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Antimicrobials

Vancomycin

Intermittent Infusion (IIV) Vancomycin

Guidelines for use

Please click on the titles below to read more:

1. Rationale

Recent data has suggested that vancomycin trough targets for intermittent infusions of 10-15 mg/L are as efficacious as trough levels of 15-20 mg/L and are associated with less nephrotoxicity
Total daily doses should not exceed 4 g/day to mitigate the risk of nephrotoxicity

2. Administration

Please refer to IV drug monograph on pharmacy intranet page for additional administration information.

Intermittent Infusion: Infuse 1 g over 60 minutes
- increase infusion duration by 30 minutes for each additional 0.5 g dose above 1 g

3. Empiric Dosing

Loading Dose

A 2 g loading dose may be considered in patients who are critically ill AND where serious MRSA infection is suspected

Maintenance Dosing

IIV Empiric Dosing in Patients ≤100kg:

Creatinine Clearance* (mL/min)	Empiric initial dosing interval (target trough 10-15 mg/L)
>80	Consider 1g IV q8h
60-80	1 g IV q12h

36 – 59	1 g IV q24h
20 – 35	1 g IV q48h
≤ 19	Give single dose and order peak and 24 h random level, then consult pharmacy
Peritoneal Dialysis	1 g load; then 500 mg q3 - 4 days
Hemodialysis (HD)	Desired pre-dialysis level 15 - 20 mg/L: 1 g given towards the end of HD. (None on non-dialysis days).
CRRT	1 g IV q24h

* Estimating Creatinine Clearance: Male CrCl (mL/min) = [(140 - age) x (total body weight in kg) x 60] / [50 x SCr (µmol/L)]; Female CrCl = 0.85 x male CrCl;

IIV Empiric Dosing for Weights > 100 kg:

Creatinine Clearance*

(mL/min)

Empiric initial dosing interval (target trough 10-15 mg/L)

≥ 60

1g IV q8h

< 60

1-2 g IV at dosing interval based on CrCl of table above

4. Therapeutic Drug Monitoring (TDM)

Vancomycin TDM is used to enhance the safety and efficacy of therapy

Vancomycin Trough Targets

Target levels are different for intermittent infusions vs continuous infusions
Trough levels 10-15 mg/L (15-20 mg/L in hemodialysis) are considered safe and effective for most types of infections when Vancomycin is administered by intermittent infusion including:
- Bacteremia
- Skin and skin structure infections *
- Urinary tract infections *
- Osteomyelitis
- Endocarditis
- CNS infections (continuous infusion preferred)
- Empyema
- Pneumonia

*Note: troughs < 10 mg/L are reasonable in stable patients for these non-deep seated sites

Recommended Levels

Patients NOT Receiving Intermittent Hemodialysis (iHD/SLED):

When to order

How to order

Notes

Trough level*

(target 10-15 mg/L)

Prior to the 3^rd or 4^th dose

Draw just prior to vancomycin dose (before beginning the infusion)

Consider pre-4^th dose trough in the following situations:

· reduced creatinine clearance

· dosing interval ≤ q8h

Peak Level*

(may be considered in patients who are being converted from intermittent dosing to continuous infusions)

Post 3^rd of 4^th dose

Draw 2 hours after the end of vancomycin infusion.

· Optional

· No known clinical importance

· Used to determine individualized pharmacokinetics in patients whose daily dose is expected to be ≥ 4g/day

*Note: in patients with creatinine clearance <20 ml/mL, we recommend the following:

Draw peak level after the first dose
Draw a random level in 24 hours
Consult pharmacy for assistance with dosing

Patients Receiving Intermittent Hemodialysis (iHD/SLED):

When to order

How to order

Notes

Pre-dialysis level

(target 15-20 mg/L)

The morning of the next dialysis session (following receipt of maintenance dose)

Draw prior to dialysis session

· Pre-dialysis level following a loading dose can also be considered

The table below provides guidance as to dose adjustments that may be considered; however, the optimal approach will depend on factors such as the accuracy of empiric dosing interval and renal stability

Trough/Empiric Dosing	1 g IV q24h	1 g IV q12h	1 g IV q8h
Trough ≤ 5 mg/L	Increase to 1 g IV q12h	Increase to 1 g IV q8h	Consult Pharmacy
Trough 5 – 9 mg/L	Increase to 1.25-1.5 g IV q24h	Increase to 1.25-1.5 g IV q12h	Increase to 1.25 g IV q8h and consult pharmacy
Trough 10-15 mg/L	Maintain current dosing; monitor as per below
Trough 15-20 mg/L	Decrease to 750 mg IV q24h	Decrease to 750 mg IV q12h	Decrease to 750 mg IV q8h
Trough > 20 mg/L	Hold vancomycin and consult pharmacy

6. Monitoring

Serum Creatinine, CBC with differential, transaminases

· At least 2-3 times per week while patient is on therapy (more frequent monitoring recommended if patient has unstable renal function or abnormal lab values)

Vancomycin trough levels

· Before the 4^th dose after therapy initiation

· Before the 4^th dose after each dose adjustment

· With any change in renal function

· Once weekly once target level achieved and patient’s creatinine remains stable

Last updated: December 6, 2021