Antimicrobials

Vancomycin

Intermittent Infusion (IIV) Vancomycin

Guidelines for use

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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 3rd or 4th dose

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

Consider pre-4th 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 3rd of 4th 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


5. Dose Adjustments 

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 4th dose after therapy initiation

· Before the 4th 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