Can I give vancomycin to a patient on hemodialysis (HD)?

Vancomycin Administration in Hemodialysis Patients

Yes, vancomycin can be safely administered to patients on hemodialysis, but it requires specific dosing modifications and careful monitoring to ensure therapeutic efficacy while avoiding toxicity. 1, 2

Dosing Regimen for Vancomycin in Hemodialysis

Initial Dosing

• Loading dose: 20 mg/kg (actual body weight) during the last hour of dialysis session 2
• This loading dose rapidly and reliably establishes therapeutic pre-dialysis serum levels (10-25 μg/mL) 3

Maintenance Dosing

• 500 mg during the last 30 minutes of each subsequent dialysis session 2
• This approach maintains therapeutic levels while preventing drug accumulation 3

Administration Timing

• Administer vancomycin during the last hour of the hemodialysis session or post-dialysis 2, 4
• Do not administer before dialysis as this leads to significant drug removal (33-40%) and therapeutic failure 2, 5
• Post-dialysis administration prevents premature removal but requires patients to remain in the unit longer 6
• Intradialytic administration (during the last hour) is more convenient but requires dose adjustment to account for removal by high-flux dialyzers 4, 5

Monitoring

• Measure trough levels before the next dialysis session 2
• Target pre-dialysis levels:
  • 10-20 μg/mL for most infections
  • 15-20 μg/mL for severe infections 2
• Monitor for vancomycin toxicity, particularly:
  • Nephrotoxicity (increased serum creatinine ≥0.5 mg/dL or ≥150% from baseline)
  • Ototoxicity (hearing loss, tinnitus) 2, 7

Special Considerations

Catheter-Related Bloodstream Infections (CRBSI)

• For hemodialysis CRBSI, empirical antibiotic therapy should include vancomycin and coverage for gram-negative bacilli 1
• Always remove infected catheters for CRBSI due to S. aureus, Pseudomonas, or Candida species 1
• For other pathogens (e.g., coagulase-negative staphylococci), consider catheter salvage if symptoms resolve within 2-3 days 1
• Consider antibiotic lock therapy as adjunctive treatment for catheter salvage 1, 2

Treatment Duration

• Standard course: 10-14 days for uncomplicated infections 2
• Extended duration:
  • 4-6 weeks for persistent bacteremia (>72 hours), endocarditis, or suppurative thrombophlebitis
  • 6-8 weeks for osteomyelitis 1, 2

Pitfalls and Caveats

1. Once-weekly dosing is inadequate with high-flux dialyzers - leads to subtherapeutic levels after 5-7 days 3, 8
2. Standard 1g fixed dosing may result in subtherapeutic levels in up to 16% of patients 8
3. Rapid infusion can cause "red man syndrome" (hypotension, flushing) - administer over at least 60 minutes 7
4. Drug interactions: Monitor closely when combining with other nephrotoxic agents (aminoglycosides, amphotericin B) 7
5. Hemodialysis membrane type affects vancomycin clearance - high-flux membranes remove more drug than low-flux membranes 5, 8

By following these guidelines, vancomycin can be safely and effectively administered to patients on hemodialysis, ensuring adequate antimicrobial coverage while minimizing the risk of toxicity.