Adult Vancomycin Dosing and Monitoring Recommendations

Baptist Health Louisville

Vancomycin Loading Doses
Consider a loading dose in the following patients:
Critically ill (meet criteria for severe sepsis or septic shock, see below)
Meningitis
Neutropenic patients (absolute neutrophil count < 500 cells/mm3)
Confirmed invasive Staphylococcus aureus infections
Obesity (see page 2)
Vancomycin maintenance dosing intervals greater than every 12 hours
Sepsis

Severe Sepsis and Septic Shock

( 2/4 SIRS criteria secondary to infection):

Temp > 38.3C (100.9F) or < 36C (96.8F)
Heart rate > 90 beats per minute
WBC > 12,000 or < 4,000
or bands (Immature granulocytes) > 10%
Respirations > 20 breaths per minute

(Sepsis + 1 of the following secondary to sepsis)

Coagulopathy (INR > 1.5)
Vasopressors
Lactate > 2.2 mmol/L
Platelet < 100,000 L
Acute kidney injury or serum Sepsis induced hypotension
creatinine > 2 mg/dL
MAP < 60 or SBP < 90 mmHg
Bilirubin > 2 mg/dL
Mechanical ventilation

Recommended loading dose: 20-25 mg/kg x 1

Round doses to the nearest 250 mg
Maximum initial dose: 3000 mg
Actual body weight is recommended for initial vancomycin dosing (see obesity section below)
Maintenance doses may start as soon as necessary after initial doses to maintain therapeutic concentrations
or facilitate a convenient vancomycin dosing schedule

Revised March 2015

Vancomycin Maintenance Doses

Creatinine Clearance (CrCl)
100 mL/min & age 50 years
100 mL/min & age > 50 years
70-99 mL/min
50-69 mL/min
30-49 mL/min
< 30 mL/min

< 15 mL/min (not on hemodialysis)

OR
Unstable renal function*
OR
Sustained low-efficiency daily
diafiltration (SLEDD), peritoneal
dialysis (PD), or ultrafiltration (UF)*
Intermittent hemodialysis
Continuous Renal Replacement
Therapy (CRRT)

Recommended Dose & Interval

10-15 mg/kg IV Q8hr
(30-45 mg/kg/day)
15-20 mg/kg IV Q12hr (30-40 mg/kg/day)
15-20 mg/kg IV Q12hr (30-40 mg/kg/day)
10-15 mg/kg IV Q12hr (20-30 mg/kg/day)
15-20 mg/kg IV Q24hr (15-20 mg/kg/day)
Initial dose: 15-20 mg/kg x1
Obtain random concentration with AM labs or at a 12 or 24 hour interval
as applicable
Re-dose at 10-15 mg/kg when concentration estimated < 20 mg/L
Attempt to schedule maintenance dose once dose predictable based on
previous concentration or at steady state and renal function stable.
Initial dose: 15-20 mg/kg x1
Obtain random concentration with AM labs or at a 12 or 24 hour interval
as applicable
Re-dose at 5-10 mg/kg when concentration estimated < 20 mg/L
Attempt to schedule maintenance dose once dose predictable based on
previous concentration or at steady state and renal function stable.
SLEDD/PD/UF: may obtain concentrations every 48 hours
See hemodialysis section on page 5
Consider initial dose 15-25 mg/kg depending on severity of illness
Maintenance dose 10-15 mg/kg Q12-24hr
May estimate clearance based on CRRT rate
Monitor serum concentrations closely
Dose per levels if CRRT is stopped
*See page 4 for definition of unstable renal function and page 5 for comment on SLEDD/PD/UF

