Guidelines
Initial Dose

Initial Dose

Loading Dose

  • Severe infections where rapid attainment of target level of 10-15 mg/L is desired
  • Significant renal dysfunction in order to decrease the time required to attain steady state

Recommended Dose: 25-30 mg/kg IV

  • Based on actual body weight, for 1 dose, followed by maintenance dose separated by recommended dosing interval
  • Consider capping the loading dose at a maximum of 3 g
  • Loading doses DO NOT need to be adjusted in patients with renal dysfunction; only maintenance dosing interval requires adjustment

If loading dose not used then proceed with administration of a maintenance dose at recommended dosing interval

Maintenance Dose

15-20 mg/kg IV

  • Based on actual body weight; 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 mg

Dosing Interval

Interval depends on patient’s renal function and targeted serum vancomycin concentration

  • There is no reliable data to support the use of a 15-20 mg/L target trough
  • However, there is data demonstrating that target troughs of 15-20 mg/L are associated with greater nephrotoxicity.
Creatinine Clearance (mL/min) Dosing Interval
Greater than 80 q8-12h
40 to 80 q24h
20 to 39 q36h
10 to 19 q48h
Less than 10 Consider a loading dose, then adjust maintenance dose based on serial serum drug levels to target trough

CrCl = [(140-age) x weight (in kg)] / SCr (in mcmol/L)

Weight

  • Use ideal body weight unless actual weight is 20% above ideal body weight (IBW), in such case use adjusted body weight
  • If actual weight is less than ideal body weight, use actual weight

IBW

  • 45.5 kg + (0.92 x cm above 150 cm) or
  • 45.5 kg + (2.3 x inches above 60”)

Adjusted body weight

  • 0.4 x (actual body weight – IBW) + IBW

CrCl = [(140-age) x weight (in kg) x 1.2] / SCr (in mcmol/L)

Weight

  • Use ideal body weight unless actual weight is 20% above ideal body weight (IBW), in such case use adjusted body weight
  • If actual weight is less than ideal body weight, use actual weight

IBW

  • 50 kg + (0.92 x cm above 150 cm) or
  • 50 kg + (2.3 x inches above 60”)

Adjusted body weight

  • 0.4 x (actual body weight – IBW) + IBW

Clinical Pearls

  • Use care when selecting patients for q8h dosing - recommend avoiding in patients that are older and/or with multiple co-morbidities (ex. diabetes, heart failure, etc.) or where estimated creatinine clearance would be expected to be an overestimate (ex. low muscle mass in an elderly patient, dysmobility, paraplegia, etc.)
  • Consider q8h dosing for patients who are younger and otherwise well with few medical co-morbidities
  • The provided ranges for estimated creatinine clearance are only intended to be a guide for the selection of an empiric dosing interval and should not be used in isolation without considering patient and infection-related factors - especially when estimated creatinine clearance approaches either end of the range