Table of Contents

VANCOMYCIN EMPIRIC DOSING GUIDELINES
(Click here to download pdf version)

TABLE 1 INITIAL DOSE PER INTERVAL
 

TOTAL BODY WEIGHT

LOADING DOSE
(Maximum 2000 mg/dose)

 

MAINTENANCE DOSE

 

kg

Target pre-level

5-15 mg/L

 

(20 mg/kg)

Target pre-level

15-20 mg/L

 

(25 mg/kg)

 

 

 

(15mg/kg)

40-50

1000 mg

1250 mg

750 mg

51-60

1250 mg

1500 mg

1000 mg

61-70

1250 mg

1750 mg

1000 mg

71-80

1500 mg

2000 mg

1250 mg

81-90

1750 mg

2000 mg

1250 mg

91-100

2000 mg

2000 mg

1500 mg

 TABLE 2 INITIAL DOSING INTERVAL (hours)*

Serum Creatinine (µmol/L)

Age Group (years)

20-29

30-39

40-49

50-59

60-69

70-79

40-60

8

8

12

12

12

18

61-80

8

12

12

12

18

18

81-100

12

12

12

18

18

18

101-120

12

12

18

18

18

24

121-140

12

18

18

18

24

**

141-160

18

24

24

24

**

**

161-180

24

24

**

**

**

**

181-200

24

**

**

**

**

**

 *  The maintenance dose and interval on Tables 1 and 2 are intended to achieve
    a prevancomycin 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.  Contact a regional clinical pharmacist
    for assistance with interpretation of pre steady-state serum levels.

KEY


1.
  Establish patient age, weight and serum creatinine concentration.

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
Order a vancomycin level in the following conditions:

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 a pregnant or pediatric patient, especially when
aggressive dosing is required.


 SUGGESTED TARGET VANCOMYCIN LEVELS

Vancomycin Pre-Level 5-15 mg/L (goal ~ 10 mg/L)

Vancomycin Pre-Level 15-20 mg/L

·  Skin and soft tissue infection not due to MRSA

·  Uncomplicated catheter-associated bacteremia due to coagulase-negative Staphylococcus*

·  Urinary tract infection (catheter-associated; rule out bacteremia)

 

·   CNS infection

·   Deep-seated or sequestered infection (e.g. abscess)

·   Endocarditis

·   Osteomyelitis

·   MRSA bacteremia, pneumonia or skin and soft tissue infection

·   MSSA bacteremia (penicillin allergic patient)

*uncomplicated refers to lack of septic thrombosis, tunnel infection, or port abscess for tunnelled or implantable catheters