Guidelines
Vancomycin Guideline

Vancomycin Guideline

Update

The IDSA recommends against using target trough concentrations of 15-20 mg/L since there is increased risk of renal toxicity with minimal evidence of improved efficacy

Loading Dose

  • Serious MRSA infections or serious MSSA infections with absolute contraindications to beta lactams where rapid attainment of target trough level is desired such as pneumonia, epidural abscess, septic shock and meningitis.
  • Patients with significant renal dysfunction in order to decrease the time required to attain target trough level.

Dosing if needed: 25-30 mg/kg IV x 1 dose

  • Use actual body weight
  • Round to nearest 250 mg
  • Max dose of 3000mg

Skip loading dose for indications not listed above, start with maintenance dose as below

Maintenance Dose

15 mg/kg/dose

  • Use actual body weight 
  • Round to nearest 250 mg
  • Max dose of 2000 mg (Consider ID consult if total daily dose is more than 4000 mg)

Maintenance dosing frequency:

CrCl (mL/min) Dosing interval
≥ 60 15 mg/kg Q12H*
30-59 15 mg/kg Q24H
< 30 15 mg/kg Q48H
Hemodialysis Usually dosed after each dialysis, consult pharmacist and dialysis order sets

* If targeting a higher trough, near 15 mg/L, and patient’s creatinine clearance is ≥ 90mL/min and < 60 years old, may use 15mg/kg q8h for critically ill patients

Target Trough

Most indications: Target trough of 10 -15 mg/L

  • 10-20 mg/L for enterococci or staphylococci

  • 10-15 mg/L for viridans group streptococci

Trough Monitoring

In patients on q48H dosing, draw a trough level prior to the second dose to ensure level is not above target range

Do not hold doses of vancomycin while the trough level is pending unless there has been an acute change in the patient's creatinine clearance

Monitor levels more frequently in:

  • patients with variable kidney function

  • states of altered volumes of distribution (i.e. burns, cystic fibrosis, sepsis, critical care, pregnancy)

  • those requiring large doses to attain target trough

  • those on more than one nephrotoxic drug or agent simultaneously (i.e. IV contrast)

Dosage Adjustment

  • Dose is usually adjusted in increments of 250 mg
  • Frequency is usually adjusted to q12h, q24h, or q48h
  • If level outside desired range, contact clinical pharmacist for assistance with dosing and interpretation of levels as required

If pre 3rd or 4th dose level is low but near target, maintain the dose and repeat the level since vancomycin level will likely increase with subsequent doses

Outpatient VON Vancomycin order form