ࡱ>  bjbj 4yyT: : 8|JZ(000   5J7J7J7J7J7J7J$4MO[J9     [J00J 005J 5JRE>@0Fw^9?!JJ0JW?bPoP<@@<PE,       [J[J<   J    P         : Z:  Vancomycin Dosing in Paediatrics (intermittent infusion only)  Childrens Ward  Warning Document uncontrolled when printed  Policy Reference: Date of Issue: Prepared by: Date of Review Lead Reviewer: Version: Authorised by: Date: Distribution Consultant Pharmacist  Ward Method CD Rom ( E-mail ( Paper ( Intranet (  DRUG NAME INDICATION Infections due to Gram-positive bacteria including endocarditis, osteomyelitis, septicaemia and soft-tissue infections. The dosing below is based on recommendations in a report to the Neonatal and Paediatric Pharmacist Group January 2016, on empirical dosing of intermittent intravenous vancomycin in children aged over 1 month, for optimum trough levels. This report showed that in certain age groups, the BNFc dosing did not produce adequate trough levels, AUC24 values, or MICs. AGEDOSEFREQUENCYROUTE<1 month see separate vancomycin policy for neonates1 month to <6 months12.5mg/kg8 hourlyGive over at least 60 minutes using an infusion pump. The rate should be below 10mg/minute. Central administration is preferable but concentrations up to 5mg/ml may be given via a large peripheral vein.6 months to < 1 year20mg/kg8 hourly1 year to 6 years25mg/kg8 hourly> 6 years to 16 years20mg/kg8 hourlyIn renal impairmentGFR 10 to 50ml/min/1.73m2Give usual starting dose and adjust according to levelsTake a trough level 12 hours after the first dose was given. Give the next dose when the trough is within the target range. If the first level is above the target range, re-check in a further 12 hours. GFR <10ml/min/1.73m210mg/kg starting dose, (do not repeat dose) then adjust according to levelsTake trough level 24 hours after the first dose. Give the next dose if the trough is within the target range. If the first level is above the target range, re-check in 12 or 24 hours, depending on how elevated the level is. Seek advice on subsequent dosing. Aiming for levels 10-20mg/L Child over 1 year: Estimated glomerular filtration rate (mL/minute/ 1.73m2) = 40 x height (cm)/serum creatinine (micromol/litre) Children with low muscle mass, those who have had a bone marrow transplant, or peritoneal dialysis, may need a formal GFR checked by nuclear medicine. SUPPLY Vials containing vancomycin (as hydrochloride) powder for reconstitution. Strengths available: 500mg, 1g. PREPARATION Reconstitute vial with water for injection taking displacement values into consideration. Average displacement value is 0.2ml for 500mg and 0.4ml for 1g vial as per Medusa. Reconstitute with water for injections adding 9.8mL to each 500mg vial (giving a concentration of 50mg/mL) and 19.6mL to each 1g vial (giving a concentration of 50mg/mL). For IV infusion further dilute with sodium chloride 0.9% or glucose 5% to a concentration of d"5mg/ml. The following table can be used as a guide: DoseVolume to administer in (mL)less than 100mg25mL100mg to 250mg50mL250mg to 500mg100mL500mg to 1.25g250mL1.25g to 2g500mL In fluid restricted patients, maximum concentration is 10mg in 1ml, via CENTRAL LINE ONLY Intravenous infusion at rates as per the following table: DoseAmount of time to give over500mg or less60 minutes 500mg 900mg90 minutes900mg 1.2g120 minutesGreater than 1.2gMaximum rate of 10mg / minute MONITORING Blood for vancomycin levels should be taken peripherally and not from an existing indwelling venous access device to reduce the risk of falsely elevated results. Take 1st trough level immediately before the 4th dose andadminister dose without waiting for levelresults. The result obtained will determine what to do for the next dose i.e.5th dose. Monitor renal function regularly i.e. daily. If renal function is impaired, e.g. a change in creatinine of more than 15 to 20%, the trough level should be known before the next dose is administered. See dosing table for monitoring in renal impairment If levels are within the therapeutic range, repeat every 3 days. If levels are sub-therapeutic orare above the therapeutic range,adjust the doseas per tables belowand repeat the level 24 hours after ANY dose adjustment. Therapeutic range: Trough 10-20mg/L e.g. proven infections, bacteraemia, endocarditis. Trough levels of 15-20mg/L may be recommended by Paediatric Infectious Diseases / Micro for severe infections Approx. time to steady state: 1-2 days Note vancomycin may increase the risk of aminoglycoside induced ototoxicity use caution if co-prescribing with other agents that may cause ototoxicity e.g. furosemide, gentamicin, tobramycin. If the measured concentration is unexpectedly HIGH or LOW, consider the following: Were the dose and sample times recorded accurately? Was the correct dose administered? Was the sample taken from the line used to administer the drug? Was the sample taken during drug administration? Has renal function declined or improved? Does the patient have oedema or ascites? If in doubt, take another sample before modifying the dosage regimen and / or contact pharmacy for advice. Level (mg/L)Suggested dose change< 10 Confirm all doses given. If so, and: Dosage interval 8 hours: change to 6 hourly Take further level 24 hours after ANY dosage adjustment.10-15If the patient is responding, maintain the present dosage regimen. If the patient is seriously ill, change an 8 hourly dose to 6 hourly. 15-20Maintain current dosage regimen. Repeat level in 3 days. > 20Confirm trough sample taken appropriately. Stop, reanalyse every 12 hours until level is < 20mg/L and seek advice.  Seek help from pharmacy or microbiology if you need help interpreting the result. CompatibleSolution Compatibility Sodium chloride 0.9%, glucose 5%, glucose 5% in sodium chloride 0.9%, sodium lactate compound (Hartmann's solution). Compatible Medicine InfusionsAciclovir, amiodarone (in glucose 5%), anidulafungin (in glucose 5%), atracurium, calcium gluconate, cisatracurium, clarithromycin (in glucose 5%), dexmedetomidine, glyceryl trinitrate, esmolol, fentanyl, fluconazole, insulin (soluble), labetalol, levofloxacin (in glucose 5%), magnesium sulfate (in glucose 5%), midazolam (in glucose 5%), milrinone, morphine sulfate (in glucose 5%), potassium chloride, remifentanil, tigecycline (in sodium chloride 0.9%).IncompatibleSolution Incompatibility: Ampicillin, cefotaxime, ceftazidime, ceftriaxone, cefuroxime, foscarnet, heparin, omeprazole, pantoprazole, piperacillin/tazobactam, dexamethasone sodium phosphate, phenobarbital.      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