What is the recommended dosing of Vancomycin (vancomycin) for a patient with impaired renal function, specifically a creatinine clearance (CrCl) of 19 ml/min?

From the Guidelines

For patients with impaired renal function and a creatinine clearance (CrCl) of 19 ml/min, the recommended vancomycin dosing should be adjusted to prevent toxicity while maintaining efficacy, with a suggested dose of 500-750 mg every 24 hours or 15-20 mg/kg (based on actual body weight) given every 48-72 hours. When considering vancomycin dosing for a patient with a CrCl of 19 ml/min, it's crucial to understand that vancomycin is primarily eliminated unchanged by the kidneys, and thus, renal impairment significantly affects its clearance 1. The goal is to achieve trough serum vancomycin concentrations of 15–20 mg/L for severe infections like meningitis, and hospital-acquired pneumonia caused by S. aureus, as these levels are associated with an AUC/MIC of 1400 for most patients if the MIC is ≤1 mg/L 1. Key considerations include:

• Initial dosing should be followed by therapeutic drug monitoring to ensure trough concentrations are within the therapeutic range, adjusting for the patient's renal function and clinical response.
• Loading doses of 20-25 mg/kg may be considered to rapidly achieve therapeutic levels, regardless of renal function.
• Regular monitoring of vancomycin levels, renal function, and clinical response is essential, with dose adjustments made based on measured drug levels to prevent nephrotoxicity and ototoxicity.
• Infusion-related reactions can be minimized by administering vancomycin over at least 60 minutes, extending to 90-120 minutes for doses exceeding 1 gram. Given the potential for vancomycin toxicity with impaired renal function, careful monitoring and adjustment of dosing regimens are critical to balance efficacy with safety, prioritizing the patient's morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

DOSAGE TABLE FOR VANCOMYCIN IN PATIENTS WITH IMPAIRED RENAL FUNCTION (Adapted from Moellering et al. 1) Creatinine ClearancemL/minVancomycin Dosemg/24 h ... 20310 10155 The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency.

The recommended dosing of Vancomycin for a patient with a creatinine clearance (CrCl) of 19 ml/min is 155 mg/24 hr or approximately 6.5 mg/hr. However, the initial dose should be no less than 15 mg/kg. 2

From the Research

Vancomycin Dosing for Impaired Renal Function

• The recommended dosing of Vancomycin for a patient with impaired renal function, specifically a creatinine clearance (CrCl) of 19 ml/min, is not directly stated in the provided studies.
• However, a study on optimizing Vancomycin dosing in chronic kidney disease patients 3 suggests that a population pharmacokinetic analysis can be used to construct a Vancomycin dose prediction model for patients with impaired renal function.
• Another study on the nephrotoxicity of Vancomycin 4 discusses the risk factors for nephrotoxicity, including the potential synergistic nephrotoxicity of Vancomycin and other medications.
• A study comparing Vancomycin and daptomycin for severe Gram-positive infections 5 found that Vancomycin treatment was associated with a higher risk of nephrotoxicity, especially in patients with baseline creatinine clearance <80 mL/min.
• It is essential to consider the patient's renal function and other risk factors when determining the Vancomycin dosing regimen to minimize the risk of nephrotoxicity 6, 5, 4.
• The use of a web-based tool, such as the one described in the study on optimizing Vancomycin dosing 3, may help clinicians determine the appropriate Vancomycin dose for patients with impaired renal function.
• Clinicians should carefully monitor patients with impaired renal function for signs of nephrotoxicity and adjust the Vancomycin dose accordingly 5, 4.