VANCOMYCIN DOSING GUIDELINES

Question 1

VANCOMYCIN

Mechanism of Action/Spectrum

Answer 1

Inhibits cell wall synthesis

Slowly bactericidal against most gram-positive organisms

Bacteriostatic against enterococci when used alone

Bactericidal against enterococci with concurrent aminoglycoside therapy

Question 2

VANCOMYCIN

Spectrum

Answer 2

Targets staphylococci, streptococci, enterococci gram-positive bacteria Synergy with gentamicin against gram-positive bacteria (staphylococci, streptococci, and enterococci) IV/PO Vancomycin has poor oral absorption (F<5%) and oral vancomycin is only used for C. difficile infections
o IV formulation may be compounded for oral use

Question 3

Pharmacokinetic/Pharmacodynamic parameters associated with efficacy

Answer 3

Time above MIC AUC24/MIC

Question 4

Dosing

Answer 4

Maximum single dose=2500 mg
For obese patients, consider using AdjBW for dose estimations
Doses should be rounded to nearest 250 mg increments
Preferred dosing intervals: 8, 12, 24 hours – note that non-standard intervals may be used for patient-specific reasons
Initial dosing regimens should be <6000 mg/24 hours – continuing regimens should be based off patient-specific kinetics and serum concentrations

Question 5

Loading dose

Answer 5

Usual: ~20 mg/kg TBW

Critically ill/meningitis: 25-30 mg/kg TBW

Question 6

Maintenance dose

Answer 6

15-20 mg/kg TBW (usually Q 8-12 hours)

o To be dosed and adjusted using kinetic calculations

Question 7

Target serum concentrations

Answer 7

Target Peak (mg/mL)
25-40
Target Trough (mg/mL)
10-20

minimum serum vancomycin concentration should be ≥10 mg/L to avoid development of resistance

Question 8

Target Troughs cont

Answer 8

vancomycin trough goals of 15-20 mg/L should be considered for complicated infections such as bacteremia, endocarditis, osteomyelitis, bacterial meningitis and nosocomial, health-care associated and ventilator-associated pneumonia. for MRSA with a MIC=1, target troughs should be 15-20 mg/L (AUC24:MIC ratio of ~400) for adequate treatment. for MRSA with a MIC > 1, may consider alternate therapy

Question 9

Follow-up Monitoring

Answer 9

Ensure BUN/SCr or metabolic panel and ABC or CBC ordered at least QOD while on vancomycin therapy

Pertinent labs and culture results monitored at least daily
o MRSA nasal swabs have a 99.2% negative predictive value. If the indication is pneumonia and the MRSA nasal swab is negative, discuss discontinuing vancomycin with the prescribing physician.

Question 10

Serum Concentrations

Answer 10

Warranted within 3-5 days of initiation of vancomycin therapy if continued therapy planned, and every 5-7 days thereafter, unless change in patient parameters dictates increased frequency

Initial level to be drawn prior to the 3rd or4th maintenance dose (4th or 5th total dose)

 In case of critical illness, labile renal function, dialysis or other patient-specific factors, levels may be drawn earlier when, in the pharmacists judgment, this benefits patient care