased risk of nephrotoxicity and ototoxicity when Vancomycin electronic Medicines Compendium information on Vancomycin is given with aminoglycosides such as gentamicin1.

There is an increased risk of nephrotoxicity when vancomycin given with ciclosporin1

There is an increased risk of ototoxicity when Vancomycin electronic Medicines Compendium information on Vancomycin given with loop diuretics such as furosemide1

Vancomycin electronic Medicines Compendium information on Vancomycin enhances the effects of suxamethonium1

(Please see the BNFC for all interactions with Vancomycin electronic Medicines Compendium information on Vancomycin)
[THIS LIST IS NOT EXHAUSTIVE]

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Side effects and monitoring required

There is an increased risk of nephrotoxicity when Vancomycin electronic Medicines Compendium information on Vancomycin is given with aminoglycosides such as gentamicin1. Literature reports have estimated that Vancomycin electronic Medicines Compendium information on Vancomycin may increase the risk of nephrotoxicity in a patient by 3 to 4 fold8, 7.

Monitor urine output and biochemical renal function if necessary and at least weekly U&Es or more frequently if clinically indicated.

Reports of ototoxicity related to Vancomycin electronic Medicines Compendium information on Vancomycin are rare and the exact relationship between Vancomycin electronic Medicines Compendium information on Vancomycin and hearing loss is unknown8.

Infusion related side effects:

Rapid infusion (less than 1hour) may cause severe hypotension (including shock and cardiac arrest), wheezing, dyspnoea, urticaria, pruritus, flushing of the upper body (‘red man' syndrome), pain and muscle spasm of back and chest. Stop the infusion if they occur, the side effects should resolve on discontinuation of the infusion1,4, 11. Giving the infusion at a slower rate or giving premedication prior to further doses may prevent these occurring again.

Peripheral administration may cause injection site pain and thrombophlebitis therefore rotate injection sites11.

 (Please see the BNFC for the full list of side effects)

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DRUG INDICATIONS
Prophylaxis indications in LTHT

Vancomycin electronic Medicines Compendium information on Vancomycin is not routinely used for prophylaxis in LTH for paediatric patients.

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Treatment indications in LTHT

Intravenous Vancomycin electronic Medicines Compendium information on Vancomycin is used to treat patients with methicillin resistant Staphylococcus aureus and methicillin resistant coagulase negative Staphylococcus infections such as septicaemia, osteomyelitis, endocarditis and soft tissue infections 1, 2, 8.

Calculating creatinine clearance in paediatrics (not neonates)1 2

Initial dose: If the estimated creatinine clearance is > 60mL/min/1.73m2 prescribe 750mg 6 hourly. If creatinine clearance is reduced, please start on the following doses;

Estimated creatinine clearance

Dose

50-60mL/min/1.73m2

750mg 8 hourly
 Check levels before the 4th dose

10-50mL/min/1.73m2

750mg 12 hourly
Check levels before the third dose

<10mL/min/1.73m2

Give a stat dose of 750mg
Check levels before the second dose

In normal renal function, a Vancomycin electronic Medicines Compendium information on Vancomycin level should be taken prior to the 5th dose (Target trough level 10-20mg/L). In impaired renal function, a Vancomycin electronic Medicines Compendium information on Vancomycin level should be taken at 24 hours, prior to the next dose

The dose should be adjusted proportionally to the level achieved. For example, if a patient had a vancomycin level of 7mg/L before the 5th dose and had normal renal function, the dose could be increased by 25% (1g 6 hourly)

Doses shouldn’t be increased by more than 50% in any one step. Always check renal function before changing any doses.

Consider taking a further pre-dose level after another 24 hours, if there has been a change in dose.

If the level is within range (10-20mg/L) no dosage adjustment is required. To continue on the current dose and take a further trough level every 7 days or sooner if there is a change in renal function.

