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

Publication: 06/03/2014  --
Last review: 13/05/2020  
Next review: 01/05/2023  
Clinical Guideline
CURRENT 
ID: 3743 
Approved By: LTHT Drugs and Therapeutics Committee [DTC] 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

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.

The use of 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 for children 1 month to 11 years of 10-15mg/kg every 6 hours and for children 12-17 years 15-20mg/kg every 8 to 12 hours with a maximum daily dose of 2g1. The dose is then adjusted according to the Vancomycin trough levels to reach the desired plasma concentration of 10-20mg/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 susceptibility highlights the need to provide optimal Vancomycin dosing3.

An audit of 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 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 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) for patients with normal renal function. See prescribing guidance below for further information.

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Antimicrobial activity

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.

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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 is a concentration independent antibiotic which has complex pharmacokinetics characterised by a two or three compartment model5,6

It is a glycopeptide antibiotic, which is not well absorbed orally. 80% to 90% of Vancomycin is excreted unchanged by the kidneys within 24 hours after an administration of a single dose6,7.

The half-life of Vancomycin ranges from 2 to 10 hours depending on age8.

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Allergy advice

Vancomycin is contraindicated in patients with known hypersensitivity to this drug 4,9

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Key interactions (include BNF black dot)

There is an increased risk of nephrotoxicity and ototoxicity when Vancomycin is given with aminoglycosides such as gentamicin1.

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

There is an increased risk of ototoxicity when Vancomycin is given with loop diuretics such as furosemide1

Vancomycin enhances the effects of suxamethonium1

(Please see the BNFC for all interactions with Vancomycin )
[THIS LIST IS NOT EXHAUSTIVE]

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Side effects and monitoring required

There is an increased risk of nephrotoxicity when Vancomycin is given with aminoglycosides such as gentamicin1. Literature reports have estimated that Vancomycin may increase the risk of nephrotoxicity in a patient by 3 to 4 fold6, 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 are rare and the exact relationship between Vancomycin and hearing loss is unknown7.

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, 10. 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 sites10.

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

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DRUG INDICATIONS
Prophylaxis indications in LTHT

Vancomycin is not routinely used for prophylaxis in LTH for paediatric patients.

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Treatment indications in LTHT

Intravenous 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 infections1, 2, 7.

Before prescribing Vancomycin, where serum creatinine is available, always calculate glomerular filtration rate to ensure appropriate dosing.

Calculating Estimated Glomerular Filtration Rate (eGFR) in paediatric patients (not neonates)1 2

eGFR (mL/minute/ 1.73 m2)= 40 x height (cm)/serum creatinine (micromol/ litre)

 

eGFR (mL/min)

Initial Dose

When to do First level

How to Interpret Level

>60

15mg/kg (max. 750mg)
6 hourly

Take level prior to fifth dose. Give the fifth dose after level is taken rather than waiting for result if creatinine is stable.

See Flowchart A

30 - 60

15mg/kg (max. 750mg)
12 hourly

Prior to third dose*.
Give the third dose after level is taken rather than waiting for result if creatinine is stable.

See Flowchart B

< 30

10mg/kg (max. 750mg)
stat dose

24 hours post dose.
Do not give another dose until this level has come back.

See Flowchart C

For patients on Renal Replacement Therapy (HD, PD or CVVHD)

10mg/kg (max. 750mg)
stat dose

24 hours post dose.
Do not give another dose until this level has come back.

For patients on haemodialysis, levels need to be done pre-dialysis.

Need to be reviewed on a case-by-case basis by renal or PICU team depending on location.

*If creatinine is rising or unstable, consider a level prior to the second dose. If this level is low (<10 mg/L) or in range (10-20mg/L), do not adjust the dosing frequency yet as it takes 24 hours to reach steady state, continue on same regime and take a level 12 hours later. If the level is high (>20-25), reduce as per flow diagram.

Flowchart A - For eGFR >60mL/min


Flowchart B - For eGFR 30 - 60 mL/min

 

Flowchart C- For eGFR <30mL/min


If the level is within the target range (normally 10 - 20mg/L) no dose adjustment is necessary, continue the current dose and take further levels every 7 days in normal renal function or sooner if renal function deteriorates. In patients with an eGFR <50mL/min take levels every 3 days in renal impairment initially.

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

Always check renal function before changing any doses. For patients with unstable creatinine, consider taking levels more frequently.

For patients with any degree of renal impairment, do daily U&E’s during initial therapy until they have levels that are consistently in range with a stable renal function.

Administration:
Vancomycin is available as powder for reconstitution. Strengths available are 500mg and 1gram. Follow manufacturer’s instructions on how to reconstitute this with water for injection.

The reconstituted 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. For doses greater than 500mg, give at a rate of 10mg per minute. The concentration can go up to 10mg/ml in a central line.1, 5, 10.

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 chest10. 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 sites10.

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Prescribing restriction

Vancomycin is not on LTH Protected (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. Joint Formulary Committee. 2020. British National Formulary for Children. [Online]. Available at: https://bnfc.nice.org.uk/. (Accessed: 22/04/20)

  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. Electronic Medicines Compendium. 2018. Vancomycin 1g powder for solution for infusion. [Online]. Available at: https://www.medicines.org.uk/emc/product/649/smpc . (Accessed: 22/04/20).

  5. Safarnavedeh ,T. et al Steady-state pharmacokinetics analysis of vancomycin in Iranian   paediatric patients. DARU. 2009, 17(2), pp.124–130.

  6. Rybak, M.J. The Pharmacokinetic and Pharmacodynamic Properties of Vancomycin. Clinical Infectious Diseases. 2006, 42(1), pp. S35-S39.

  7. Walter Dehority, MD. Use of vancomycin in pediatrics. The Pediatric Infectious Disease Journal. 2010, 29(5), pp.462-464.

  8. 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.

  9. Guy’s and St Thomas’, King college and University Lewisham Hospitals. 2020. Paediatric Formulary. Guy’s and St Thomas’ NHS Foundation Trust. [Online]. Available at: http://cms.ubqo.com/public/d2595446-ce3c-47ff-9dcc-63167d9f4b80/content/
    e3c8b187-0bcd-4245-865e-fbe49439af78
    . (Accessed: 22/04/20)

  10. Medusa Injectable Medicines Guide. 2020. Vancomycin. [Online]. Available at: https://medusa.wales.nhs.uk/IVGuideDisplay.asp . (Accessed: 22/04/20)

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Approved By

LTHT Drugs and Therapeutics Committee [DTC]

Document history

LHP version 1.0

Related information

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