Vancomycin IV

C difficile risk
Low
Oral Bioavailability
None

Dosing

Dosing based on actual body weightConsider a loading dose of 25-30 mg/kg IV if severe infection, adjusting maintenance doses based on renal function.

  • consider capping the loading dose at a maximum of 3 g.

  • maximum of 2g/dose for initial maintenance doses (prior to vancomycin levels).Doses greater than 500 mg

  • Round to the nearest 250 mg

Doses less than 500 mg

  • Round to the nearest 50 mgAdjust dose for serum drug levels where applicable. For prolonged therapies, consider pharmacy consult for appropriate dosing and monitoring

CrCl >80CrCl 40-8015 - 20 mg/kg IV q8-12h15 - 20 mg/kg IV q24h

Dosing based on actual body weightConsider a loading dose of 25-30 mg/kg IV if severe infection, adjusting maintenance doses based on renal function.

  • consider capping the loading dose at a maximum of 3 g.

  • maximum of 2g/dose for initial maintenance doses (prior to vancomycin levels).Doses greater than 500 mg

  • Round to the nearest 250 mg

Doses less than 500 mg

  • Round to the nearest 50 mgAdjust dose for serum drug levels where applicable. For prolonged therapies, consider pharmacy consult for appropriate dosing and monitoringTarget trough level of 10-15 mg/L for ALL infections

CrCl 20-39CrCl 10-19CrCl <1015 - 20 mg/kg IV q36h15 - 20 mg/kg IV q48hConsider loading dose of 25-30 mg/kg IV; then use serial serum drug levels to adjust

Note>100kg70-100kg<70kgAdjust maintenance doses based on pre-dialysis vancomycin trough levels

  • Target trough: 10-15 mg/L1500mg IV loading dose, then 1000mg IV maintenance dose infused after dialysis on dialysis days1250mg IV loading dose, then 750mg IV maintenance dose infused after dialysis on dialysis days1000mg IV loading dose, then 500mg IV maintenance dose infused after dialysis on dialysis days

General Information

Serious infections due to beta-lactam resistant, Gram-positive microorganisms such as:

  • Methicillin resistant Staphylococcus aureus (MRSA)

  • Ampicillin resistant Enterococcus spp.

  • Methicillin resistant coagulase-negative staphylococci

  • Ceftriaxone resistant S. pneumoniae (meningitis)

Infections due to Gram-positive microorganisms in patients with a history of severe delayed skin reactions/organ dysfunction to beta-lactam antimicrobials. For example:

  • Stevens-Johnson syndrome (SJS)

  • Toxic epidermal necrolysis (TEN)

  • Drug rash with eosinophilia & systemic symptoms (DRESS)

Surgical prophylaxis
Vancomycin should be reserved for the following:

  • Patients with a history of anaphylaxis to cefazolin

  • Patients with a history of severe delayed skin reaction/organ dysfunction to any beta-lactam antimicrobial. For example, SJS, TEN, DRESS.

  • Refer to Beta-lactam allergy guideline for more information.

Levels are recommended in:

  • patients who are severely ill

  • patients with anticipated therapy duration of 7 days or greater

  • patients with impaired renal function (CrCl 50 mL/min or less) or unstable renal function

  • patients on dialysis

  • concomitant use of other nephrotoxic drugs

  • patients with altered volume of distribution or clearance of vancomycin, including

    • morbidly obese patients
    • cystic fibrosis
    • burns more than 20% BSA
    • pregnancy

Trough (pre) levels are taken within 30 minutes before a dose

First trough level should be taken at steady state, typically:
- prior to 4th dose if q12h interval
- prior to the 5th dose if q8h interval

After a thorough review of the available evidence, NB-ASC recommends a target trough level of 10-15 mg/L for ALL infections.

  • There is no reliable data to support the use of a target trough of 15-20mg/L.

  • However, there is data demonstrating that target troughs of 15-20 mg/L are associated with greater risk of nephrotoxicity.

  • Vancomycin levels should always be maintained above 10 mg/L to avoid the development of resistance.

Interpreting trough level and adjust vancomycin dose:

  • If trough low, increase dose (do not exceed 2g/dose) OR decrease dosing interval.

  • If trough >15 - 20, increase dosing interval or decrease dose

  • If trough level is significantly elevated (i.e. greater than 25 mg/L) hold vancomycin and use repeat levels to determine when to restart vancomycin and new dosing regimen

Subsequent vancomycin trough levels:

  • With dosage change: trough should be repeated at new steady state

  • Once target trough achieved: trough should be taken approximately every 7 days in hemodynamically stable patients

General Monitoring:

  • Patient’s clinical response to vancomycin

  • CBC at least weekly on long-term vancomycin therapy

  • Serum creatinine (SCr) at least twice a week initially, then at least weekly on long-term therapy

  • More frequent monitoring should be considered if

    • renal function changing
    • concurrent nephrotoxic drug
    • underlying renal dysfunction
    • age greater than 60

  • Nephrotoxicity

  • Cytopenias (esp. neutropenia, thrombocytopenia)

  • Ototoxicity (controversial)

  • Histamine-release (red person syndrome) or flushing can result from rapid infusion rates and is not a true allergy. Refer to the IV manual for recommended minimum administration time

  • Aminoglycosides may potentiate nephrotoxicity.

  • May enhance neuromuscular blockade of NM blocking agents.

  • Careful with concomitant nephrotoxins.

Special Considerations:

  • Oral vancomycin administration is suitable only for C. difficile infection as it is not absorbed beyond the GI tract. Do not use oral vancomycin as stepdown therapy for IV vancomycin

  • Vancomycin is a less effective choice than a beta-lactam antimicrobial for methicillin-susceptible staphylococcal infections

  • Staphylococcus aureus with an MIC of greater than or equal to 2 mg/L have a high failure rate; consider an ID consult

Antimicrobial class: Glycopeptide

Pregnancy category: C

Average serum half life: 8 hours

Urine penetration: Therapeutic

Lung penetration: Therapeutic

CSF penetration: Moderate

Biliary penetration: Moderate