Vancomycin Dosing for Sepsis
For patients with sepsis, vancomycin should be dosed at 15-20 mg/kg every 8-12 hours based on actual body weight, with target trough concentrations of 15-20 μg/mL for serious infections. 1, 2
Initial Dosing Recommendations
Adult Patients
- Loading dose: 25-30 mg/kg based on actual body weight for serious infections like sepsis 2, 3
- Maintenance dose: 15-20 mg/kg every 8-12 hours based on actual body weight 1, 2
- Maximum infusion rate: 10 mg/min or over at least 60 minutes (whichever is longer) 3
- For individual doses >1g, extend infusion to 1.5-2 hours 2
Pediatric Patients
- Children with serious infections: 15 mg/kg/dose every 6 hours 1
- Neonates: Initial dose of 15 mg/kg, followed by 10 mg/kg every 12 hours (first week of life) or every 8 hours thereafter 3
Dosing Adjustments for Special Populations
Renal Impairment
Daily dose (mg) should be approximately 15 times the glomerular filtration rate in mL/min 2, 3
| Creatinine Clearance (mL/min) | Vancomycin Dose (mg/24h) |
|---|---|
| 100 | 1,545 |
| 70 | 1,080 |
| 50 | 770 |
| 30 | 465 |
| 10 | 155 |
Obese Patients
- Use actual body weight for initial dosing calculations 2, 3
- Monitor serum levels closely
- Standard doses of 1g every 12h are likely inadequate 1
Therapeutic Monitoring
- Target trough concentrations: 15-20 μg/mL for serious infections including sepsis 1, 2
- Monitor trough levels before the fourth or fifth dose (at steady state) 2
- For most patients with skin and soft tissue infections who have normal renal function and are not obese, traditional doses of 1g every 12h are adequate and trough monitoring is not required 1
Important Clinical Considerations
- Recent research suggests that for patients with sepsis or septic shock with creatinine clearance ≥80 mL/min/1.73m², higher doses of ≥2g every 8 hours may be needed to achieve optimal therapeutic exposure 4
- Higher loading doses (>20 mg/kg) have not been associated with increased nephrotoxicity in emergency department sepsis patients 5
- Vancomycin clearance and volume of distribution may change significantly during sepsis, particularly within the first 72 hours of admission 4
- Therapeutic drug monitoring is essential in critically ill patients with sepsis due to rapid pharmacokinetic changes that occur as clinical condition changes 6
Potential Pitfalls and Caveats
- Underdosing is common, particularly in obese patients when conventional non-weight-based dosing strategies are used 1
- Inappropriate vancomycin use may contribute to development of resistant organisms 2
- Nephrotoxicity risk increases with elevated serum levels, underlying renal impairment, and concomitant nephrotoxic medications 2
- Continuous infusion vancomycin is not recommended due to lack of clear benefit over intermittent dosing 1
- Vancomycin trough concentrations <10 μg/mL should be avoided due to risk of treatment failure and development of resistance 1