Maximum maintenance dose: 2000 mg/dose

Minimum dose: 500 mg
Use BHL Vancomycin Dosing Calculator to assess empiric dosing.
Dosing in Obesity
In patients 100 kg and actual weight is 140% of ideal body weight:
o Initial dose: 20-25 mg/kg (actual body weight maximum 3000 mg)
o Maintenance dose: 10-15 mg/kg (actual body weight dosing interval based on CrCl in above chart)

o If renal function stable, consider obtaining 2 levels within the same dosing interval after the initial dose
to perform patient specific pharmacokinetics. Clinical pharmacist will follow-up on day shift.
Schedule empiric 10-15 mg/kg maintenance dose recommended above while levels are being
drawn and interpreted to avoid delays in vancomycin dosing.
Level 1 should be timed for 1-4 hours after the end of the infusion
Level 2 should be timed immediately prior to next scheduled dose. If no subsequent dose is
scheduled (due to CrCl < 30 mL/min), obtain Level 2 at 18-24 hours after Level 1.
Adjust dose to target levels based on patient specific pharmacokinetic values.
2 levels must be obtained after a single dose administered all at once
2 levels ideally obtained in different half-lives
Revised March 2015

Monitoring Vancomycin Concentrations

Vancomycin Indication
Mild-moderate skin and soft tissue infection
Urologic infections
All indications (unless specified above)

Target Trough Concentration

10-20 mg/L
15-20 mg/L

Trough concentrations should be obtained 30 minutes prior to the 4th or 5th dose.
o Earlier concentrations may be considered to ensure therapeutic concentrations in critically ill patients
and patients at the extremes of body weights (i.e. obese or underweight).
For out-of-range concentrations in patients with stable renal function, make proportional daily dose
adjustment to the target concentration (see equation and chart below).
=

( )

o This equation is most accurate when the dose (mg) is changed and dosing interval remains unchanged.
Shortening the interval will result in a slightly higher than calculated Target Concentration and
lengthening the interval will result in a slightly lower than calculated Target Concentration.
Avoid changing both the dose and interval, unless necessary, due to less predictability in subsequent
concentrations.
Recommended dose adjustments for patients with stable renal function
Concentration
Recommended Dose or Interval Change*
Decrease total daily dose by proportion (use above equation).
Consider lengthening dosing interval (may require change in dose and interval).
> 25 mg/L
Hold dose until concentration estimated to be < 20 mg/L.
May repeat random concentration if not predictable (generally not needed with
stable renal function).
>20-25 mg/L
Decrease total daily dose by proportion (use above equation).
> 10 and < 15 mg/L
Increase total daily dose by proportion (use above equation).
Increase total daily dose by proportion (use above equation).
< 10 mg/L
Consider shortening dosing interval.
Consider additional loading dose.
*Also consider likely trend in concentration and renal function (i.e. accumulation or increase/decrease in renal function)
* Ensure all scheduled doses were given and concentrations were timed appropriately

Repeat vancomycin concentrations

o Stable renal function: 3 to 7 days after initial concentration (if obtained at steady state)
o Unstable renal function: more frequent monitoring is recommended (clinical judgment)
Unstable: serum creatinine (SCr) change of 0.3 mg/dL within 48 hours
o Previous trough concentration 10 mg/L out of range: repeat trough after 3-4 additional doses
When available or at the pharmacists discretion, two serum concentrations may be obtained within a single
dosing interval to perform patient specific pharmacokinetics to guide further dosing in patients with stable renal
function. Doses may be adjusted to an area-under-the-curve to minimum-inhibitory concentration (AUC24:MIC)
of 400:1 or an AUC of 400-600 in the absence of patient specific MIC data.

Revised March 2015

Monitoring Renal Function

Recommended frequency of serum creatinine monitoring:
Day of Vancomycin Therapy
Frequency of Serum Creatinine Monitoring
Days 1-3
Every 24 hours
Stable Renal Function*
Days 4-7
Every 48 hours
Days 8
Every 72 hours**
Unstable Renal Function
SCr change 0.3 mg/dL
within 48 hours

Anytime during therapy

Every 24 hours
(Until stable)

*Stable renal function may be considered 2 consecutive similar measurements or 3 measurements within a range of 0.3 mg/dL.
**Monitoring every 7 days for very stable patients is reasonable (e.g. rehab patients)

