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    2013 Vancomycin Do Sing Guide

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    aLPHA1
    Vancomycin is a glycopeptide antibiotic that prevents bacterial cell wall synthesis. It exhibits concentration-independent killing of bacteria. The guidelines recommend determining creatinine clearance and dosing based on total body weight or adjusted body weight. An initial loading dose of 15-30 mg/kg is recommended, followed by maintenance doses of 10-20 mg/kg every 8-24 hours depending on renal function. Therapeutic drug monitoring aims for trough levels of 10-20 mcg/mL depending on infection type.

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    2013 Vancomycin Do Sing Guide

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    aLPHA1
    63 views1 page
    Vancomycin is a glycopeptide antibiotic that prevents bacterial cell wall synthesis. It exhibits concentration-independent killing of bacteria. The guidelines recommend determining creatinine clearance and dosing based on total body weight or adjusted body weight. An initial loading dose of 15-30 mg/kg is recommended, followed by maintenance doses of 10-20 mg/kg every 8-24 hours depending on renal function. Therapeutic drug monitoring aims for trough levels of 10-20 mcg/mL depending on infection type.

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    2013 Vancomycin Do Sing Guide

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    Vancomycin is a glycopeptide antibiotic that prevents bacterial cell wall synthesis. It exhibits concentration-independent killing of bacteria. The guidelines recommend determining creatinine clearance and dosing based on total body weight or adjusted body weight. An initial loading dose of 15-30 mg/kg is recommended, followed by maintenance doses of 10-20 mg/kg every 8-24 hours depending on renal function. Therapeutic drug monitoring aims for trough levels of 10-20 mcg/mL depending on infection type.

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    63 views1 page

    2013 Vancomycin Do Sing Guide

    Uploaded by

    aLPHA1
    Vancomycin is a glycopeptide antibiotic that prevents bacterial cell wall synthesis. It exhibits concentration-independent killing of bacteria. The guidelines recommend determining creatinine clearance and dosing based on total body weight or adjusted body weight. An initial loading dose of 15-30 mg/kg is recommended, followed by maintenance doses of 10-20 mg/kg every 8-24 hours depending on renal function. Therapeutic drug monitoring aims for trough levels of 10-20 mcg/mL depending on infection type.

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    Stanford Hospital & Clinics Vancomycin Dosing Guidelines 2013

    Vancomycin is a tricyclic glycopeptide antibiotic that exhibits bactericidal activity by preventing the synthesis and assembly of a growing bacterial cell
    wall, altering the permeability of the bacterial cytoplasmic membrane, and selectively inhibiting bacterial RNA synthesis. Vancomycin is considered to
    be a concentration-independent or time-dependent killer of bacteria.

    I. DETERMINE CREATININE CLEARANCE AND DOSE

    A. Determine the dose with total body weight (TBW)


    B. Calculate creatinine clearance with the Cockcroft-Gault equation using an ideal body weight (IBW) or an adjusted body weight (ABW) if
    the patient is obese (TBW >20% over IBW)

    IBW (male) = 50 kg + (2.3 x height in inches > 60 inches)


    CrCL (mL/min) = (140 – age) x IBW ( x 0.85 for females ) IBW (female) = 45 kg + (2.3 x height inches > 60 inches)
    SCr x 72 ABW (kg) = IBW + 0.4 (TBW – IBW)

    II. INITIAL EMPIRIC DOSING

    A. Loading Dose: A loading dose can be used to facilitate rapid attainment of target trough serum vancomycin concentration
    i. Normal renal function – Consider a loading dose of 25 – 30 mg/kg (max 2gm) for severe infections and ICU patients
    ii. Renal insufficiency – Use a lower loading dose of 15 – 20 mg/kg

    Recommended
    Patient Weight Infusion Rate
    Loading Dose
    25 – 35 kg 750 mg x 1 60 minutes
    36 – 45 kg 1,000 mg x 1 60 minutes
    46 – 55 kg 1,250 mg x 1 90 minutes
    Central line only: Up to 1000 mg in 100 mL of compatible diluent
    56 – 65 kg 1,500 mg x 1 90 minutes
    66 – 75 kg 1,750 mg x 1 120 minutes Peripheral line: At least 500 mg per 100 mL of compatible diluent
    ≥ 76 kg 2,000 mg x 1 120 minutes

    Red man syndrome may occur if the infusion is too rapid. It is not an allergic reaction, but may be characterized by hypotension
    and/or a maculopapular rash appearing on the face, neck, trunk, and/or upper extremities. If this should occur, slow the infusion
    rate to over 11/2 to 2 hours and increase the dilution volume. Reactions are often treated with antihistamines and steroids.

    B. Maintenance Dose:

    Creatinine Dose & Frequency


    Clearance (mL/min) Total body weight (TBW) Timing Trough Level

    > 50 15–20 mg/kg Q8–12H Before 4th or 5th dose

    30-49 15–20 mg/kg Q12–24H Before 3rd or 4th dose

    15-29 10–15 mg/kg Q24H Before 3rd dose


    Q24H – before 3rd dose
    <15 10–15 mg/kg Q24–48H
    Q48H – before 2nd dose
    Pre-dialysis – Assumes that HD is
    Load: 20 – 25 mg/kg x 1 high flux and removes ~20% of
    Hemodialysis Maintenance: 10 – 15 mg/kg post-dialysis when levels vancomycin per 3 hour session
    <15mg/L or <20 mg/L in severe infections Alternative: 4 hours after
    completion of dialysis session
    Load: 20 – 25 mg/kg x 1
    CRRT Before 3rd or 4th dose
    Maintenance: 10 – 15 mg/kg Q24H

    III. THERAPEUTIC DRUG MONITORING

    Goal Trough (mcg/mL) Indication


    10 – 15 cellulitis, skin/soft tissue infections
    15 – 20 pneumonia, bacteremia, endocarditis, osteomyelitis

    Recommend trough levels >10 mcg/mL to avoid microbial resistance

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