What is the appropriate Vancomycin (vancomycin) dose in neonates with impaired renal function?

From the Guidelines

For neonates with renal failure, vancomycin dosing should be adjusted based on the degree of renal impairment, with a recommended starting dose and interval that prioritizes minimizing toxicity while maintaining efficacy. When considering vancomycin dosing in neonates with renal failure, it's crucial to recognize the importance of adjusting the dose based on the degree of renal impairment to avoid toxicity, as highlighted in the context of pediatric patients by 1.

Key Considerations

• The degree of renal impairment significantly affects vancomycin clearance, necessitating dose adjustments to prevent toxicity.
• Therapeutic drug monitoring is essential, with target trough concentrations of 10-15 mg/L for most infections and 15-20 mg/L for severe infections.
• Serum creatinine and blood urea nitrogen should be monitored regularly to guide dosing adjustments.
• Continuous infusion may be considered in some cases, especially when trying to maintain a stable drug concentration.

Dosing Recommendations

• For mild renal impairment, administer vancomycin every 24 hours.
• For moderate impairment, every 36-48 hours.
• For severe impairment, every 48-72 hours.
• A starting dose of 15-20 mg/kg/dose is recommended, with adjustments based on trough levels and renal function.
• Continuous infusion at 20-30 mg/kg/day after a loading dose of 15 mg/kg may be an option in certain cases, as it allows for more consistent drug levels.

Monitoring and Adjustments

• The first trough level should be drawn before the third or fourth dose to assess the need for dose adjustments.
• Dosing adjustments should be made based on trough levels, with the goal of achieving target concentrations while minimizing the risk of toxicity.
• Regular monitoring of serum creatinine and blood urea nitrogen is crucial to assess the impact of renal impairment on vancomycin clearance and to guide further dose adjustments, as suggested by the need for careful monitoring in pediatric patients with renal issues, as mentioned in 1.

From the FDA Drug Label

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. Patients with Impaired Renal Function and Elderly Patients Dosage adjustment must be made in patients with impaired renal function. In premature infants and the elderly, greater dosage reductions than expected may be necessary because of decreased 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 vancomycin dose in renal failure in neonates should be adjusted based on the glomerular filtration rate.

• The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency.
• For neonates with renal impairment, the dose required to maintain stable concentrations is not explicitly stated in the table, but it is recommended to use the table for dosage adjustment based on creatinine clearance.
• In premature infants, greater dosage reductions than expected may be necessary because of decreased renal function.
• Close monitoring of serum concentrations of vancomycin is recommended in these patients 2.

From the Research

Vancomycin Dosing in Neonates with Renal Failure

• The optimal vancomycin dosing regimen in neonates with renal failure is not well established, and there is a need for individualized dosing regimens to achieve target serum concentrations 3, 4.
• A study published in 2011 proposed a simplified dosing regimen consisting of a loading dose of 7 mg/kg followed by a constant continuous dose of 30 mg/kg/day, with a target serum vancomycin concentration ranging from 10 mg/l to 30 mg/l 3.
• However, another study published in 2019 found that a simplified dosing regimen did not achieve therapeutic ranges in neonates, and a patient-tailored dosing regimen taking into account corrected gestational age and serum creatinine level may be more suitable 4.
• In patients with renal failure, vancomycin dosing is critical to avoid nephrotoxicity, and target trough levels of 15-20 microg/ml are proposed 5.
• A vancomycin dosing chart for use in patients with renal impairment has been described, which provides an exact dose and dosing interval based on the patient's body weight and creatinine clearance 6.
• In patients on intermittent hemodialysis, vancomycin dosing is influenced by the timing of administration, type of filter used, and duration of dialysis, and a weight-based loading dose of 20-25 mg/kg is recommended 7.