Vancomycin Guideline


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


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


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)

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

If level outside desired range, contact clinical pharmacist for assistance with dosing and interpretation of levels as required

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 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

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