Vancomycin Dosing and Monitoring
Intermittent Hemodialysis

Intermittent Hemodialysis

General Comments

In patients undergoing intermittent hemodialysis:

  • Vancomycin IV is given on dialysis days, typically 3 times a week
  • Give the first dose of vancomycin the day it is ordered and subsequent doses on dialysis days
  • Vancomycin doses are administered during the last portion of the hemodialysis session (intradialytic administration) or after hemodialysis

Loading Dose

20 mg/kg IV x 1 dose (using most recent post-dialysis weight, rounded to the nearest 250 mg)

Max loading dose = 2g

Maintenance Dose

500 mg IV near the end of dialysis

750 mg IV near the end of dialysis

1g IV near the end of dialysis

Levels

Target Pre-Dialysis Vancomycin Levels:

  • 10 - 20 mg/L
  • 10 – 15 mg/L reasonable if acute renal dysfunction and renal recovery is expected
  • Vancomycin levels are drawn before the beginning of the hemodialysis session
  • Do not hold post-dialysis vancomycin dose while waiting for results of pre-dialysis vancomycin levels unless there is a specific reason to do so
  • Draw pre-dialysis level pre-third dose after initiating vancomycin or after any dose change.
  • Trough levels may be obtained before each dialysis session if renal function unstable.
  • Pre-dialysis level once weekly after steady state has been achieved and patient clinically stable.

Pre-dialysis level < 10 mg/L:

  • increase the last administered dose by 250 mg

Pre-dialysis level 10 – 20 mg/L:

  • no change in dose required

Pre-dialysis level > 20 – 25 mg/L:

  • decrease the last administer dose by 250 mg

Pre-dialysis level > 25:

  • consult pharmacy