Management of Vancomycin Level of 37 mg/L
Immediately hold the next scheduled vancomycin dose and recheck the trough level before administering any subsequent doses. 1, 2
Immediate Actions
Hold vancomycin therapy immediately. A level of 37 mg/L is significantly elevated—nearly double the upper limit of the therapeutic range (15-20 mg/L for serious infections) and well above the 20 μg/mL threshold where nephrotoxicity risk substantially increases. 1, 3, 2
Critical Monitoring Steps
Assess renal function urgently by checking serum creatinine and comparing to baseline. Nephrotoxicity is defined as an increase in serum creatinine ≥0.5 mg/dL or a 150% increase from baseline. 1, 2
Recheck vancomycin level before considering any additional doses to confirm the level is decreasing toward the therapeutic range. 1, 2
Monitor for ototoxicity symptoms, particularly in patients >53 years old where the risk increases to 19%. 4 While ototoxicity is less common than nephrotoxicity, consider audiometric evaluation if the patient reports hearing changes or tinnitus. 5, 1
Resuming Therapy
Once the trough level decreases to 15-20 mg/L, resume vancomycin at a substantially reduced dose or with an extended dosing interval. 1, 2 For patients with normal renal function, reduce the dose by approximately 15-20% or extend the dosing interval. 2
Dosing Adjustments
Calculate new dosing based on actual pharmacokinetics rather than relying on nomograms, as individual patient factors significantly affect vancomycin clearance. 2
Target an AUC/MIC ratio ≥400 for serious infections with MIC ≤1 mg/L, but recognize that achieving therapeutic targets while avoiding toxicity at this elevated level requires careful recalculation. 2, 6
Alternative Therapy Considerations
Consider switching to alternative antibiotics if the patient develops significant renal impairment (creatinine increase ≥0.5 mg/dL) or if the infection involves an organism with vancomycin MIC ≥2 mg/L, as target AUC/MIC ratios are not achievable with safe dosing. 1, 2
High-Risk Scenarios Requiring Alternative Therapy
- Sustained nephrotoxicity despite dose adjustment 1, 2
- Concomitant use of other nephrotoxic agents (aminoglycosides, NSAIDs, contrast dye) 2
- Patients with baseline renal dysfunction or fluctuating volumes of distribution 2
Common Pitfalls to Avoid
Do not continue the same dosage despite this markedly elevated level—this dramatically increases nephrotoxicity risk. 2
Do not discontinue vancomycin completely if still clinically indicated; instead, hold temporarily and resume at adjusted dosing once levels normalize. 2
Do not rely solely on trough monitoring going forward—this elevated level suggests the current dosing strategy failed, requiring more comprehensive pharmacokinetic assessment. 2, 6
Avoid measuring peak levels, as this provides limited clinical value and is not recommended for vancomycin monitoring. 2, 6
Dialysis Consideration
Evaluate for hemodialysis or hemofiltration if the patient develops acute kidney injury with this toxic level, particularly if creatinine continues rising despite holding vancomycin. 2, 7 Vancomycin is poorly removed by standard dialysis, but hemofiltration and hemoperfusion with polysulfone resin can increase clearance. 7