If the level is greater than 25mg/L, no further doses should be given until the level falls below 20mg/L

 

Prescribing guidance in renal impairment
Patients with renal impairment will require a reduced Vancomycin dosing schedule. See the table below for guidance on initial Vancomycin electronic Medicines Compendium information on Vancomycin doses for patient with renal impairment.

Estimated creatinine clearance

Dose

31-60mL/min/1.73m2

15mg/kg 8 hourly
 Check levels before the 4th dose

10-30mL/min/1.73m2

15mg/kg 12 hourly
Check levels before the 3rd dose

<10mL/min/1.73m2

Give a stat dose of 15mg/kg.
before a 2nd dose

The Vancomycin electronic Medicines Compendium information on Vancomycin level MUST be known before further doses are given and a level checked every 24 hours for patients with renal impairment. Further doses prescribed will be dependent on degree of renal function.

Administration:
The reconstituted Vancomycin electronic Medicines Compendium information on Vancomycin should be further diluted in sodium chloride 0.9% or glucose 5% to a concentration up to 5mg/ml and given over at least 60 minutes in a peripheral line. This can be 10mg/ml in a central line.

The rate should not exceed 10mg/minute for doses over 500mg1, 5, 11.

Aseptics will prepare the doses up within working hours, but it can be safely made on the ward out of hours and if needed urgently.

Rapid infusion (<1hour) may cause severe hypotension (including shock and cardiac arrest), wheezing, dyspnoea, urticaria, pruritus, flushing of the upper body (‘red man' syndrome), pain and muscle spasm of back and chest11. Stop the infusion if they occur.

Giving the infusion over 2 hours and a premedication of chlorphenamine may be used if previously had red man syndrome. Patients must be watched closely for signed of allergic reaction.

Peripheral administration may cause injection site pain and thrombophlebitis therefore rotate injection sites11.

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Prescribing restriction

Vancomycin electronic Medicines Compendium information on Vancomycin is not on LTH restricted antimicrobials list.

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Provenance

Record: 3743
Objective:
Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

  1. Paediatric Formulary Committee. British National Formulary for Children 2012–2013. London: British Medical Association, Royal Pharmaceutical Society, Royal College of Paediatric and Child Health and Neonatal and Paediatric Pharmacists Group.
  2. Wilson, F. et al. An audit of vancomycin levels in paediatric medical and oncology patients. United Kingdom Clinical Pharmacy Association autumn symposium 2012. Clinical pharmacist. 2013, 1, pp.S7-S8.
  3. Frymoyer, A. et al. Impact of hospital-wide change in empiric pediatric vancomycin dosing and associated therapeutic concentrations. Pharmacotherapy. 2011, 31(9), pp.871–876.
  4. Joint Formulary Committee. British National Formulary 64th edition.  London: British Medical Association, Royal Pharmaceutical Society of Great Britain. 2013.
  5. Electronic Medicines Compendium. Vancomycin 1g powder for solution for infusion. [Online]. 2012. [Accessed August 2013]. 
  6. Safarnavedeh ,T. et al Steady-state pharmacokinetics analysis of vancomycin in Iranian   paediatric patients. DARU. 2009, 17(2), pp.124–130.
  7. Rybak, M.J. The Pharmacokinetic and Pharmacodynamic Properties of Vancomycin. Clinical Infectious Diseases. 2006, 42(1), pp. S35-S39.
  8. Walter Dehority, MD. Use of vancomycin in pediatrics. The Pediatric Infectious Disease Journal. 2010, 29(5), pp.462-464.
  9. Broome, L. And So, T.Z. An evaluation of initial vancomycin dosing in infants, children and adolescents. International Journal of Pediatrics. 2011, pp.1-4.
  10. Guy’s and St Thomas’, King college and University Lewisham Hospitals. Paediatric Formulary. 7th edition. London: Guy’s and St Thomas’ NHS Foundation Trust, 2005.
  11. Medusa Injectable Medicines Guide. Vancomycin. [Online]. 2013.

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Approved By

LTHT Drugs and Therapeutics Committee [DTC]

Document history

LHP version 1.0

Related information

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