a.  Vancomycin Adult Dosing and Monitoring

 

VANCOMYCIN DOSING

Vancomycin dosing is based on the patientís actual body weight and requires adjustment in renal dysfunction. 

 

Creatinine Clearance (based on Cockcroft and Gault and not eGRF)

Dose*

>60 ml/min

Uncomplicated Infections: 10-15 mg/kg q12h1

 

Serious Infections: Consider loading dose of 25mg/kg IV x1, followed by 15-20 mg/kg q8-12h (45-60mg/kg/day divided q12h or q8h)2

 

40-60 ml/min

10-15 mg/kg q12h-q24h

20-40 ml/min

5-10 mg/kg q24h

10-20 ml/min

5-10 mg/kg q24h-q48h

<10 ml/min

10 - 15 mg/kg IV loading dose x1; redose according to serum levels

Hemodialysis

15-20 mg/kg load, then 500 mg IV post HD only

CVVH

10-15 mg/kg q24h

* round dose to 250mg, 500mg, 750mg, 1g, 1.25g, 1.5g, 1.75g or 2g (maximum: 2gm/dose)

Higher total daily doses of vancomycin have been associated with nephrotoxicity

 

1 For patients with uncomplicated infections requiring vancomycin, trough levels of 10-15 mcg/ml are recommended.

2 For patients with serious infections due to MRSA (central nervous system infections, endocarditis, ventilator-associated pneumonia, bacteremia or osteomyelitis) , trough levels of 15-20 mcg/ml are recommended. ID CONSULT IS RECOMMENDED.

 

 

VANCOMYCIN TROUGH MONITORING

 

Vancomycin troughs are not recommended in patients in whom anticipated duration of therapy is short (≤ 3 days)

 

Trough levels are recommended for routine monitoring (for intermittent hemodialysis, a pre-dialysis level should be drawn). Trough levels should be obtained within 30 minutes before 4th dose of a new regimen or dosage change.

 

Once weekly monitoring is reasonable in patients with stable renal function and clinical status. (Data supporting safety or prolonged troughs of 15-20 mcg/ml is limited.)