Can vancomycin (Vancomycin) be used to treat a urinary tract infection (UTI) in a patient with impaired renal function undergoing dialysis, and if so, what is the appropriate dose?

From the Guidelines

Vancomycin can be used to treat a urinary tract infection (UTI) in a patient with impaired renal function undergoing dialysis, with a recommended loading dose of 20-mg/kg infused during the last hour of the dialysis session, and then 500 mg during the last 30 min of each subsequent dialysis session. This dosing regimen is based on the clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection, which provides guidance on empirical dosing pending culture results 1. It's essential to note that vancomycin is primarily eliminated by the kidneys, so patients with renal failure require significant dose adjustments to prevent toxicity.

For patients undergoing dialysis, it's crucial to monitor vancomycin levels regularly, especially before the fourth dose or before a hemodialysis session, to ensure trough levels are within the therapeutic range of 15-20 mg/L for serious infections 1. While vancomycin can treat UTIs caused by resistant gram-positive organisms like MRSA, other antibiotics with better urinary penetration (such as cephalosporins, fluoroquinolones, or trimethoprim-sulfamethoxazole) are generally preferred for UTIs if the pathogens are susceptible. Key considerations for vancomycin use in dialysis patients include:

• Loading dose: 20-mg/kg infused during the last hour of the dialysis session
• Maintenance dose: 500 mg during the last 30 min of each subsequent dialysis session
• Trough level monitoring: essential to prevent toxicity and ensure therapeutic levels
• Alternative antibiotics: may be preferred for UTIs if the pathogens are susceptible due to better urinary penetration.

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 1001,545 901,390 801,235 701,080 60925 50770 40620 30465 20310 10155 The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency. The table is not valid for functionally anephric patients For such patients, an initial dose of 15 mg/kg of body weight should be given to achieve prompt therapeutic serum concentrations. The dose required to maintain stable concentrations is 1. 9 mg/kg/24 hr. In patients with marked renal impairment, it may be more convenient to give maintenance doses of 250 to 1,000 mg once every several days rather than administering the drug on a daily basis. In anuria, a dose of 1,000 mg every 7 to 10 days has been recommended

Vancomycin can be used to treat a urinary tract infection (UTI) in a patient with impaired renal function undergoing dialysis.

• The initial dose should be no less than 15 mg/kg of body weight, even in patients with mild to moderate renal insufficiency.
• For functionally anephric patients, an initial dose of 15 mg/kg of body weight should be given to achieve prompt therapeutic serum concentrations.
• The maintenance dose required to maintain stable concentrations is 1.9 mg/kg/24 hr.
• In patients with marked renal impairment, it may be more convenient to give maintenance doses of 250 to 1,000 mg once every several days rather than administering the drug on a daily basis.
• In anuria, a dose of 1,000 mg every 7 to 10 days has been recommended 2

From the Research

Vancomycin Use in Patients with Impaired Renal Function Undergoing Dialysis

• Vancomycin can be used to treat urinary tract infections (UTIs) in patients with impaired renal function undergoing dialysis, but requires careful dosing due to the risk of nephrotoxicity and ototoxicity 3.
• The timing of vancomycin administration, type of dialysis filter used, and duration of dialysis can affect vancomycin levels in patients undergoing hemodialysis 3, 4.

Dosing Considerations

• A weight-based loading dose of 20-25 mg/kg is recommended for patients with normal kidney function and those undergoing dialysis 3.
• Maintenance dosing regimens may need to be adjusted based on individual patient factors, such as actual body weight, interdialytic interval, and residual renal function 3.
• Administering vancomycin during the last hour of hemodialysis may be a viable option, with studies suggesting that a dose of 1.4 g can achieve recommended vancomycin concentrations despite the use of high-flux membranes 5.
• A loading dose of 18-23 mg/kg (1.5-2 g) followed by a maintenance dose of 8-13 mg/kg (1 g) administered in the last hour of dialysis has been shown to result in vancomycin pre-dialysis concentrations of ≥13 mg/L and favorable clinical outcomes 6.

Practical Considerations

• Administering vancomycin during the last 60-90 minutes of hemodialysis is preferred to prevent vascular damage and preserve patients' vascular access 6.
• A protocolized approach to vancomycin dosing, including automated intravenous vancomycin dosing and adjustments based on trough levels, can be effective in achieving therapeutic vancomycin levels and treating infection in hemodialysis patients 7.