How to manage Vancomycin toxicity?

From the Guidelines

Vancomycin toxicity should be managed by monitoring trough serum concentrations to reduce nephrotoxicity, particularly in patients receiving aggressive dose targeting, those with unstable renal function, or those at risk of toxicity.

Key Considerations

• Monitoring of trough serum vancomycin concentrations is recommended to achieve target concentrations of 15–20 mg/L in patients with serious MRSA infections and to ensure target concentrations in those who are morbidly obese, have renal dysfunction, or have fluctuating volumes of distribution 1.
• A patient should be considered to have vancomycin-induced nephrotoxicity if multiple high serum creatinine concentrations are documented after several days of vancomycin therapy in the absence of an alternative explanation 1.
• Vancomycin dosing should be based on actual body weight, with a recommended dose of 15–20 mg/kg/dose every 8–12 hours, not to exceed 2 g per dose 1.
• In critically ill patients, an IV loading dose of 25–30 mg/kg (based on actual body weight) is suggested to rapidly achieve the target trough drug concentration 1.

Management Strategies

• Trough monitoring: Regular monitoring of trough serum vancomycin concentrations to ensure target concentrations are achieved and to minimize the risk of nephrotoxicity.
• Dose adjustment: Adjusting vancomycin doses based on trough concentrations and patient factors, such as renal function and body weight.
• Alternative therapies: Considering alternative antibiotics in patients who are at high risk of vancomycin toxicity or who have developed nephrotoxicity.
• Supportive care: Providing supportive care, such as fluid management and renal replacement therapy, as needed to manage vancomycin toxicity.

From the FDA Drug Label

Supportive care is advised, with maintenance of glomerular filtration. Vancomycin is poorly removed by dialysis. Hemofiltration and hemoperfusion with polysulfone resin have been reported to result in increased vancomycin clearance. To manage Vancomycin toxicity, supportive care is advised, with a focus on maintaining glomerular filtration. Additionally, hemofiltration and hemoperfusion with polysulfone resin may be considered to increase vancomycin clearance. It is also recommended to contact a certified Regional Poison Control Center for up-to-date information on treating overdose 2.

• Key considerations in managing overdosage include:
  • Possibility of multiple drug overdoses
  • Interaction among drugs
  • Unusual drug kinetics in the patient

From the Research

Managing Vancomycin Toxicity

To manage vancomycin toxicity, several strategies can be employed:

• Monitoring vancomycin trough levels to avoid high levels (>20 mg/L) that can increase the risk of nephrotoxicity 3, 4, 5, 6
• Avoiding high daily doses (>4 grams) and prolonged therapy (>6-7 days) 3, 4, 5
• Being cautious when using vancomycin in patients with preexisting renal disease, obesity, or those who are critically ill 3, 4, 5
• Avoiding concomitant use of other nephrotoxic agents 3, 4, 5
• Considering alternative antibacterial agents that do not require monitoring 6

Risk Factors for Nephrotoxicity

Several risk factors can increase the likelihood of vancomycin-induced nephrotoxicity:

• High trough vancomycin levels (>20 mg/L) 3, 4, 5, 6
• High daily doses (>4 grams) 3, 4, 5
• Prolonged therapy (>6-7 days) 3, 4, 5
• Preexisting renal disease 3, 4, 5
• Obesity 3, 4, 5
• Critically ill patients 4, 5
• Concomitant use of other nephrotoxic agents 3, 4, 5

Consequences of Nephrotoxicity

Vancomycin-induced nephrotoxicity can have serious consequences, including:

• Reversible renal damage 3, 4, 6
• Permanent renal damage 3
• Prolonged hospital stays 6
• Increased medical costs and mortality 6
• Need for additional antibiotics or dialysis treatment 6