Vancomycin IV

Restricted
C difficile risk
None
Oral Bioavailability
NA

Spectrum Of Activity

Dosing

eGFR 0-10eGFR 10-50 eGFR > 50 25mg/kg IV first dose then dosing as per random concentrations

For specific dosing and guidance contact Pharmacy25mg/kg IV first dose then 15mg/kg IV with interval determined by dosing nomogram

For specific dosing and guidance contact Pharmacy25mg/kg IV first dose then 15mg/kg IV q8-12h with interval determined by dosing nomogram

For specific dosing and guidance contact Pharmacy

Loading dose: Maintenance dose: 25mg/kg IV once then as per belowLess than or equal to 100kg:
750 mg IV qHD (given during last hour of HD session)

Greater than 100kg:
1000mg IV qHD (given during last hour of HD session)

For specific dosing and guidance contact Pharmacy

15mg/kg load then 7.5-10mg/kg IV q12h

For specific dosing and guidance contact Pharmacy

Intraperitoneal Treatment of Peritonitis Intravenous Administration for a Systemic InfectionThe on-call peritoneal dialysis nurse will determine initial dose of vancomycin and administer to the patient. Ward nurses do not administer intraperitoneal doses of medication (exception: 6th medicine, SPH).

Contact the PD pharmacist for advice on drawing drug concentrations & subsequent dosage adjustments
25mg/kg IV x 1 dose then 15mg/kg administered once serum concentration close to desired therapeutic range

For specific dosing and guidance contact Pharmacy

25mg/kg IV loading dose rounded to nearest 250mg.

15mg/kg IV q8-12h maintenance depending on trough goal.

See VANCOMYCIN DOSING NOMOGRAM under Syndromes

For specific dosing and guidance contact Pharmacy

Therapy is UNRESTRICTED for the first 72 hours of therapy after which Infectious Diseases service approval is required for continuation of therapy (see below for exceptions/rules).

Approval may be granted via phone conversation or formal consult and must be reflected in the patient orders section.

The following conditions are also in place:

  •  Nephrologists are authorized to prescribe without I.D. approval for nephrological diseases

  •  Vancomycin may be used for surgical prophylaxis for up to 24 hours post-op in patients with documented penicillin allergy or patients who are known to be MRSA carriers/colonized. (I.D. approval is required for continuation of therapy beyond 24 hours).

General Information

Suspected or proven MRSA, coagulase-negative Staphylococcal infections, Enterococcal spp. infections.

General monitoring
1. SCr and urea 2-3 times a week
2. Hydration status

VANCOMYCIN TROUGH CONCENTRATION MONITORING
To be drawn 30 minutes prior to the next dose -- timing dependent upon the following parameters:

Trough concentration recommended if:

  • Aggressive therapy (i.e., trough concentration 15-20 mg/L)

  • Concomitant nephrotoxin (e.g., aminoglycosides, NSAIDs, amphotericin)

  • Serious infection (see below)

  • Prolonged course of therapy anticipated (greater than 8 days of therapy)

  • Class III Obesity(BMI greater than or equal to 40 kg/m2)

  • Unstable Renal Function (either deteriorating or improving)

  • Renal dysfunction

  • Altered Volume of Distribution

Therapeutic drug monitoring NOT generally required for anticipated short course of therapy (less than equal to 8 days) AND hemodynamically stable and/or surgical prophylaxis.

Goal Trough 15-20 mg/L if treating:

  • Central nervous system infection

  • Deep-seated or sequestered infection (e.g., abscess)

  • Endocarditis

  • Osteomyelitis

  • MRSA pneumonia, skin and soft tissue infection

  • Bacteremia due to proven or suspected MRSA or MSSA in penicillin-allergic patient

  • Other infections due to S.Aureus with Vancomycin MIC greater than or equal to 1 mg/L

Goal Trough 10-15 mg/L if treating:

  • Skin and Soft tissue infection not due to MRSA

  • Urinary tract infection

  • Bloodstream or line infections due to Coagulase Negative Staphylococci (CoNS)

  •  Nephrotoxicity

  •  Cytopenias

  •  Rash including Stevens-Johnson Syndrome

  •  Red man syndrome (histamine release- slow down infusion)

Aminoglycosides may potentiate nephrotoxicity.

May enhance neuromuscular blockade of NM blocking agents.

Careful with concomitant nephrotoxins.

Target levels vary widely based upon site of infection and organism.

Consult Infectious Diseases or Pharmacy for target recommendations and dosing assistance.

Antimicrobial class: Glycopeptide

Pregnancy category: C

Average serum half life: 8 hours

Biliary penetration: Moderate

CSF penetration: Moderate

Lung penetration: Therapeutic

Urine penetration: Therapeutic

Route of Elimination: Renal