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VANCOMYCIN
EMPIRIC DOSING GUIDELINES TABLE 1 INITIAL DOSE PER
INTERVAL
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TOTAL BODY WEIGHT |
LOADING
DOSE |
MAINTENANCE DOSE
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|
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)*
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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 |
|
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.
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
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Vancomycin Pre-Level 5-15 mg/L (goal ~ 10 mg/L) |
Vancomycin Pre-Level 15-20 mg/L |
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· 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)
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· 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) |
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*uncomplicated refers to lack of septic thrombosis, tunnel infection, or port abscess for tunnelled or implantable catheters |
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