Management of Vancomycin Trough Level of 28 mg/L
Hold the next scheduled vancomycin dose immediately and recheck the trough level before administering any subsequent doses. 1
Immediate Actions Required
- Stop vancomycin administration now - a trough of 28 mg/L is significantly above the therapeutic range of 15-20 mg/L and substantially increases nephrotoxicity risk 1
- Sustained trough concentrations >20 μg/mL markedly increase the risk of vancomycin-induced nephrotoxicity 1, 2
- Measure serum creatinine immediately and monitor closely for nephrotoxicity, defined as multiple (at least 2-3 consecutive) increases in serum creatinine of 0.5 mg/dL or 150% increase from baseline 1
When to Resume Vancomycin
- Do not restart vancomycin until the trough level decreases to the target range of 15-20 mg/L 1
- Recheck the trough level before each potential dose until it falls into the therapeutic window 1
- Once the trough reaches 15-20 mg/L, resume vancomycin at a reduced dose or with an extended dosing interval 1
Dose Adjustment Strategy
- For patients with normal renal function, reduce the dose by approximately 15-20% or extend the dosing interval 1
- For example, if the patient was receiving 1000 mg every 12 hours, consider either:
- Reducing to 750-850 mg every 12 hours, OR
- Maintaining 1000 mg but extending to every 18-24 hours 1
- Individual pharmacokinetic adjustments are recommended rather than relying solely on nomograms 1
Ongoing Monitoring
- Recheck trough level before the fourth dose of the new regimen to confirm steady-state achievement and appropriate therapeutic range 1, 2
- Continue monitoring serum creatinine at least every 2-3 days throughout vancomycin therapy 1
- If renal function deteriorates despite dose adjustment, consider dialysis and alternative antibiotic therapy 1
Critical Pitfalls to Avoid
- Never continue the same dosage despite elevated trough levels - this dramatically increases nephrotoxicity risk 1
- Do not discontinue vancomycin therapy completely if still clinically indicated; instead, hold temporarily and adjust the dose appropriately 1
- Avoid using concomitant nephrotoxic agents (e.g., NSAIDs, aminoglycosides) which compound the risk of kidney injury 1
- Do not rely on peak level monitoring, which provides limited clinical value and is not recommended 1