What is the proper administration and dosing of vancomycin (Vancomycin hydrochloride) for intravenous (IV) use?

How to Give Vancomycin

Administer vancomycin at 15-20 mg/kg (actual body weight) intravenously every 8-12 hours, with each dose infused over at least 60 minutes at a rate not exceeding 10 mg/min, using concentrations ≤5 mg/mL. 1, 2, 3

Standard Dosing for Adults with Normal Renal Function

• Dose 15-20 mg/kg based on actual body weight every 8-12 hours, not to exceed 2 grams per dose. 1, 4, 3
• For non-obese patients with non-severe infections, traditional doses of 1 gram every 12 hours may be adequate, but weight-based dosing is strongly preferred. 4
• Never use fixed 1 gram doses without considering patient weight—this leads to underdosing in most patients, especially those >70 kg. 1, 2

Loading Dose for Severe Infections

For seriously ill patients with suspected MRSA infection, sepsis, bacteremia, endocarditis, meningitis, pneumonia, or necrotizing fasciitis, administer a loading dose of 25-30 mg/kg (actual body weight). 1, 4, 2

• The loading dose is critical to rapidly achieve therapeutic concentrations in critically ill patients with expanded volume of distribution from fluid resuscitation. 4
• The loading dose is NOT affected by renal dysfunction—only maintenance doses require adjustment. 4, 2
• Prolong the infusion time to 2 hours and consider premedication with an antihistamine to reduce red man syndrome risk. 4, 2

Administration Guidelines

• Infuse each dose over at least 60 minutes at a rate not exceeding 10 mg/minute, whichever is longer. 1, 3
• Use concentrations no greater than 5 mg/mL to minimize infusion-related reactions. 1, 2, 3
• In patients requiring fluid restriction, concentrations up to 10 mg/mL may be used, but this increases the risk of infusion-related events. 3
• Infusion-related events are related to both concentration and rate of administration. 2, 3

Therapeutic Monitoring

• Obtain trough concentrations at steady state, before the fourth or fifth dose. 1, 4
• For severe infections (bacteremia, endocarditis, meningitis, pneumonia), target trough concentrations of 15-20 μg/mL. 1, 4, 2
• For mild to moderate infections, target trough concentrations of 10-15 μg/mL. 1, 4
• The optimal pharmacodynamic parameter is an AUC/MIC ratio >400. 1, 4, 2
• Monitoring is mandatory for patients with renal dysfunction, obesity, or fluctuating volumes of distribution. 1, 4, 2

Pediatric Dosing

• For children, administer 10 mg/kg per dose every 6 hours. 1, 3
• Each dose should be administered over at least 60 minutes. 3
• For neonates, give an initial dose of 15 mg/kg, followed by 10 mg/kg every 12 hours in the first week of life and every 8 hours thereafter up to 1 month of age. 3
• In premature infants, longer dosing intervals may be necessary due to decreased vancomycin clearance. 3

Renal Impairment Dosing

• Dosage adjustment is required for patients with impaired renal function—adjust maintenance doses, not loading doses. 4, 2, 3
• The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency. 3
• For functionally anephric patients, give an initial dose of 15 mg/kg, then 1.9 mg/kg/24 hours for maintenance. 3
• In anuria, a dose of 1,000 mg every 7-10 days has been recommended. 3

Critical Pitfalls to Avoid

• Do not target high trough levels (15-20 μg/mL) for non-severe infections—this unnecessarily increases nephrotoxicity risk without additional benefit. 1, 2
• If the vancomycin MIC is ≥2 μg/mL, consider alternative therapies (daptomycin, linezolid, ceftaroline) because target AUC/MIC ratios may not be achievable. 1, 4, 2
• Weight-based dosing is particularly critical in obese patients who are likely underdosed with conventional 1 gram every 12 hour regimens. 4, 2
• Standard doses of 1 gram every 12 hours fail to achieve therapeutic trough concentrations of 15-20 μg/mL in critically ill trauma patients with pneumonia. 5