Is Vancomycin (vancomycin) 1 gram intravenous (IV) every 24 hours for 7 days an appropriate dosage for a patient with Chronic Kidney Disease (CKD) stage 3B and impaired renal function, specifically a creatinine clearance of 38 milliliters per minute?

From the Guidelines

For a CKD stage 3B patient with creatinine clearance of 38 ml/min, Vancomycin 1 g IV every 24 hours for 7 days is likely not appropriate due to the potential for toxicity, and a more tailored approach to dosing is necessary. This dosing regimen may not provide adequate drug levels for severe infections, and vancomycin dosing should be individualized based on drug levels. I recommend checking a trough level before the third or fourth dose, aiming for a target of 10-15 mg/L for most infections or 15-20 mg/L for more severe infections like endocarditis, osteomyelitis, or MRSA pneumonia, as suggested by 1. Vancomycin is primarily eliminated by the kidneys, so reduced renal function in CKD stage 3B necessitates careful monitoring to prevent toxicity while ensuring efficacy. Signs of vancomycin toxicity include nephrotoxicity and ototoxicity, so renal function should be monitored throughout treatment. If the patient's clinical status or renal function changes during treatment, dose adjustments may be necessary based on subsequent drug levels. According to 1, vancomycin dosing to a trough target of 15–20 mg/L is recommended to maximize the probability of achieving appropriate pharmacodynamic targets, improve tissue penetration, and optimize clinical outcomes. Additionally, a loading dose of 25–30 mg/kg (based on actual body weight) is suggested to rapidly achieve the target trough drug concentration, as stated in 1. Therefore, a more appropriate dosing strategy for this patient would be to administer a loading dose followed by adjusted maintenance doses based on trough levels, while closely monitoring renal function and adjusting the dose as needed to minimize the risk of toxicity.

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 ... 30465 20310 10155

For a patient with a creatinine clearance of 38 mL/min, the recommended dosage can be estimated using the provided table.

• The closest creatinine clearance value in the table to 38 mL/min is 30 mL/min, which corresponds to a vancomycin dose of 465 mg/24 hours, and 40 mL/min, which corresponds to a vancomycin dose of 620 mg/24 hours.
• Given that the patient's creatinine clearance is between these two values, a dose between 465 mg/24 hours and 620 mg/24 hours would be expected.
• However, the provided dosage of 1 gram (1000 mg) every 24 hours is higher than the estimated dose based on the creatinine clearance.
• Vancomycin dosage for a patient with CKD stage 3B and impaired renal function (creatinine clearance of 38 mL/min) should be adjusted to avoid potential toxicity.
• A more appropriate dosage might be closer to 500-600 mg every 24 hours, but this should be individualized based on the patient's specific clinical situation and serum vancomycin concentrations, if available 2.

From the Research

Vancomycin Dosage for CKD Stage 3B Patients

• The provided studies do not directly address the specific dosage of vancomycin 1 gram intravenous (IV) every 24 hours for 7 days in patients with Chronic Kidney Disease (CKD) stage 3B and impaired renal function, specifically a creatinine clearance of 38 milliliters per minute.
• However, studies such as 3 and 4 provide guidance on vancomycin dosage adjustment in patients with impaired renal function, suggesting that vancomycin clearance is highly correlated with creatinine clearance.
• The study 3 constructed a nomogram for vancomycin dosage adjustment based on a mean steady-state serum vancomycin concentration of 15 micrograms/mL in patients with various degrees of renal functional impairment.
• Another study 4 described a vancomycin dosing chart for use in patients with impaired renal function, which is based on a linear relationship between vancomycin clearance and creatinine clearance.
• The study 5 found a very good correlation between vancomycin clearance and measured creatinine clearance, but a poor correlation with estimated creatinine clearance using the Cockcroft-Gault formula.
• The study 6 suggested that the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is the best predictor of clearances of vancomycin for calculation of a therapeutic vancomycin regimen in critically ill patients.
• The study 7 evaluated vancomycin pharmacokinetics in patients with augmented renal clearances, but did not provide direct guidance on dosage adjustment for patients with impaired renal function.

Considerations for Dosage Adjustment

• Vancomycin dosage adjustment is crucial in patients with impaired renal function to achieve optimal therapeutic levels and minimize the risk of toxicity.
• Measured creatinine clearance is a reliable method for estimating vancomycin clearance, but it may not always be available in clinical practice.
• The CKD-EPI equation may be a useful alternative for estimating vancomycin clearance in patients with impaired renal function, as suggested by study 6.
• Further studies are needed to provide specific guidance on vancomycin dosage adjustment in patients with CKD stage 3B and impaired renal function.