Management of Vancomycin Trough of 31 µg/mL
Immediately hold the next scheduled vancomycin dose and do not resume until the trough decreases to 15-20 µg/mL. 1
Immediate Actions Required
Stop vancomycin immediately - a trough of 31 µg/mL is significantly above the therapeutic range of 15-20 µg/mL and dramatically increases nephrotoxicity risk. 1, 2
Recheck the trough level before administering any subsequent doses to confirm the level has decreased to the target therapeutic range. 1, 2
Monitor serum creatinine closely for signs of vancomycin-induced nephrotoxicity, defined as multiple (at least 2-3 consecutive) increases in serum creatinine of 0.5 mg/dL or 150% increase from baseline. 2
Understanding the Risk
Sustained trough concentrations >20 µg/mL significantly increase the risk of nephrotoxicity, and your patient's level of 31 µg/mL represents substantial overdosing. 3, 2
The elevated level indicates urgent need for dosage adjustment to prevent kidney injury. 2
Continuing the same dose despite this elevated trough is the most critical error to avoid, as it dramatically escalates nephrotoxicity risk. 1, 2
Resuming Therapy
Once the trough decreases to 15-20 µg/mL, resume vancomycin at a reduced dose or with an extended dosing interval. 1, 2
For patients with normal renal function, consider reducing the dose by approximately 15-20% or extending the dosing interval. 2
Recheck trough with each dose adjustment to ensure you achieve the target range of 15-20 µg/mL for serious infections. 1
Ongoing Monitoring Strategy
Monitor serum creatinine at least twice weekly throughout therapy to detect early nephrotoxicity. 1
For stable patients on prolonged therapy after achieving target levels, recheck trough weekly. 1
The target therapeutic range of 15-20 µg/mL achieves an AUC/MIC ratio ≥400 for organisms with MIC ≤1 mg/L, which is the pharmacodynamic parameter that best predicts vancomycin efficacy. 3, 2
Critical Considerations
Never rely on peak level monitoring - it provides no clinical value and is not recommended. 1, 2
If the patient develops acute kidney injury with this elevated level, consider dialysis, particularly if there is an increase in serum creatinine ≥0.5 mg/dL or 150% increase from baseline. 2
If vancomycin MIC is ≥2 mg/L, switch to alternative therapy (daptomycin, linezolid, or ceftaroline) as target AUC/MIC ratios are not achievable with conventional dosing. 3, 2
The risk of nephrotoxicity is further amplified if the patient is receiving concurrent nephrotoxic agents (aminoglycosides, piperacillin-tazobactam, CT contrast, amphotericin B, NSAIDs). 3