Vancomycin IV

Restricted
C difficile risk
None
Oral Bioavailability
N/A

Dosing

General dosingMild to Moderate InfectionsSevere Infections (sepsis, osteomyelitis), Meningitis (< 6 mo. of age)Meningitis (6 mo. of age and older)Infants and children: 60 mg/kg/DAY IV divided q6-8h; maximum 4 g/DAY
(q6h interval is preferred unless patient has active renal impairment)

Adjust dose based on serum drug concentration - see drug monitoring section for details. 40-60 mg/kg/DAY IV divided q6-8h60 mg/kg/DAY IV divided q6-8h80 – 100 mg/kg/DAY IV divided q6-8h

Less than 29 weeks corrected GA29 to 34 weeks corrected GAGreater than 34 weeks corrected GA15-24mg/kg/DAY IV divided q24h20-22mg/kg/DAY IV divided q12-18h40-45mg/kg/DAY IV divided q12h

Less than 29 weeks corrected GA29 to 34 weeks corrected GA34 to 38 weeks corrected GA26-30mg/kg/DAY IV divided q24h40-45mg/kg/DAY IV divided q12h40-45mg/kg/DAY IV divided q8h

38 to 46 weeks corrected GA40-60mg/kg/DAY IV divided q8h

No dosage adjustment required

Consult a pharmacist for renal dosing.
Renally cleared, requires dosage adjustment with changes in renal function.

Hemodialysis: Administer dose following dialysis treatment
CRRT: Clearance of vancomycin dependent upon method of renal replacement, filter type and flow rate

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 infections

Consult pharmacy for drug monitoring and interpretation as dosing is highly patient specific

When to check serum concentrations:

Check pre-concentration: 0-1 hours before dose
Initial concentration: prior to 3rd-4th dose for neonates and 5th-6th dose for infants/children
Subsequent concentrations: once weekly for courses more than 7 days (twice weekly if receiving other nephrotoxic agents, elevated baseline serum creatinine, or pre-dose serum concentration target greater than 15mg/L)

Pre-dose serum concentrations:
Target 7-12 mg/L: bacteremia including infections with coagulase negative staphylococci (e.g. S. epidermidis), skin or soft tissue infections caused by methicillin resistant Staphylococcus. aureus (MRSA; MIC less than 1 mcg/mL), or line infections
Target 12-15 mg/L: suspected or documented bacterial meningitis sepsis, deep, severe soft tissue infections, pneumonia, osteomyelitis
Target 15-20 mg/L: RARELY indicated in children due to lack of clinical evidence of efficacy. Consider for infective endocarditis or infections with vancomycin sensitive organisms that fail therapy at lower pre-dose serum concentration

Monitor urine output daily and serum creatinine and CBC (to assess for neutropenia) weekly with pre-dose concentration.

Red man syndrome (histamine release - slow down infusion), nephrotoxicity, cytopenias.

Management: Slow infusion to infuse over 120 minutes. Pre-dose with Diphenhydramine IV 0.5mg/kg/DOSE.

Aminoglycosides may potentiate nephrotoxicity.

Use caution and increase monitoring of renal function when used with concomitant nephrotoxins.

Antimicrobial class: Glycopeptide

Average serum half life:

  • Newborns: 6 to 10 hours

  • Infants and Children 3 months to 4 years: 4 hours

  • Children and Adolescents >3 years: 2.2 to 3 hours

Route of Elimination: Primarily via glomerular filtration; excreted as unchanged drug in the urine (80% to 90%)