Vancomycin IV

C. diff Risk

None

Oral Bioavailability

NA

Dosing

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

General Information

Acceptable Uses

  • 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:

  • MRSA

  • Methicillin-resistant coagulase-negative staphylococci

  • Ampicillin-resistant enterococcus

  • Ceftriaxone-resistant S. pneumonia (CSF only)

  • Closdtridium difficile infection (oral therapy)

Unacceptable Uses

  • 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)

Additional Information

  • 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

Adverse Effects

  •  Nephrotoxicity

  •  Cytopenias

  •  Rash including Stevens-Johnson Syndrome

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

Common Usage

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

Drug Monitoring

Lab

  • 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)

Clinical

  • Hypersensitivity

  • Red man syndrome (slow down infusion)

  • Phlebitis

  • GI effects

Major Interactions

Aminoglycosides may potentiate nephrotoxicity

May enhance neuromuscular blockade of NM blocking agents

Careful with concomitant nephrotoxins

Pharmacology

Antimicrobial class: Glycopeptide

Pregnancy category: C

Average serum half life: 8 hours

Biliary penetration: Moderate

CSF penetration: Moderate

Lung penetration: Therapeutic

Urine penetration: Therapeutic