What is the recommended dose of vancomycin for skin and tissue infections?

Vancomycin Dosing for Skin and Tissue Infections

For skin and tissue infections, vancomycin should be dosed at 15 mg/kg every 12 hours intravenously, not to exceed 2 g per dose in patients with normal renal function. 1, 2

Standard Dosing Recommendations

Adults:

• Standard dosing: 15 mg/kg IV every 12 hours 1, 2
• Maximum dose: 2 g per dose 2
• Administration rate: No more than 10 mg/min or over at least 60 minutes (whichever is longer) 2
• For most uncomplicated skin infections with normal renal function: 1 g every 12 hours is often adequate 1

Children:

• 15 mg/kg IV every 6 hours 1
• Each dose administered over at least 60 minutes 2

Neonates:

• Initial dose: 15 mg/kg 2
• Maintenance: 10 mg/kg every 12 hours (first week of life) 2
• Maintenance: 10 mg/kg every 8 hours (after first week until 1 month) 2

Dosing Considerations for Special Populations

Patients with Renal Impairment:

• Dosage adjustment required based on creatinine clearance 2
• Daily dose (mg) ≈ 15 × glomerular filtration rate (mL/min) 2
• Initial dose should still be at least 15 mg/kg even in mild-moderate renal impairment 2

Elderly Patients:

• May require greater dose reductions due to decreased renal function 2
• Monitoring of serum concentrations is particularly important 2

Obese Patients:

• Use actual body weight for dosing calculations 1
• Trough monitoring recommended 1

Therapeutic Monitoring

When to Monitor:

• For serious infections (including severe skin/tissue infections like necrotizing fasciitis) 1
• For patients who are morbidly obese 1
• For patients with renal dysfunction 1
• For patients with fluctuating volume of distribution 1

Target Concentrations:

• For severe skin and tissue infections: Trough concentrations of 15-20 μg/mL 1
• For most uncomplicated skin infections: Trough monitoring not required 1
• Obtain trough levels at steady state (before 4th or 5th dose) 1

Clinical Considerations

MRSA Coverage:

• Consider local prevalence of MRSA when deciding on empiric therapy 3
• For confirmed MRSA infections with vancomycin MIC >2 μg/mL, consider alternative agents 1

Treatment Duration:

• 5-10 days for mild infections 3
• 14-21 days for severe infections or those with complications 3

Common Pitfalls:

1. Underdosing in obese patients by not using actual body weight
2. Failing to adjust doses based on renal function
3. Not monitoring trough levels in severe infections
4. Inadequate tissue penetration in patients with vascular compromise 4, 5

Important Cautions:

• Tissue penetration can be variable, especially in diabetic patients with limb infections 5
• Serum concentrations may not reliably predict tissue concentrations at infection sites 5
• For infections with poor vascular perfusion, higher doses may be needed to achieve adequate tissue concentrations 4

Alternative Agents

If vancomycin treatment fails or is contraindicated, consider:

• Linezolid 600 mg IV/PO twice daily 1, 6
• Daptomycin 4-6 mg/kg IV once daily 3
• TMP-SMX 1-2 double-strength tablets PO twice daily (for MRSA) 3
• Clindamycin 300-450 mg PO four times daily (if susceptible) 3

Remember that surgical drainage remains essential for purulent infections, and vancomycin should be part of a comprehensive treatment approach that includes appropriate surgical intervention when indicated.