When available, urine output should also be monitored. The recommended actions listed above may be
considered in patients with acute decreases in urine output.
Recommended action in patients with changing renal function:
Increase in Serum Creatinine
Recommended Action
0.3 mg/dL within 48 hours
1) Serum creatinine should be repeated the next day
OR
2) Vancomycin concentration obtained prior to next dose
0.3 mg/dL from previously
3) Hold vancomycin maintenance dose until the concentration result
known baseline
is available (depending on severity of illness).
4) Notify nurse to hold dose
0.3 mg/dL within 24 hours
1) Vancomycin maintenance doses should be discontinued
OR
2) Vancomycin concentration obtained within 24 hours
0.5 md/dL within 48 hours
3) Serum creatinine should be repeated the next day
4) Dose vancomycin intermittently per concentrations until renal
function stable

Miscellaneous
Nurses may routinely give scheduled maintenance doses prior to the concentration returning unless there is
concern for high concentrations or in the setting of changing renal function. When necessary, pharmacists
should communicate to nurses to hold a vancomycin dose until a concentration result returns.
The default vancomycin infusion time is 10 mg/min (600 mg/hour) to minimize the likelihood of infusion
reactions. Infusion times may be increased to 16.7 mg/min (1 gram/hour) if necessary.
Vancomycin doses should be scheduled during daytime hours when possible (i.e. avoid scheduling doses
between 0000-0500).
Routine vancomycin concentrations should be obtained during daytime hours in clinically stable patients. It
is reasonable to wait an additional dose if necessary to obtain a steady state concentration during daytime
hours in a clinically stable patient.

Revised March 2015

Vancomycin Dosing in Intermittent Hemodialysis

Patients with end-stage renal disease and minimal residual renal function will not appreciably eliminate
vancomycin. Non-renal elimination is about 10% of total daily vancomycin clearance. Intermittent hemodialysis
(IHD) will remove approximately 10% serum vancomycin per hour with the high-flux membranes (f160, f180,
f200) used at Baptist Health Louisville. The usual IHD session is 3 to 4 hours. Peritoneal dialysis (PD) result in low
vancomycin removal and ultrafiltration (UF or SCUF) results in minimal drug removal. Concentrations are not
expected to significantly change during PD or SCUF or UF. Depending on the duration of SLEDD, vancomycin
removal may be comparable to that of IHD. However, the below recommendations do not apply to SLEDD and
more frequent concentration monitoring is recommended due to less predictability in concentrations.

Recommended initial dose: 20 mg/kg x 1 (actual body weight)

Consider 20-25 mg/kg x 1 if:
o Critically ill (meet criteria for severe sepsis and septic shock, see above)
o Meningitis
o Neutropenic patients (absolute neutrophil count < 500 cells/mm3)
o Confirmed invasive Staphylococcus aureus infections
o Residual renal function
o > 24 hours until next anticipated IHD session
Vancomycin Maintenance Doses for Intermittent Hemodialysis
Supplemental vancomycin doses should be given after each IHD session using high-flux membranes.
Dose initially based on recommended empiric doses below.
Actual Body Weight
< 70 kg
70-99 kg
100 kg

Recommended Empiric Post IHD Dose*

500 mg
750 mg
1000 mg
* Dosing recommendations apply to IHD with f160, f180, f200 filters

Serum Concentration Monitoring

Vancomycin Indication
General
Critically ill, meningitis, or S. aureus infection

Target Pre-IHD Concentration

15-20 mg/L
20-25 mg/L

Obtain a pre-IHD concentration prior to the second IHD session (after 2 total vancomycin doses).
o An earlier concentration may be obtained in patients that are critically ill, with significant residual renal
function, or when there is a > 48 hours before an IHD session to ensure therapeutic concentrations.
o Routine concentrations on non-IHD days are not recommended. If obtained, a pre-IHD concentration
may be estimated using ~10% non-renal vancomycin clearance per day.
= 0.9
o Post-IHD concentrations, if needed, should be obtained > 6 hours after the last IHD session.
For supra- or subtherapeutic concentrations, doses should be adjusted by proportional dose increase or
decrease to within the desired range. Round doses to the nearest 250 mg.
=

( )

Repeat pre-IHD concentrations are recommended no more than every 5 -7 days in clinically stable patients.
Revised March 2015

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Revised March 2015