From the Guidelines
For a critical vancomycin level, immediately hold the next dose and notify the prescriber. If the level is significantly elevated (>30 μg/mL), consider obtaining nephrology consultation. Monitor renal function closely with daily serum creatinine measurements. Increase IV fluid administration to enhance vancomycin clearance, typically with normal saline at 100-150 mL/hr if the patient can tolerate the fluid. Check vancomycin levels every 12-24 hours until they return to therapeutic range (10-20 μg/mL for most indications) 1. Once levels decrease appropriately, vancomycin can be restarted at a reduced dose with adjusted frequency based on renal function.
Key Considerations
- Monitor trough serum vancomycin concentrations to reduce nephrotoxicity, especially in patients receiving aggressive dose targeting or who are at risk of toxicity 1.
- Watch for signs of ototoxicity (hearing loss, tinnitus) and nephrotoxicity (decreased urine output, rising creatinine).
- Vancomycin toxicity occurs because the drug has a narrow therapeutic window and is primarily eliminated by the kidneys, so high levels can cause direct tubular damage and accumulate further when renal function declines, creating a dangerous cycle.
Management
- Hold the next dose and notify the prescriber immediately if the vancomycin level is critical.
- Consider obtaining nephrology consultation if the level is significantly elevated.
- Monitor renal function closely and increase IV fluid administration to enhance vancomycin clearance.
- Check vancomycin levels regularly until they return to the therapeutic range.
- Restart vancomycin at a reduced dose with adjusted frequency based on renal function once levels decrease appropriately.
From the FDA Drug Label
Supportive care is advised, with maintenance of glomerular filtration. Vancomycin is poorly removed by dialysis. Hemofiltration and hemoperfusion with polysulfone resin have been reported to result in increased vancomycin clearance. For a critical lab value indicating vancomycin toxicity, supportive care is advised. This includes maintenance of glomerular filtration.
- Dialysis is not effective in removing vancomycin.
- Hemofiltration and hemoperfusion with polysulfone resin may be considered to increase vancomycin clearance. It is recommended to contact a certified Regional Poison Control Center for up-to-date information on treating vancomycin overdose 2.
From the Research
Treatment of Critical Lab for Vancomycin
To treat a critical lab for vancomycin, the following steps can be taken:
- Monitor vancomycin trough levels closely, as levels > 20 μg/mL are associated with an increased risk of nephrotoxicity 3, 4, 5
- Adjust vancomycin dosing to achieve trough levels between 10-20 μg/mL, as recommended by the Infectious Diseases Society of America 6
- Avoid concomitant use of nephrotoxic agents, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, loop diuretics, and non-steroidal anti-inflammatory drugs, as these can increase the risk of vancomycin-induced nephrotoxicity 3, 4, 5
- Monitor renal function closely, including serum creatinine levels and creatinine clearance, as vancomycin can cause nephrotoxicity 3, 4, 5, 7
- Consider using alternative antibiotics or adjusting vancomycin dosing in patients with pre-existing renal disease or those who are at high risk of developing nephrotoxicity 4, 5
Risk Factors for Vancomycin Nephrotoxicity
Several risk factors have been identified for vancomycin nephrotoxicity, including:
- High vancomycin trough levels (> 20 μg/mL) 3, 4, 5
- Concomitant use of nephrotoxic agents 3, 4, 5
- Prolonged vancomycin therapy (> 7 days) 4, 5
- High vancomycin doses (> 4 g/day) 4, 5
- Pre-existing renal disease 4, 5
- Increasing age 7
- Increasing body weight 7
- Critically ill patients 7
- Site of infection 7
Prevention and Management of Vancomycin Nephrotoxicity
To prevent and manage vancomycin nephrotoxicity, the following strategies can be employed:
- Monitor vancomycin trough levels and adjust dosing as needed 3, 4, 6, 5
- Avoid concomitant use of nephrotoxic agents 3, 4, 5
- Monitor renal function closely 3, 4, 5, 7
- Consider using alternative antibiotics or adjusting vancomycin dosing in patients with pre-existing renal disease or those who are at high risk of developing nephrotoxicity 4, 5
- Discontinue vancomycin therapy if nephrotoxicity occurs, as most cases are reversible with discontinuation of the drug 4