From the Guidelines
Vancomycin dosing should start at 15-20 mg/kg (based on actual body weight) administered intravenously every 8-12 hours for adults with normal renal function, with a maximum dose not to exceed 2 g per dose, as recommended by the Infectious Diseases Society of America 1. The dose should be adjusted based on therapeutic drug monitoring, aiming for trough concentrations of 15-20 lg/mL for serious infections such as bacteremia, infective endocarditis, osteomyelitis, meningitis, pneumonia, and severe skin and soft tissue infections (SSTI) due to MRSA 1. For patients with renal impairment, dose adjustments are necessary, which may include extending the dosing interval to 24-48 hours or reducing the dose amount 1. Therapeutic drug monitoring is essential, with the first trough level typically drawn before the fourth dose, to ensure that the target trough concentrations are achieved and to minimize the risk of toxicity 1. Vancomycin's efficacy depends on maintaining adequate serum concentrations relative to the minimum inhibitory concentration (MIC) of the target organism, with an AUC/MIC ratio ≥400 being the pharmacodynamic target for serious infections 1. Some experts suggest considering loading doses of 25 mg/kg in critically ill patients to achieve therapeutic levels more rapidly, although clinical data are limited 1. It is also important to note that continuous infusion vancomycin regimens are not recommended due to the lack of clear benefit over intermittent dosing 1. Key points to consider when dosing vancomycin include:
- Using actual body weight for dosing calculations
- Adjusting the dose based on renal function and therapeutic drug monitoring
- Targeting trough concentrations of 15-20 lg/mL for serious infections
- Considering loading doses in critically ill patients
- Avoiding continuous infusion regimens.
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. Pediatric patients The usual intravenous dosage of vancomycin is 10 mg/kg per dose given every 6 hours. In premature infants, vancomycin clearance decreases as postconceptional age decreases. Therefore, longer dosing intervals may be necessary in premature infants DOSAGE TABLE FOR VANCOMYCIN IN PATIENTS WITH IMPAIRED RENAL FUNCTION
The recommended vancomycin dose and frequency are 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: 15 mg/kg initially, followed by 10 mg/kg every 12 hours for the first week of life, and every 8 hours thereafter, up to 1 month of age.
- Patients with impaired renal function: dosage adjustment is necessary, and can be calculated using the provided table or formula to estimate creatinine clearance 2.
From the Research
Vancomycin Dosing and Frequency
- The current vancomycin therapeutic guidelines recommend empiric doses of 15-20 mg/kg administered by intermittent infusion every 8-12 h in patients with normal kidney function 3.
- A loading dose of 15-20 mg/kg (actual body weight) is likely to yield an optimal pre-hemodialysis serum concentration at a median elapsed time of 24 h 4.
- The guidelines recommend trough concentration of 15-20 mg/L as a therapeutic goal for adult patients with severe infections 3.
- Vancomycin use is associated with a higher risk of acute kidney injury (AKI) when serum levels exceed > 20 mg/L 5.
Administration Methods
- Administering vancomycin by continuous infusion compared to intermittent infusion has its advantages 3.
- The current practice of trough-only monitoring versus the area under concentration-time curve (AUC) is being revised 3.
- Weight-based dosing versus AUC-based dosing is also being assessed 3.