What is the dosing regimen for intraperitoneal Vancomycin (vancomycin) in a peritoneal dialysis (PD) patient with peritonitis?

From the Guidelines

For peritoneal dialysis patients with peritonitis, intraperitoneal vancomycin should be dosed at 20-mg/kg loading dose infused during the last hour of the dialysis session, and then 500 mg during the last 30 min of each subsequent dialysis session. This dosing regimen is based on the clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America 1.

Key Considerations

• The loading dose of vancomycin is crucial to ensure adequate tissue penetration and antimicrobial activity in the peritoneal cavity.
• The maintenance dose of 500 mg during the last 30 min of each subsequent dialysis session helps to maintain therapeutic levels of vancomycin in the peritoneal fluid.
• It is essential to note that the dosing regimen may need to be adjusted based on the patient's clinical response, vancomycin levels, and renal function.

Additional Recommendations

• Gentamicin (or tobramycin) can be added to the regimen for empirical gram-negative rod coverage, with a dose of 1 mg/kg, not to exceed 100 mg after each dialysis session 1.
• Ceftazidime or cefazolin can be used as alternative antibiotics, depending on the local antibiogram data and the prevalence of methicillin-resistant staphylococci 1.

Monitoring and Adjustments

• Monitoring vancomycin levels is crucial to ensure therapeutic levels and minimize toxicity.
• Dose adjustments may be needed based on vancomycin levels, clinical response, and renal function.
• The treatment regimen should be continued for 14-21 days, depending on the clinical response and the resolution of peritonitis.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Infusion-related events are related to both the concentration and the rate of administration of vancomycin. The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency.

The dosing regimen for intraperitoneal Vancomycin in a peritoneal dialysis (PD) patient with peritonitis is not explicitly stated in the provided drug label. However, based on the information provided for patients with impaired renal function, the initial dose should be no less than 15 mg/kg.

• The label does not provide specific guidance for intraperitoneal administration in PD patients.
• It is recommended to consult other resources or clinical guidelines for specific dosing recommendations in this patient population 2.

From the Research

Dosing Regimen for Intraperitoneal Vancomycin

• The dosing regimen for intraperitoneal vancomycin in peritoneal dialysis (PD) patients with peritonitis is not well-established, with studies suggesting that the current recommendations are based on clinical experience rather than evidence 3.
• A study found that an intraperitoneal vancomycin regimen of 30 mg/kg every 3-5 days resulted in subtherapeutic serum vancomycin levels in most patients following the loading dose, but therapeutic levels thereafter 4.
• The same study noted that all patients received a loading dose of 30 mg/kg, which was repeated every 3-5 days depending on PD modality 4.
• Another study suggested that a loading dose of vancomycin 1000 mg/L may lead to higher than desired vancomycin levels in pediatric patients, and proposed a lower loading dose of 500 mg/L 5.
• However, it is unclear whether these findings can be extrapolated to adult patients, and further studies are needed to determine the optimal dosing regimen for intraperitoneal vancomycin in PD patients with peritonitis.

Key Considerations

• The choice of antibiotic therapy for peritonitis in PD patients should be based on the results of culture and sensitivity testing, as well as the patient's clinical condition and medical history 6, 7.
• Vancomycin is commonly used as a first-line therapy for gram-positive coverage in the management of PD-associated peritonitis, but its use should be guided by pharmacokinetic and pharmacodynamic principles to ensure optimal efficacy and minimize the risk of adverse effects 3, 4.
• Further studies are needed to evaluate the clinical outcomes of different antibiotic regimens and to determine the optimal dosing regimen for intraperitoneal vancomycin in PD patients with peritonitis 7.