Vancomycin IV

Vancomycin IV


General Information

Suspected or proven MRSA, coagulase-negative Staphylococcal infections, Enterococcal spp. infections.


  • Inpatients: at baseline then twice weekly

  • Outpatients: at baseline then once weekly

  • More frequent monitoring may be required if fluctuating renal status or multiple risk factors for nephrotoxicity (e.g. target trough 15-20 mg/L, baseline SCr greater than 100 micromol/L, BMI greater than or equal to 40 kg/m², concurrent nephrotoxins, daily dose greater than 4000 mg, when SCr is a poor indicator of renal function)

Hydration status

VANCOMYCIN TROUGH CONCENTRATION MONITORING To be drawn 30 minutes prior to the next dose once at steady state Repeat concentrations every 5-7 days if hemodynamically stable, concentrations may be required earlier if hemodynamically unstable or BMI greater than 40 kg/m² when total daily dose greater than 4000 mg

Therapeutic drug monitoring NOT required for:

  • Anticipated short course of therapy (less than 5 days) AND hemodynamically stable

  • Treating non-Staphylococcal aureus indications EXCEPT in cases of anticipated prolonged therapy (e.g. Enterococcal spp. endocarditis)

Goal Trough 10-20 mg/L if treating:

  • skin and soft tissue infection

  • urinary tract infection

  • bloodstream or line infections due to Coagulase Negative Staphylococci (CoNS)

  • Other infections due to Enterococci spp.

  • any other infection not specified in goal 15-20 mg/L category

Goal Trough 15-20 mg/L if treating:

  • any patient on renal replacement therapy or dialysis

  • deep-seated or sequestered infections (e.g. abscess) and/or invasive infections where antibiotic penetration may be compromised/decreased (e.g. CNS infections, osteomyelitis, empyema etc.)

  • pneumonia due to MRSA or HAP/VAP (where MRSA suspected or confirmed)

  • other infections due to S. aureus with vancomycin MIC greater than or equal to 1 mg/L

  •  Nephrotoxicity

  •  Cytopenias

  •  Rash including Stevens-Johnson Syndrome

  •  Red man syndrome (histamine release- slow down infusion)

Aminoglycosides may potentiate nephrotoxicity.

May enhance neuromuscular blockade of NM blocking agents.

Careful with concomitant nephrotoxins.

Antimicrobial class: Glycopeptide

Pregnancy category: C

Average serum half life: 8 hours

Biliary penetration: Moderate

CSF penetration: Moderate

Lung penetration: Therapeutic

Urine penetration: Therapeutic

Route of Elimination: Renal

Target concentrations vary widely based upon site of infection and organism.

Consult Infectious Diseases or Pharmacy for target recommendations and dosing assistance.