Paediatric

Paediatric: Vancomycin

Formulary antimicrobial: Use in accordance with Trust guidelines

Intravenous Vancomycin - general information

  • For patients over 35 weeks corrected gestational age
  • Not for use in patients on the neonatal unit - see separate guidance

Cautions/Contra-indications:

  • Use with caution in patients with renal impairment.
  • Use with caution in patients with a history of deafness.
  • Use nephrotoxic drugs with caution alongside vancomycin e.g. ACE-inhibitor, diuretics (especially IV), NSAIDs, ciclosporin, colistimethate sodium, radio-contrast media, high-dose methotrexate or amphotericin B liposomal (Tillomed/Gilead/AmBisome).

Adverse effects:

  • Nephrotoxicity
  • Ototoxicity
  • Blood disorders (including neutropenia, thrombocytopenia and agranulocytosis)
  • Skin rash
  • Thrombophlebitis (usually on rapid administration)
  • Rapid administration of vancomycin may cause upper body flushing (Vancomycin Flushing Syndrome), pain, fever and muscle spasm of the chest and back. Symptoms should resolve on reducing the rate of administration.

Renal impairment:

  • If eGFR 50ml/min/1.73m2 or less, the IV vancomycin dose must be reduced. See relevant section below for further guidance.
  • If creatinine level is within range but has recently doubled this is a sign of decreasing renal function. Dose with caution.
  • If concerned about renal function, calculate eGFR using the following calculation:

eGFR (ml/min/1.73 m2) = (height in cm x 35) / Creatinine (micromol/L)

Hepatic impairment:

No dose adjustment is required in patients with hepatic impairment.

 

Intravenous Vancomycin - Monitoring

  • IV vancomycin requires pre-dose (trough) levels. See below for further guidance.
  • Ensure a creatinine level is taken with every vancomycin level.
  • If IV vancomycin is prescribed for more than 5 days, monitor U&Es and FBC twice weekly due to risk of nephrotoxicity and neutropenia.
  • Audiology monitoring should be considered in patients who
    • require therapy for 2 weeks or longer 
    • receive high or toxic level (more than 25mg/L)
    • receive concurrent ototoxic medications or in those with underlying hearing loss
    • See Audiometry and intravenous aminoglycosides

Intravenous Vancomycin Paediatric Dosing Guideline if eGFR over 90ml/min/1.73m2

(Note: For patients with eGFR 90mL/min/1.73m2 or less see guideline in next section) 

Initial dosing: 

Neonates over 35 weeks corrected gestational age 15mg/kg every 8 hours with a level before the 4th dose is due

Infants over 44 weeks corrected gestational age and up to 

6 months old and normal renal function

 10mg/kg every 6 hours with a level before the 4th dose is due 
Infants and children aged 6 months and over and no renal impairment  15mg/kg (max 1.5g) every 6 hours with a level before the 4th dose is due 

THEN follow the guidance "how to interpret vancomycin trough levels" table below

Intravenous Vancomycin Paediatric Dosing Guideline if eGFR 90ml/min/1.73m2 or less

Note: Dialysis patient: Discuss with named consultant.

 

Initial dosing:

Renal function

Dose

When to take level

eGFR 50-90ml/min/1.73 m2 

 15mg/kg (max 1.5g) every 8 hours 

 

 

Take a level before the 2nd dose and give the dose. Check result before giving the 3rd dose.

  • If the level is over 12mg/L: Reduce frequency to 12 hourly
  • If the level is 5-12 mg/L: Continue giving same dose 8 hourly
  • If the level is under 5mg/L: Increase frequency to 6 hourly

THEN take a level before the 4th dose AND follow guidance using the “how to interpret vancomycin trough levels” table below

eGFR 20-50ml/min/1.73 m2 or haemofiltration

15mg/kg (max 1g) every 12 hours

Take a level before the 2nd dose and give the dose. Check result before giving the 3rd dose.

  • If the level is over 12mg/L: Reduce dose to 10mg/kg every 12 hours
  • If the level is 5-12 mg/L: Continue giving same dose 12 hourly
  • If the level is under 5mg/L: Increase frequency to 8 hourly

THEN take a level before the 4th dose AND follow guidance using the “how to interpret vancomycin trough levels” table below

eGFR under 20ml/min/1.73 m2 or peritoneal dialysis

   15mg/kg (max 1g) as a single dose

Take a level every 12 hours until the level is between 10-20mg/L

Once level between 10-20mg/L, prescribe 10mg/kg as a single dose. Take a level every 12 hours until the level is between 10-20mg/L.

Continue dosing in this way.

How to Interpret Vancomycin Trough Levels

Trough level

Action to take

Less than 5mg/L

Increase dose by 50% and check level before 4th dose at increased dose

5mg/L up to 10mg/L

Increase dose by 25% and check level before 4th dose at the increased dose

10mg/L to 15mg/L

 Target trough level. Continue with current dose and check level every 2-3 days for patients with stable renal function

 15.1mg/L to 20 mg/L

If aiming for 10-15mg/L: Consider dose reduction before giving the next dose

If aiming for 15-20mg/L (Target trough level for severe infections or reduced sensitivity): Continue at current dose and check level every 2-3 days for patients with stable renal function

 20.1mg/L to 25 mg/L

Reduce dose by 25% and check level before 4th dose at the reduced dose.

More than 25mg/L

 

 

Check timing of sampling versus drug administration. If sample timing does not account for high concentration:

1. Omit further doses

2. Monitor concentrations at 12 hour intervals until level is 20mg/L or below

3. Restart vancomycin with approximately 50% dose reduction and check level before 4th dose

Oral vancomycin

 This guidance is NOT for use in infants under 35 weeks of gestational age – see neonatal guidance

 

See Clostridioides difficile infection guideline for dosing information