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VANCOMYCIN
EMPIRIC DOSING GUIDELINES (Vancouver Acute) TABLE 1 INITIAL DOSE PER
INTERVAL
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TOTAL BODY WEIGHT |
LOADING DOSE |
MAINTENANCE DOSE* |
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Target pre-level (20 mg/kg) |
Target pre-level (25 mg/kg) |
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40-50 |
1000 mg |
1250 mg |
750 mg |
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51-60 |
1250 mg |
1500 mg |
1000 mg |
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61-70 |
1250 mg |
1750 mg |
1000 mg |
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71-80 |
1500 mg |
2000 mg |
1250 mg |
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81-90 |
1750 mg |
2000 mg |
1250 mg |
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91-100 |
2000 mg |
2000 mg |
1500 mg |
TABLE 2 INITIAL DOSING INTERVAL (hours)*
|
Serum Creatinine (µmol/L) |
Age Group (years) |
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20-29 |
30-39 |
40-49 |
50-59 |
60-69 |
70-79 |
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40-60 |
8 |
8 |
12 |
12 |
12 |
18 |
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61-80 |
8 |
12 |
12 |
12 |
18 |
18 |
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81-100 |
12 |
12 |
12 |
18 |
18 |
18 |
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101-120 |
12 |
12 |
18 |
18 |
18 |
24 |
|
121-140 |
12 |
18 |
18 |
18 |
24 |
** |
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141-160 |
18 |
24 |
24 |
24 |
** |
** |
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161-180 |
24 |
24 |
** |
** |
** |
** |
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181-200 |
24 |
** |
** |
** |
** |
** |
* The maintenance
dose and interval on Tables 1 and 2 are intended to achieve
a pre-vancomycin target level of 5-15 mg/L. To achieve a
higher pre-vancomycin
serum level of 15-20 mg/L, the dosing interval should be
empirically shortened
(e.g. Q12H to Q8H). Alternatively, the maintenance dose can
be increased to 20 mg/kg.
** Patients
with significant renal impairment should receive a loading dose followed
by 3 and 24 hours post dose serum levels to determine
subsequent dosing.
Contact a regional clinical pharmacist for assistance with
interpretation of pre
steady-state serum levels.
2.
Using Table 1, identify initial loading dose and
maintenance dose per interval
according to patient weight.
3.
Using Table 2, identify initial dosing interval
according to patient age and serum creatinine.
If more aggressive therapy desired, interval should be shortened.
4. Doses over 1250 mg should be infused over 90 minutes.
THERAPEUTIC DRUG MONITORING
Vancomycin serum levels should be ordered in the following situations:
1) Pre-vancomycin
level on 3rd or 4th dose (within 48 hours) if a higher
level of
15-20 mg/L is desired; repeat weekly to ensure pre-level is within
therapeutic range
2) Pre-vancomycin
level after 7 days of therapy if aiming for levels < 15 mg/L and therapy
is to continue for 14 days AND
patient is at risk for accumulation (e.g. Q8H interval) OR
patient is receiving other nephrotoxic agents
3) Pre-vancomycin level if renal function is changing or uncertain
4) Pre-vancomycin level if patient is not responding to therapy
5)
Pre-vancomycin level if patient is obese (>90%
IBW), pregnant, pediatric or
hypermetabolic (e.g. burn patient, cystic fibrosis)
6)
Pre and 3 hour post vancomycin level (target
20-40 mg/L) if calculation of precise
kinetic parameters are necessary (e.g. in a case when a target
pre-level of 15-20 mg/L
cannot be achieved while on prolonged therapy, or in an obese,
pregnant or pediatric
patient, especially when aggressive dosing is required).
SUGGESTED TARGET VANCOMYCIN LEVELS
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Vancomycin Pre-Level
5-15 mg/L |
Vancomycin Pre-Level 15-20 mg/L |
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* uncomplicated
refers to lack of septic thrombosis, tunnel infection, or port |
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