Patients receiving intravenous vancomycin, teicoplanin or an aminoglycoside (gentamicin, tobramycin and amikacin) need regular monitoring of serum antibiotic levels.
The Biochemistry department carry out the assays of serum antibiotic levels. All advice and enquires are dealt with by the Microbiology department, Antimicrobial Pharmacist or Pharmacy Medicines Information.
Assays for vancomycin and gentamicin are performed in house. Assays for amikacin, tobramycin and teicoplanin are currently sent away for testing at another laboratory. For assays that require sending away, try to ensure that specimens are collected during the normal working week; if specimens need to be done at weekends, prior arrangement is required.
Collection of blood for monitoring of therapeutic levels of antibiotics must be done from a peripheral vein. Specimens are collected into serum gel tubes (brown cap).
For aminoglycoside assays it is essential to indicate on the request form if the patient is on a once-daily dosing regimen, multiple-daily dosing regimen, or renal impairment regimen. The time the sample is taken and the time the last dose was administered must be stated on the sample bottle to avoid confusion and speed processing. This information should also be recorded in the patient’s medical notes.
Patients receiving either aminoglycosides, vancomycin or teicoplanin MUST have their renal function checked at least twice weekly in stable renal function, or daily in patients with impaired or unstable renal function.
Introduction |
Suspected or proven MRSA infections and other Gram positive organisms in penicillin allergic patients. |
Dose regime |
CrCl >70mL/min 1g bd |
Administration |
Slow IV infusion in either Sodium chloride 0.9% or Glucose 5% over 2 hours (maximum rate 10mg/min). |
What levels should I monitor? |
Pre-dose (trough) level immediately prior to administration of dose There is NO need to routinely monitor peak vancomycin levels (for list of exceptions refer to policy on Intranet) |
When should I take levels initially? |
Twice daily dosing |
When should I repeat levels? |
If renal function remains stable |
Target assay levels |
Pre-dose (trough) level 10-20mg/L |
Recommendations for dose adjustment |
Pre-dose <10mg/L |
Do I need to wait for the level to come back before I give the next dose? |
No, not unless specifically advised |
Further advice |
Oncall microbiologist via bleep 774 or switchboard or antimicrobial pharmacist bleep 448. |
Appendix 1: Extended interval gentamicin dosing guidelines summary (Adults) Click here for full guideline |
|
Introduction |
Preferred regimen for the treatment of Gram negative sepsis
|
Dose regimen |
Gentamicin dose = 5mg/kg (maximum 500mg) Use adjusted body weight if obese (ie. if 20% over ideal body weight) |
Prescribing first dose |
Check no previous dose given in last 24hours. May prescribe on regular antibiotics section and indicate on the drug chart the need to monitor Pre-dose Level before 2nd Dose |
Administration |
Dilute with 100mL sodium chloride 0.9% or glucose 5% and give by IV infusion over 30-60mins |
What levels should I monitor? |
Pre-dose level before 2nd dose (1-4 hours before next dose is due) |
When should I take levels initially? |
Check before 2nd dose due (unless single dose therapy) |
Target assay levels |
Pre-dose level LESS THAN 1mg/L |
Recommendations for dose adjustment |
Normal pre-dose level (<1mg/L) Pre-dose level 1-2mg/L (and renal function unchanged) Pre-dose level greater than 2mg/L If the patient cannot safely be maintained on an extended interval dosing regimen, consider the renal dosing regimen. |
Do I need to wait for the level result? |
IF NORMAL and STABLE RENAL FUNCTION - Monitor pre-dose level before 2nd dose, GIVE 2nd dose and WAIT for the result of the pre-dose level before prescribing and administering 3rd or subsequent doses |
When should I repeat levels? |
Check pre-dose levels every 3-4 days if renal function remains stable. Monitor pre-dose levels daily if adjustments are being made or if the patient is renally impaired. |
How do I prescribe subsequent doses? |
Subsequent doses may be prescribed on the regular section of the drug chart, and administration boxes MUST be marked to ensure the correct dosing interval is followed, and indicate when the next level is due. |
Appendix 2: Renal gentamicin dosing guidelines summary (Adults) |
|
Introduction |
This regimen should be used where the prescriber wishes to use an extended interval gentamicin dosing regimen for the treatment of Gram negative sepsis in patients WITH severe renal impairment (CrCl <30ml/min, but if <10ml/min - discuss with microbiologist or pharmacy) or elderly patients e.g. >70years |
Dose regimen |
Gentamicin dose = 3mg/kg (maximum 300mg) Use adjusted body weight if obese (ie. if 20% over ideal body weight) |
Prescribing first dose |
Check no previous dose given in last 24hours Prescribe the first dose on the “once only” section of the drug chart |
Administration |
Dilute with 100mL sodium chloride 0.9% or glucose 5% and give by IV infusion over 30-60minutes |
What levels should I monitor? |
Pre-dose level before 2nd dose (1-4 hours before next dose is due) |
When should I take levels initially? |
Check before 2nd dose due (unless single dose therapy) |
Target assay levels |
Pre-dose level LESS THAN 1mg/L |
Recommendations for dose adjustment |
If level less than 1mg/L
If level 1mg/L OR greater than 1mg/L
No further doses should be prescribed or administered until level is <1mg/L |
Do I need to wait for the level result? |
WAIT for the result of the pre-dose level before prescribing and administering any subsequent doses |
When should I repeat levels? |
DAILY levels are required for patients on the renal gentamicin dosing regimen or those with unstable renal function. |
How do I prescribe subsequent doses? |
Subsequent doses may be prescribed on the “once only” section of the drug chart or regular section of the chart (but highlighting the need to wait for pre dose level before administration . Doses should only be administered once the pre-dose level is less than 1mg/L. |
Continuation of treatment |
If the patient requires gentamicin beyond 48 hours, this MUST be discussed with a Consultant Microbiologist. The risk of nephrotoxicity and ototoxicity increases with prolonged courses. |
Appendix 3: Traditional multiple daily dosing guidelines summary (Adults) |
|
Introduction |
Treatment of patients with endocarditis. |
Dose regimen |
1mg/kg (max 80mg) 12 hourly - modified according to renal function and level (round to nearest 20mg). Use adjusted body weight if obese (ie. if 20% over ideal body weight) |
Prescribing first dose |
Prescribe gentamicin at chosen dose and dose interval The dosing regimens recommended above are starting dose regimens only. Blood levels must be monitored to ensure target peaks and troughs are achieved. |
Administration |
IV bolus over 3-5 minutes. Dilution is not normally necessary. |
What levels should I monitor? |
Check Pre and Post dose levels around the 3rd or 4th dose. |
When should I take levels initially? |
Check pre-dose (trough) level around the 3rd or 4th dose before administering the dose. Administer dose. There is no need to wait for pre-dose level to be reported before administering dose, unless instructed to do so by your ward pharmacist or Consultant Microbiologist. Check one hour post-dose (peak) level around the 3rd or 4th dose. Level to be taken one hour after completion of the bolus/infusion. If renally impaired, check around the 2nd dose. Label your sample tubes and request form clearly with pre and post dose level as appropriate. |
Target assay levels |
Pre-dose (trough) level -less than 1mg/L for endocarditis |
Recommendations for dose adjustment Please contact your ward Pharmacist or Consultant Microbiologist for advice on changes to the dose and/or dosing interval. |
Pre-dose levels: One-hour post-dose levels: |