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 recommended vancomycin dose for patients with impaired renal function can be calculated using the provided dosage table, which is based on creatinine clearance.
- The initial dose should be no less than 15 mg/kg, 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, and the dose required to maintain stable concentrations is 1.9 mg/kg/24 hr.
- In patients with marked renal impairment, maintenance doses of 250 to 1,000 mg once every several days may be given instead of a daily dose.
- In anuria, a dose of 1,000 mg every 7 to 10 days has been recommended 1.
From the Research
Vancomycin dosing in patients with impaired renal function should be adjusted based on the patient's creatinine clearance (CrCl) or estimated glomerular filtration rate (eGFR), with a recommended loading dose of 15-20 mg/kg, followed by maintenance doses tailored to the individual's renal function, as evidenced by the most recent study 2.
Key Considerations
- For patients with mild to moderate renal impairment (CrCl 30-60 mL/min), a typical regimen is 15-20 mg/kg every 12-24 hours.
- For severe renal impairment (CrCl 10-30 mL/min), 15-20 mg/kg every 24-48 hours is recommended.
- In end-stage renal disease (CrCl <10 mL/min), 15-20 mg/kg every 48-72 hours or after hemodialysis is appropriate.
- For patients on continuous renal replacement therapy, 15-20 mg/kg loading dose followed by 7.5-10 mg/kg every 12-24 hours is suggested.
Therapeutic Drug Monitoring
Therapeutic drug monitoring is essential, with target trough concentrations of 10-15 mg/L for most infections and 15-20 mg/L for severe infections like endocarditis, osteomyelitis, or meningitis, as supported by 3 and 4.
Dosing Adjustments
Doses should be adjusted based on trough levels, clinical response, and changes in renal function, taking into account the patient's individual needs and the potential risks of toxicity, particularly nephrotoxicity and ototoxicity, as highlighted in 5 and 6.
Practical Considerations
Administering vancomycin during the last 60-90 minutes of hemodialysis is preferred to prevent vascular damage and preserve patients' vascular access, as suggested by 2. A standard maintenance dose can simplify dosing and reduce the risk of errors.