What is the recommended dosing regimen for vancomycin in pediatric patients?

Vancomycin Dosing in Pediatric Patients

For pediatric patients, vancomycin should be dosed at 15 mg/kg IV every 6 hours to achieve therapeutic levels for most serious infections. 1

Standard Dosing Recommendations by Age

Neonates and Infants (up to 1 month)

• Initial dose of 15 mg/kg, followed by 10 mg/kg every 12 hours for neonates in the first week of life 2
• After first week of life until 1 month: 10 mg/kg every 8 hours 2
• Each dose should be administered over 60 minutes 2
• Premature infants may require longer dosing intervals due to decreased vancomycin clearance 2

Infants and Children (1 month to 12 years)

• 15 mg/kg/dose IV every 6 hours (60 mg/kg/day) for most serious infections including MRSA infections, osteomyelitis, meningitis, and endocarditis 1
• For infants 1-5 months: Starting dose of 60 mg/kg/day divided every 6 hours 3
• For children 6 months-12 years: Starting dose of 70 mg/kg/day divided every 6 hours 3, 4
• Each dose should be administered over at least 60 minutes 2

Adolescents (13-18 years)

• 15 mg/kg/dose IV every 6 hours (60 mg/kg/day) for serious infections 1
• Starting dose of 60 mg/kg/day divided every 8 hours for less serious infections 3, 4
• For serious infections requiring higher trough levels (15-20 mg/L), consider 70 mg/kg/day divided every 6 hours 4

Therapeutic Monitoring

Target Trough Concentrations

• For serious infections (meningitis, endocarditis, osteomyelitis, pneumonia): 15-20 μg/mL 1
• For less complicated infections: 10-15 μg/mL 1, 3
• Obtain trough levels before the fourth or fifth dose (at steady state) 5

Dosing Adjustments

• If trough levels are subtherapeutic (<10 μg/mL), increase total daily dose by 10-15 mg/kg/day 3, 4
• Common empiric dosing regimens (40-60 mg/kg daily) are often insufficient to achieve therapeutic trough levels in most pediatric patients 3, 4
• Research shows only 39% of pediatric patients reach therapeutic trough levels with standard empiric doses 3

Special Considerations

Renal Impairment

• Close monitoring of serum concentrations is mandatory for patients with renal dysfunction 6
• Dosage adjustment must be made in patients with impaired renal function 2
• More frequent monitoring is recommended in patients with changing renal function 2

Obesity

• Use actual body weight for initial dosing calculations 5, 7
• Obese children may require different dosing strategies than standard weight-based dosing 7

ECMO Patients

• Patients on ECMO may require lower doses (median 30 mg/kg/day) due to altered pharmacokinetics 8
• More frequent monitoring is recommended in this population 8

Common Pitfalls to Avoid

• Underdosing: Standard empiric doses of 40-60 mg/kg/day often fail to achieve therapeutic levels in pediatric patients 3, 4
• Inadequate monitoring: Failure to obtain trough levels before the fourth or fifth dose may lead to prolonged subtherapeutic or toxic levels 5
• Ignoring age-specific differences: Children 6 months to 12 years typically require higher weight-based doses than infants or adolescents 3, 4
• Not adjusting for renal function: Vancomycin clearance is highly dependent on renal function, which varies significantly in pediatric populations 2, 7
• Inappropriate infusion rates: Administering vancomycin too rapidly increases the risk of infusion-related reactions; each dose should be infused over at least 60 minutes 2

Disease-Specific Dosing

MRSA Infections

• For MRSA osteomyelitis: 15 mg/kg/dose IV every 6 hours 1
• For MRSA pneumonia: 15 mg/kg/dose IV every 6 hours 1
• For MRSA meningitis: 15 mg/kg/dose IV every 6 hours 1

Septic Arthritis and Osteomyelitis

• 15 mg/kg/dose IV every 6 hours 1
• Surgical debridement and drainage of associated soft-tissue abscesses is essential 1
• Duration of therapy is typically 6-8 weeks minimum 1

Endocarditis

• 15 mg/kg/dose IV every 6 hours 1
• Duration of therapy is typically 6 weeks 1