Vancomycin Infusion Settings After Hemodialysis
Administer vancomycin during the last 60 minutes of the hemodialysis session, not after it, using a loading dose of 20 mg/kg followed by 500 mg during the last 30 minutes of each subsequent dialysis session. 1
Recommended Infusion Protocol
Loading Dose Administration
- Infuse 20 mg/kg (actual body weight) during the final hour of the hemodialysis session 1, 2
- This loading dose rapidly establishes therapeutic pre-dialysis serum levels (target 10-25 mcg/mL) 3
- The infusion should be administered through the dialysis access to avoid additional venipuncture and preserve vascular access 4
Maintenance Dose Administration
- Administer 500 mg during the last 30 minutes of each subsequent dialysis session 1, 2
- This standardized maintenance dose simplifies dosing and reduces medication errors 4
- Continue this regimen after each dialysis treatment (typically 3 times weekly) 3
Infusion Timing Rationale
Why During (Not After) Dialysis
- Administering vancomycin during the last 60-90 minutes of hemodialysis is preferred over post-dialysis administration 4
- This timing prevents vascular damage, preserves patients' vascular access, and improves quality of life by reducing treatment time 4, 5
- While infusion during dialysis decreases vancomycin exposure by approximately 25% compared to post-dialysis administration, the increased dosing compensates for dialytic losses 5
Clinical Efficacy Evidence
- This dosing strategy achieves pre-dialysis vancomycin concentrations ≥13 mg/L and demonstrates favorable clinical outcomes, particularly for bacteremia and skin/soft tissue infections 4
- In one study of 20 patients, 85% were cured using this protocol with adequate median pre-dialysis concentrations of 16.2 mcg/mL 5
- A larger study of 130 treatment courses showed that 82% of pre-dialysis levels remained therapeutic (10-25 mcg/mL), with only 13% subtherapeutic and 5% supratherapeutic 3
Critical Monitoring Parameters
Therapeutic Drug Monitoring
- Monitor vancomycin levels twice weekly in hemodialysis patients 1
- Target trough concentrations: 10-25 mcg/mL 1
- Obtain levels immediately prior to dialysis (pre-dialysis trough) 3
- More frequent monitoring is required when combining vancomycin with aminoglycosides, using higher doses, or dialyzing with high-flux membranes 1
Common Pitfalls to Avoid
Inadequate Dosing Errors
- Do not use once-weekly vancomycin dosing in high-flux hemodialysis 3
- Once-weekly dosing results in 77% of levels falling below 10 mcg/mL by day 5 and 84% by day 7, leading to treatment failure 3
- Fixed-dose maintenance regimens without weight-based loading fail to reach target levels in the majority of hemodialysis patients 6
Membrane Considerations
- High-flux polyethersulfone membranes remove significantly more vancomycin than low-flux membranes 7
- Patients dialyzed with high-flux membranes using inadequate dosing (1 g every 5-7 days) show subtherapeutic levels in 16-42% of cases 7
- The recommended protocol accounts for high-flux membrane removal and maintains therapeutic levels 5, 3