Meningitis or Serious Infection15 mg/kg/dose IV every 12 hr
Trough pre-2nd dose.
Meningitis or Serious Infection15 mg/kg/dose IV every 8 hr
Trough pre-4th dose.
Meningitis or Serious Infection15 mg/kg/dose IV every 6 hr
(max 1 gram/dose).
Trough pre-5th dose.
15 mg/kg IV every 8-12 hr depending on trough goal
Complicated infections in seriously ill patients
25-30 mg/kg IV loading dose rounded to nearest 250 mg (max of 2 gm per dose)
Recommend dose per Pharmacy
CrCl > 60 ml/minCrCl 41-60 ml/minCrCl 21-40 ml/minCrCl 10-20 ml/minCrCl < 10 ml/minIn renally impaired patients, the initial dosing interval should be individualized based on specific patient and disease-state characteristics, serum concentration goals, site of infection, weight, age, and degree and stability of renal impairment (acute versus chronic). The below recommendations are intended as a guide, until serum vancomycin concentration data is available to further assist with dosing. No dose adjustment necessary10-15 mg/kg IV every 12-24 hr10 mg/kg IV every 24 hr10 mg/kg IV every 24-48 hr10-15 mg/kg IV x1 then redose according to levels
15-25 mg/kg IV load x1 followed by 500 mg to 1 gm Post each HD session
10-15 mg/kg IV every 24 hr
Treatment of infections by gram positive organisms in patients who have severe allergic reactions to beta-lactam antibiotics
Suspected or proven MRSA, coagulase-negative Staphylococci, Ampicillin-resistant Enterococcus, or ceftriaxone resistant S. pneumonia (CSF only) infections
Note: Empiric therapy should be discontinued within 72 hours if the below criteria are not met. Proven:
Methicillin-resistant coagulase-negative staphylococci
Ceftriaxone-resistant S. pneumonia (CSF only)
Closdtridium difficile infection (oral therapy)
Treatment of a single-positive blood culture for coagulase-negative staphylococci
Continued empiric use for presumed infection with negative cultures
Prophylaxis for infection or colonization of indwelling intravascular or intracranial catheters
Routine surgical prophylaxis (exceptions listed in guideline section)
ID consult is strongly advised for proven MRSA infections and for all S. aureus bloodstream infections
Target levels vary based on site of infection. Consult Infectious Disease or Pharmacy for assistance
Rash including Stevens-Johnson Syndrome
Red man syndrome (histamine release: slow down infusion)
Suspected or proven MRSA, coagulase-negative Staphylococcal infections, Enterococcal infections.
Collect trough 30 min -1 hr before 4th dose
Target trough 10-15 mcg/mL for most serious infections, 15-20 mcg/mL for CNS infections, Pneumonia, osteomyelitis, and Endocarditis.
If trough low, increase dose (do not exceed 2g/dose) OR decrease dosing interval.
If trough >20, increase dosing interval or decrease dose
Baseline and at least weekly SCr (for dose and nephrotoxicity assessment)
Red man syndrome (slow down infusion)
Aminoglycosides may potentiate nephrotoxicity
May enhance neuromuscular blockade of NM blocking agents
Careful with concomitant nephrotoxins
Antimicrobial class: Glycopeptide
Pregnancy category: C
Average serum half life: 8 hours
Biliary penetration: Moderate
CSF penetration: Moderate
Lung penetration: Therapeutic
Urine penetration: Therapeutic