Recommended Meningeal Dose of Vancomycin for Meningitis
For treatment of meningitis, vancomycin should be administered at 15-20 mg/kg/dose IV every 8-12 hours for adults and 15 mg/kg/dose IV every 6 hours for children, with target trough concentrations of 15-20 μg/mL. 1, 2
Dosing Recommendations by Age Group
Adults
- Standard dose: 15-20 mg/kg/dose IV every 8-12 hours 1
- Consider adding rifampin 600 mg daily or 300-450 mg twice daily for enhanced CNS penetration 1
- Target trough concentrations: 15-20 μg/mL 2
Children
- Standard dose: 15 mg/kg/dose IV every 6 hours 1
- Higher frequency in children helps maintain adequate CNS concentrations
Administration Guidelines
- Infuse vancomycin over at least 60 minutes to prevent "red man syndrome" 2
- Maximum infusion rate: 10 mg/min 2
- Maximum concentration: 5 mg/mL (up to 10 mg/mL in fluid-restricted patients) 2
Monitoring and Adjustment
- Obtain serum trough concentrations at steady state (before 4th or 5th dose) 2
- Monitor renal function regularly to minimize nephrotoxicity risk 2
- Higher trough levels (15-20 μg/mL) are necessary for CNS infections to ensure adequate penetration across the blood-brain barrier 2
Special Considerations
Penicillin-Resistant Pneumococci
- For suspected or confirmed penicillin-resistant pneumococci, add vancomycin 15-20 mg/kg IV twice daily to the cephalosporin regimen 1
- Consider adding rifampin 600 mg twice daily for synergistic effect 1
Renal Impairment
- Maintain per-dose amount but extend intervals rather than reducing dose size 2
- For hemodialysis patients, administer vancomycin after dialysis 2
Elderly Patients (>59 years)
- Consider reducing dose to 10 mg/kg per day 2
Treatment Duration
- For confirmed pneumococcal meningitis: 10-14 days (longer if penicillin or cephalosporin resistant) 1
- For CNS infections generally: 4-6 weeks 2
Alternative Therapies
If vancomycin treatment fails or is contraindicated:
Clinical Pearls and Pitfalls
- Poor CSF penetration: Vancomycin penetrates the blood-brain barrier poorly in the absence of significant inflammation 3
- Higher doses may be necessary: Research suggests high-dose vancomycin regimens lead to faster resolution of fever, leukocytosis, and shorter hospital stays in bacterial meningitis 4
- Nephrotoxicity concerns: Despite higher target trough concentrations (15-20 μg/mL), studies have not shown significantly increased nephrotoxicity rates when appropriate monitoring is implemented 5
- Loading dose consideration: For seriously ill patients, consider a loading dose of 25-30 mg/kg to rapidly achieve therapeutic levels 2
Remember that vancomycin should always be part of a combination therapy approach for meningitis, typically with a third-generation cephalosporin, until culture results and sensitivities are available.