What is the recommended dosing and administration protocol for vancomycin (Vancomycin) in pediatric patients?

Vancomycin Dosing in Pediatric Patients

For children with serious or invasive infections, administer vancomycin 15 mg/kg IV every 6 hours, targeting trough concentrations of 15-20 μg/mL for severe infections such as bacteremia, meningitis, osteomyelitis, or pneumonia. 1

Standard Dosing Protocol

Initial Dosing by Infection Severity

For serious/invasive infections (MRSA bacteremia, meningitis, osteomyelitis, pneumonia, severe SSTI):

• Dose: 15 mg/kg IV every 6 hours 1
• Target trough: 15-20 μg/mL 1
• Target AUC/MIC: >400 1

For moderate infections (community-acquired pneumonia, less severe SSTI):

• Dose: 40-60 mg/kg/day divided every 6-8 hours 1
• This translates to approximately 10-15 mg/kg every 6 hours or 13-20 mg/kg every 8 hours 1

Neonatal Dosing (≤1 month old)

• Initial loading dose: 15 mg/kg 2
• Maintenance dosing:
  • First week of life: 10 mg/kg every 12 hours 2
  • After first week to 1 month: 10 mg/kg every 8 hours 2
• Premature infants: Require longer dosing intervals due to decreased vancomycin clearance as postconceptional age decreases 2
• Critical: Close monitoring of serum concentrations is mandatory in neonates 2

Administration Guidelines

Infusion Parameters

• Infusion time: Minimum 60 minutes per dose 3, 2
• Maximum rate: 10 mg/min 3, 2
• Maximum concentration: 5 mg/mL (up to 10 mg/mL only in fluid-restricted patients, though this increases infusion reaction risk) 3, 2
• Each dose must be infused over at least 60 minutes OR at ≤10 mg/min, whichever is longer 2

Loading Dose Considerations

For critically ill children with suspected MRSA sepsis, meningitis, or necrotizing infections:

• Consider loading dose of 25-30 mg/kg (actual body weight) 1, 3
• Prolong infusion to 2 hours for loading doses 1, 3
• Premedicate with antihistamine to reduce red man syndrome risk 1, 3
• Loading dose is NOT adjusted for renal dysfunction—only maintenance doses require adjustment 3

Therapeutic Drug Monitoring

When to Monitor

• Mandatory monitoring: Serious infections, renal dysfunction, obesity, fluctuating volumes of distribution 1, 3
• Obtain trough levels: Before 4th or 5th dose at steady state 1
• Peak monitoring is NOT recommended 1

Target Levels

• Serious infections: Trough 15-20 μg/mL 1, 3
• Moderate infections: Trough 10-15 μg/mL (though specific pediatric data limited) 1
• Predictive value: Trough >5 μg/mL is 81% predictive of peak >20 μg/mL 4

Dosing Adjustments

Renal Impairment

• Initial dose remains 15 mg/kg regardless of renal function 2
• Maintenance dosing: Adjust interval based on creatinine clearance 2
• Children on ECMO with renal impairment: May require significantly lower doses (median 22.5 mg/kg/day vs 42.1 mg/kg/day in non-ECMO patients with renal impairment) 5
• Early therapeutic drug monitoring recommended, even before steady state, in ECMO patients 5

Obesity

• Use actual body weight for dosing calculations 1, 3, 2
• Obese children may require doses up to 60-70 mg/kg/day to achieve target AUC/MIC ≥400 6, 7
• Weight-based dosing is critical—fixed dosing leads to underdosing in most patients 3

Evidence-Based Dosing Recommendations

Recent pharmacokinetic studies demonstrate that traditional dosing (40-45 mg/kg/day) is inadequate for most children 4, 7. Current evidence supports:

• Children <12 years: 70 mg/kg/day (approximately 17.5 mg/kg every 6 hours) achieves target AUC/MIC ≥400 in ~75% of patients 7
• Children ≥12 years: 60 mg/kg/day (15 mg/kg every 6 hours) achieves target AUC/MIC ≥400 in ~75% of patients 7
• PICU patients with normal renal function: Required mean final dose of 60 mg/kg/day to achieve conventional peak/trough targets 4

Critical Pitfalls to Avoid

Never use fixed 1 g doses without weight-based calculation—this results in underdosing in the majority of pediatric patients 3

Do not target high trough levels (15-20 μg/mL) for non-severe infections, as this unnecessarily increases nephrotoxicity risk without proven benefit 3

If vancomycin MIC ≥2 μg/mL, switch to alternative therapy (linezolid, daptomycin, clindamycin if susceptible) as target AUC/MIC ratios are not achievable 1, 3

The correlation between trough levels and AUC/MIC is imperfect: an AUC/MIC of 400 corresponds to trough concentration of only 8-9 μg/mL, not 15-20 μg/mL 7. This suggests that targeting AUC/MIC rather than trough concentrations is more appropriate 7.

For organisms with MIC ≤1 mg/L, higher trough levels (15-20 μg/mL) may not be necessary 8

Always determine the MIC of the organism being treated, as this guides appropriate trough level targets 8