What is the appropriate dosing for Vancomycin (generic name) in patients with Impaired renal function?

From the Guidelines

Vancomycin should be dosed at 15-20 mg/kg/dose every 8-12 hours, not to exceed 2 g per dose, with trough monitoring to achieve target concentrations of 15-20 mg/mL in patients with serious MRSA infections. This dosing strategy is based on the most recent and highest quality study available, which prioritizes the management of MRSA infections and the optimization of vancomycin serum trough concentrations 1. The goal of vancomycin therapy is to achieve adequate drug concentrations relative to the bacterial minimum inhibitory concentration (MIC), with the AUC/MIC ratio being the best predictor of effectiveness.

Some key points to consider when dosing vancomycin include:

• Actual body weight should be used for dosing, rather than ideal body weight, to ensure accurate calculations 1
• Trough monitoring is essential to achieve target concentrations and minimize the risk of nephrotoxicity and ototoxicity 1, 2
• Patients with renal dysfunction or fluctuating volumes of distribution may require adjusted dosing and closer monitoring 1
• Alternative therapies should be considered if the vancomycin MIC is 2 mg/L or higher, as conventional dosing methods may not achieve the desired AUC/MIC ratio 2

Regular monitoring of drug levels, renal function, and clinical response is essential to optimize vancomycin therapy and minimize potential adverse effects. By following these guidelines and prioritizing the management of MRSA infections, healthcare providers can improve patient outcomes and reduce the risk of morbidity and mortality.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Infusion-related events are related to both the concentration and the rate of administration of vancomycin. Concentrations of no more than 5 mg/mL and rates of no more than 10 mg/min, are recommended in adults The usual daily intravenous dose is 2 g divided either as 500 mg every 6 hours or 1 g every 12 hours. Patients with Normal Renal Function Adults The usual intravenous dosage of vancomycin is 10 mg/kg per dose given every 6 hours. In neonates, an initial dose of 15 mg/kg is suggested, followed by 10 mg/kg every 12 hours for neonates in the 1st week of life and every 8 hours thereafter up to the age of 1 month. Dosage adjustment must be made in patients with impaired renal function. The dosage of vancomycin hydrochloride for injection per day in mg is about 15 times the glomerular filtration rate in mL/min

The recommended vancomycin dosing is as follows:

• Adults with normal renal function: 2 g daily, divided as 500 mg every 6 hours or 1 g every 12 hours, at a rate of no more than 10 mg/min.
• Pediatric patients: 10 mg/kg per dose, given every 6 hours.
• Neonates: initial dose of 15 mg/kg, followed by 10 mg/kg every 12 hours for the first week of life, and every 8 hours thereafter.
• Patients with impaired renal function: dosage adjustment is required, with the daily dose in mg being approximately 15 times the glomerular filtration rate in mL/min 3.

From the Research

Vancomycin Dosing

• Vancomycin is a cornerstone of treatment for methicillin-resistant Staphylococcus aureus (MRSA) infections 4, 5.
• Elevations in the vancomycin minimum inhibitory concentration within the susceptible range are associated with treatment failure and mortality in the treatment of MRSA infections 5.
• Vancomycin is less effective for infections with MRSA isolates that have a higher MIC within the susceptible range 4.
• Initial treatment for S aureus bacteremia typically includes antibiotics active against MRSA such as vancomycin or daptomycin 6.
• Empirical antibiotic treatment should include vancomycin or daptomycin, which are active against MRSA 6.

Alternative Treatments

• Ceftaroline and ceftobiprole are anti-MRSA cephalosporins and are noninferior to comparator agents in the treatment of acute bacterial skin and skin structure infections (ABSSSIs) and pneumonia 5.
• Tedizolid is more potent than linezolid, has improved pharmacokinetics and reduced toxicity and is active against cfr-containing S. aureus 5.
• Linezolid is an effective and generally well tolerated therapeutic option for patients with serious Gram-positive infections, including those caused by suspected or proven multidrug-resistant pathogens such as MRSA 7.
• Daptomycin has shown to be non-inferior to either vancomycin or β-lactams in the treatment of staphylococcal SSTIs, bacteremia, and right-sided endocarditis 4.

Treatment Considerations

• Source control is a critical component of treating S aureus bacteremia and may include removal of infected intravascular or implanted devices, drainage of abscesses, and surgical debridement 6.
• All patients with S aureus bacteremia should undergo transthoracic echocardiography; transesophageal echocardiography should be performed in patients at high risk for endocarditis 6.
• Other imaging modalities, such as computed tomography or magnetic resonance imaging, should be performed based on symptoms and localizing signs of metastatic infection 6.