From the Guidelines
Vancomycin dosing in neonates should be based on weight and adjusted according to gestational and postnatal age, with recommended doses ranging from 10-15 mg/kg given every 8-24 hours, depending on the neonate's age and weight. The dosing regimen for vancomycin in neonates is complex and depends on various factors, including postnatal age, weight, and renal function 1. For neonates with a postnatal age of ≤7 days and weight <1200 g, the recommended dose is 15 mg/kg/day given every 24 hours, while those with a weight of 1200–2000 g should receive 10–15 mg/kg given every 12–18 hours, and those with a weight >2000 g should receive 10–15 mg/kg given every 8–12 hours 1. After 7 days of postnatal age, the dosing regimen changes, with neonates weighing <1200 g receiving 15 mg/kg/day given every 24 hours, those weighing 1200–2000 g receiving 10–15 mg/kg given every 8–12 hours, and those weighing >2000 g receiving 15–20 mg/kg given every 8 hours 1. It is essential to monitor vancomycin trough levels and adjust the dose accordingly to ensure effective treatment and minimize the risk of toxicity 1. Therapeutic drug monitoring should target trough concentrations of 10-15 mg/L for most infections and 15-20 mg/L for severe infections 1. Blood samples for trough levels should be drawn just before the third or fourth dose, and infusion should occur over at least 60 minutes to prevent "red man syndrome" 1. Renal function should be monitored throughout treatment, and dose adjustments may be necessary based on trough levels and clinical response 1.
From the FDA Drug Label
In neonates, an initial dose of 15 mg/kg is suggested, followed by 10 mg/kg every 12 hours for neonates in the 1st week of life and every 8 hours thereafter up to the age of 1 month. The recommended vancomycin dose in neonates is:
- An initial dose of 15 mg/kg
- Followed by 10 mg/kg every 12 hours for the first week of life
- Then 10 mg/kg every 8 hours thereafter, up to the age of 1 month 2
From the Research
Vancomycin Dosing in Neonates
- The optimal vancomycin dosage for neonates is difficult to determine due to their immature renal function 3.
- Serum creatinine-based dosing has been introduced to maintain appropriate serum levels of vancomycin in neonates, with 81.8% of trough concentrations within the therapeutic range after its introduction 3.
- The pharmacokinetic behavior of vancomycin in neonates is mainly determined by postconceptional age and renal function, with factors such as patent ductus arteriosus, indomethacin, and extracorporeal membrane oxygenation (ECMO) affecting its volume of distribution and clearance 4.
Therapeutic Target Attainment
- The therapeutic target attainment of vancomycin in neonates varies across studies, with a target range of 10-20 mg/L commonly used 5, 6, 7.
- The probability of target attainment is often less than 80% in tested dosing algorithms, highlighting the need for optimized dosing regimens 7.
- Revised empirical vancomycin dosage regimens have been proposed to improve target attainment, such as increasing the dose to 20 mg/kg/day to 40 mg/kg/day depending on postmenstrual age and postnatal age 5, 6.
Clinical Efficacy and Toxicity
- Few studies have reported on vancomycin efficacy and toxicity in neonates, with vancomycin-related nephrotoxicity and ototoxicity being rare and not clearly related to serum concentrations 4, 7.
- Further research is needed to identify a dosing regimen with a high probability of target attainment without toxicity, with consistent and homogeneous comparative randomized clinical trials required to address the current heterogeneity in dosing strategies 7.