10-20 mg/kg IV q8 - 12 h
Final dose depends on trough goal
Recommend dose per pharmacy
Acceptable Empiric Use
Treatment of suspected community-or nosocomial-acquired bacterial meningitis.
Treatment of healthcare-associated (including ventilator-associated) pneumonia.
Treatment of peritoneal dialysis-related peritonitis in a severely ill patient.
Treatment ofsepsis in a patient at risk for MRSA bacteremia [catheter in place, indwelling hardware, known MRSA colonization, transfer from a nursing home or subacute facility, recent (within 3 months) or current prolonged hospitalization >2 weeks, hemodialysis].
Treatment of surgical-site infection following placement of hardware.
Treatment of severe diabetic foot infection in a patient at risk for MRSA.
Treatment of necrotizing fasciitis.
Treatment of suspected endocarditis in a moderately or severely ill patient after appropriate blood cultures are obtained.
Treatment of Gram-positive cocci in clusters in ≥ 1 set of blood cultures in a moderately or severely ill patient.
Treatment of Gram-positive cocci in clusters or chains in ≥ 2 sets of blood cultures in any patient.
Note: empiric therapy should be discontinued within 72 hours if criteria for definitive therapy (listed below) are not met:
Acceptable Use for Definitive Intravenous Therapy
Proven infection with beta-lactam resistant organisms:
Methicillin-resistant coagulase-negative staphylococcus
Ampicillin-resistant enterococcus (if susceptible)
Ceftriaxone-resistant S. pneumoniae (CSF only)
Treatment of infections caused by Gram-positive organisms in patients who have severe allergic reactions to beta-lactam antibiotics (see discussion of penicillin allergy).
Acceptable Use for Definitive Oral Therapy
Clostridium difficile infection (see CDI section)
Acceptable Use for Prophylaxis
Prophylaxis for cardiac, vascular, or orthopedic (jointreplacement, spinal fusion, ORIF only) surgery with a documented reason in the chart or in patients with severe beta-lactam allergy (no more than one pre-op and one post-op dose).
Continued empiric use for presumed infection with negative cultures.
Treatment of a single-positive blood culture for coagulase-negative staphylococci.
Routine surgical prophylaxis except as above.
Empiric treatment for first fever in neutropenic patients without evidence of catheterrelated bloodstream infection (e.g. inflamed IV catheter site), severe mucositis, or history of MRSA.
Prophylaxis for infection or colonization of indwelling intravascular or intracranial catheters.
Selective decontamination of the digestive tract.
Eradication of MRSA colonization.
Routine prophylaxis for patients on continuous ambulatory peritoneal dialysis or hemodialysis.
When chosen only for convenience of dosing for treatment of infections caused by betalactam susceptible organisms in patients who are HD-dependent.
Topical application or irrigation.
Suspected or proven MRSA, coagulase-negative Staphylococcal infections, Enterococcal infections
Collect trough 30 min before 4th dose if abnormal/fluctuating renal function.
Target trough 10-15 mcg/mL for most serious infections, 15-20 mcg/mL for meningitis or osteomyelitis
If trough low, increase dose (do not exceed 2g/dose) OR decrease dosing interval.
If trough >20, increase dosing interval or decrease dose
Recommend dose per pharmacy
Cr baseline and weekly (for potential dose adjustment and nephrotoxicity assessment)
Red man syndrome
Nephrotoxicity (usually in combination with other nephrotoxins)
Aminoglycosides may potentiate nephrotoxicity
May enhance neuromuscular blockade of NM blocking agents
Careful with concomitant nephrotoxins
Target levels vary widely based on site of infection. Consult Infectious Disease or Pharmacy for assistance
ID Consult is strongly advised for proven or suspected MRSA infections and for all S aureus bloodstream infections
Antimicrobial class: Glycopeptide
Pregnancy category: C
Average serum half life: 8 hours
Biliary penetration: Moderate
CSF penetration: Moderate
Lung penetration: Therapeutic
Urine penetration: Therapeutic