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
| Calculated Creatinine Clearance (CRCL) (mL/min) | Dosing Interval for trough 10-20 mg/L | Dosing Interval for trough 15-20 mg/L |
| ≥80 q12h q8h | q12h | q8h |
| 40 – 80 q24h q12h | q24h | q12h |
| 20 – 40 q36h q24h | q36h | q24h |
| 10 – 20 q48h q48h | q48h | q48h |
| <10 | Consider loading dose. Obtain a pharmacist consult. | |
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).
| Infection | Desired Trough Level (mg/L) |
| Osteomyelitis, Pneumonia, CNS infection, Endocarditis, Bacteremia, Serious MRSA infections | 15-20 |
| Other Infections | 10-20 |
- 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 * t1/2
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.