Vancomycin Empiric Dosing Guidelines

VANCOMYCIN EMPIRIC DOSING GUIDELINES (Vancouver Acute)
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TABLE 1 INITIAL DOSE PER INTERVAL

*   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.

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.

THERAPEUTIC DRUG MONITORING
Vancomycin serum levels should be ordered in the following situations:

1) Pre-vancomycin level on 3^rd or 4^th 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).

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

TABLE 1 INITIAL DOSE PER INTERVAL

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

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