Vancomycin IV

C. diff Risk

None

Oral Bioavailability

NA

Dosing

15-20 mg/kg q8-12h in patients with normal renal function.

Initial dosing in obese and non-obese patients should be based on actual body weight. Subsequent dosing should be adjusted based on serum trough vancomycin concentrations, renal function and patient specific pharmacokinetic calculations.Consider more aggressive dosing in serious, invasive infections where a trough level target of 15-20 mg/L is desired (see Monitoring section).In complicated infections and seriously ill patients, consider a loading dose of 25-30 mg/kg to facilitate rapid attainment of target trough concentrations. Do NOT adjust loading dose for renal dysfunction.Avoid maintenance doses larger than 2 g; instead consider shorter dosing interval.Pharmacokinetics may be altered in patients with: burns, critical illness, unstable renal function, morbid obesity, pregnancy, cystic fibrosis.IV vancomycin is ineffective against the treatment of C. difficile infections. See oral vancomycin monograph for C. difficile treatment.

Actual Body Weight 40-49 kgActual Body Weight 50-64 kgActual Body Weight 65-74 kgActual Body Weight 75-89 kgActual Body Weight 90-114 kgActual Body Weight 115-130 kgActual Body Weight Greater Than 130 kg750 mg1000 mg1250 mg1500 mg1750 mg2000 mgConsider alternate dosing strategy.

Initial dosing in obese and non-obese patients should be based on actual body weight. Subsequent dosing should be adjusted based on serum trough vancomycin concentrations, renal function and patient specific pharmacokinetic calculations.Consider more aggressive dosing in serious, invasive infections where a trough level target of 15-20 mg/L is desired (see Monitoring section).In complicated infections and seriously ill patients, consider a loading dose of 25-30 mg/kg to facilitate rapid attainment of target trough concentrations. Infuse at a rate of 500 mg/hr. Do NOT adjust loading dose for renal dysfunction.Avoid maintenance doses larger than 2 g; instead consider shorter dosing interval.Pharmacokinetics may be altered in patients with: burns, critical illness, unstable renal function, morbid obesity, pregnancy, cystic fibrosis.IV vancomycin is ineffective against the treatment of C. difficile infections. See oral vancomycin monograph for C. difficile treatment.

Actual Body Weight 40-49 kgActual Body Weight 50-64 kgActual Body Weight 65-74 kgActual Body Weight 75-89 kgActual Body Weight 90-114 kgActual Body Weight 115-130 kgActual Body Weight Greater Than 130 kg750 mg1000 mg1250 mg1500 mg1750 mg2000 mgConsider alternate dosing strategy

CrCl Greater Than or Equal to 60 mL/minCrCl 41-59 mL/minCrCl 31-40 mL/minCrCl 16-30 mL/minCrCl 10-15 mL/minCrCl Less Than 10 mL/min, Anuric Dosing or HemodialysisCRRTq12hq24hq36hq48hq72hOrder random level and repeat every 1 to 2 days. Repeat dose when level less than 20 mg/L.500 mg q24-48h.
Drug clearance is highly dependent on the method of renal replacement, filter type, and flow rate. Appropriate dosing requires close monitoring of pharmacologic response, signs of adverse reactions due to drug accumulation, as well as drug concentrations in relation to target trough (if appropriate). Dose adjustments are made based on levels. Discuss patient specific dosing with pharmacy.

General Information

Collect trough levels at least 30 minutes before 4th dose at steady-state conditions in patients with normal renal function.

Serum trough concentrations should always be maintained above 10 mg/L to avoid development of resistance.

Collecting serum peak concentrations is no longer recommended.

Target serum trough concentration range:

  • 15 to 20 mg/L for most serious infections (bacteremia, endocarditis, osteomyelitis, meningitis, and hospital-acquired pneumonia caused by S. aureus)

  • 10 to 15 mg/L for uncomplicated infections

  • Higher serum trough concentrations of 20 to 25 mg/L may be targeted for some serious, aggressive, life-threatening infections. Discuss indication specific target trough range with ID/Pharmacy.

If trough low, increase dose (do not exceed 2 g/dose) OR decrease dosing interval (younger patients may require more frequent dosing due to more rapid clearance).

If trough greater than 20 mg/L, may consider holding a dose if appropriate, and assess to increase dosing interval OR decrease dose.

  •  Nephrotoxicity

  •  Cytopenias

  •  Rash including Stevens-Johnson Syndrome

  •  Red Man Syndrome (histamine release- slow down infusion)

  • Ototoxicity is rarely associated with monotherapy; has been reported in patients receiving excessive doses, those who have underlying hearing loss, or those receiving concomitant ototoxic drugs (eg. aminoglycosides).

Aminoglycosides may potentiate nephrotoxicity.

May enhance neuromuscular blockade of NM blocking agents.

Use cautiously with concomitant nephrotoxins.

Piperacillin may enhance the nephrotoxic effect of vancomycin.

Pharmacists may adjust vancomycin dosing and order serum levels and creatinine for monitoring purposes.

Antimicrobial class: Glycopeptide

Pregnancy category: C

Average serum half life: 8 hours

Biliary penetration: Moderate

CSF penetration: Moderate

Lung penetration: Therapeutic

Urine penetration: Therapeutic

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