Bottom line: Use guideline-based Vancomycin dosing and monitoring to maximize treatment success and reduce unnecessary plasma Vancomycin levels and needless dosage changes.
Adult Dosing Recommendations:

Loading dose

Use a loading dose in:

• Serious infections where rapid attainment of target trough level of 15-20 mg/L is desired, e.g. vertebral osteomyelitis, MRSA pneumonia, epidural abscess, septic shock.
• Patients with significant renal dysfunction to decrease the time required to attain target trough level.
• 25-30 mg/kg (based on actual body weight; no maximum dose) single dose, followed by maintenance dose separated by the recommended dosing interval.

Maintenance dose

• 15 mg/kg (based on actual body weight) dose (maximum of 2 g/dose)
• Doses >500 mg – round to the nearest 250 mg.
• Doses <500 mg – round to the nearest 50 mg.

Dosing interval

For more details and pediatric dosing, see http://bugsanddrugs.albertahealthservices.ca

Monitoring

• Peak (post) levels are NOT recommended.
• Trough (pre) levels (taken 30 minutes or less before next dose) are recommended in:
  • Patients with deteriorating/unstable renal function (increase in baseline serum creatinine of 40 µmol/L or greater, or increase of 50% or more from baseline).
  • Morbidly obese patients (190% or greater of ideal body weight, or BMI 40 kg/m² or greater).
  • Patients with anticipated therapy ≥ 7 days.
  • Patients who are severely ill (e.g. sepsis) and/or require a target trough of 15-20 mg/L (see table on next page).
  • Patients with the altered volume of distribution or clearance of vancomycin (e.g. cystic fibrosis, pediatrics, elderly 60 years or older, cancer, burns more than 20% body surface area).
  • Selected dialysis patients (e.g. high flux and continuous hemodialysis/filtration).

• The first trough level should be taken at steady-state* and after at least 2 maintenance doses (~30 hours if normal renal function, prior to 4th dose if q12h, or prior to 5th dose if q8h.)
  • Vancomycin clearance is enhanced in obesity. For morbidly obese patients, consider drawing first level sooner (e.g. before 2nd or 3rd dose).
• Subsequent trough levels:
  • With dosage change: trough should be taken at new steady-state* as described above.
  • Once target trough is achieved: trough should be taken every 7-10 days in hemodynamically stable patients; may need more frequently if hemodynamically unstable, renal function changing, or the patient is on concurrent nephrotoxic drugs.
• NB: Do NOT hold the next vancomycin dose while waiting for results of plasma levels unless there is a specific order to do so, e.g. because of concerns of toxicity/adverse events and/or significant decline in kidney function.

*Steady-state (SS) occurs in 4 to 5 half-lives and can be estimated for vancomycin by using the following equations:
ke = CRCL*0.00083 + 0.0044                                                     t1/2 = 0.693 / ke                                       SS = 4 to 5 * t_1/2

Pharmacist Adaptation Policy

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References

http://bugsanddrugs.albertahealthservices.ca, accessed 9 November 2018.
Optimizing Vancomycin Dosing & Monitoring:
https://insite.albertahealthservices.ca/Main/assets/tms/phm/tms-phm-pub-ASB-Vancomycinslides-2015.pdf, accessed 9 November 2018.