Vancomycin
SUGGESTED TARGET VANCOMYCIN LEVELS
Vancomycin Pre-Level 5-15 mg/L
(goal ~ 10 mg/L)
Vancomycin Pre-Level 15-20 mg/L
abscess for tunnelled or implantable catheters
METHOD 1
Quick and simple way to dose vancomycin
1. Loading dose (LD, see below)
Initial dosing intervals in hrs before serum levels are analyzed
Serum Creatinine (µmol/L)
(For umol/dL divide by 100) Age Group (years)
20-29
30-39
40-49
50-59
60-69
70-79
40-60
8
8
12
12
12
18
61-80
8
12
12
12
18
18
81-100
12
12
12
18
18
18
101-120
12
12
18
18
18
24
121-140
12
18
18
18
24
**
141-160
18
24
24
24
**
**
161-180
24
24
**
**
**
**
181-200
24
**
**
**
**
**
METHOD 2 Renal Dosing
Rough estimates (Ideally, base initial regimen on patient-specific pharmacokinetic dosing calculations.):
Vancomycin: Dose adjustment for renal impairment.
Cockcroft-Gault CrCl estimates (using the creatinine clearance calculator) should be used for drug dosing rather than the automated MDRD eGFR produced by the clinical chemistry laboratory available on NOTIS.
Crcl (ml/min)
Dose
20 – 50
(or >65 yrs if Crcl >50ml/min)
1. Vancomycin should be infused intravenously over one hour to avoid blunted peaks especially in the setting of meningitis. It maynot be given IM.
2. Loading dose (optional): An initial loading dose of 15mg/kg may be used to insure immediate attainment of a therapeutic peak concentration (>20 mcg/ml).
3. Maintenance dose: Physicians may order “vancomycin per pharmacy” in addition to using the dosing recommendations below.
Patients > 1 week through 1 month chronological age and >36 weeks post conceptual age (PCA) with normal serum creatinine (SCr ≤ 0.6)*
Indication
Initial Dosing
Pneumonia, endocarditis, meningitis, osteomyelitis
45 mg/kg/day divided every 8 hours
All other indications
30 mg/kg/day divided every 8 hours
*Patients < 1 week of age regardless of gestational age, refer to the NICU guideline.
Patients 1 through 3 months of age and > 36 weeks PCA with normal serum creatinine (SCr < 0.9)
Indication
Initial Dosing
Pneumonia, endocarditis, meningitis, osteomyelitis
60 mg/kg/day divided every 6 hours
All other indications
40-50 mg/kg/day divided every 6 hours
Patients 3 months through 12 years of age with normal renal function (SCr < 0.9)
Indication
Initial Dosing
Pneumonia, endocarditis, meningitis, osteomyelitis
60 mg/kg/day divided every 6 hours
All other indications
40-50 mg/kg/day divided every 6 hours
Patients >12 years of age with normal renal function (SCr <0.9)
Indication
Initial Dosing**
Pneumonia, endocarditis, meningitis, osteomyelitis
60 mg/kg/day divided every 8 hours
Or call pharmacy for a dosage assessment,
especially for obese patients
(Maximum dose = 1250-1500mg every 8-12 hours)
All other indications
40 mg/kg/day divided every 8 hours
**The typical adult maximum dose for adult patients is 1250 - 1500mg every 8 – 12 hours or 4000mg/day. Consider using adult pharmacokinetics in larger and/or older pediatric patients. Refer further to the LBMMC Vancomycin Guideline.
DISCLAIMER
The information contained on this website is for informational purposes only, and should not be used to replace professional medical advice. Visitors to the website are responsible for how they chose to utilize this content.
This information should not be considered complete, nor should it be relied on in diagnosing or treating a medical condition. Content on this website does not contain information on all diseases, ailments, physical conditions or their treatment.
It is best to seek advice and attention from your physician or qualified healthcare professional. Always consult your physician before beginning a new treatment, diet or fitness program.
Walnut HealthCare and the participating hospitals do not endorse nor have responsibility for the contents of any other websites linked to or from www.walnuthealthcare.com or www.walnuthealthcare.org.
Please note that all inpatient pharmacists at the participating hospitals are trained and contiuously recertified before they can use any of the protocols per pharmacy on patients. Per Pharmacy Protocols are those Protocols which are approved by hospital’s P&T committee and to which the pharmacy adheres in order to provide medications to patients in a safe, efficient and ethical manner.
SUGGESTED TARGET VANCOMYCIN LEVELS
Vancomycin Pre-Level 5-15 mg/L
(goal ~ 10 mg/L)
Vancomycin Pre-Level 15-20 mg/L
- Skin and soft tissue infection not due to MRSA
- Uncomplicated catheter-associated bacteremia due to coagulase-negativeStaphylococcus*
- Urinary tract infection (catheter-associated; rule out bacteremia)
- CNS infection
- Deep-seated or sequestered infection (e.g. abscess)
- Endocarditis
- Osteomyelitis
- MRSA bacteremia, pneumonia or skin and soft tissue infection
- MSSA bacteremia (penicillin allergic pt)
abscess for tunnelled or implantable catheters
METHOD 1
Quick and simple way to dose vancomycin
1. Loading dose (LD, see below)
- 750mg for 40> to =<60 kg
- 1000mg for 60> to =<80 kg
- 1250mg for >80 to =<100 kg
- 1500mg for >100 to =<120 kg
- 1750mg for >120 to =<140 kg
- 2000mg for>140 kg
Initial dosing intervals in hrs before serum levels are analyzed
Serum Creatinine (µmol/L)
(For umol/dL divide by 100) Age Group (years)
20-29
30-39
40-49
50-59
60-69
70-79
40-60
8
8
12
12
12
18
61-80
8
12
12
12
18
18
81-100
12
12
12
18
18
18
101-120
12
12
18
18
18
24
121-140
12
18
18
18
24
**
141-160
18
24
24
24
**
**
161-180
24
24
**
**
**
**
181-200
24
**
**
**
**
**
METHOD 2 Renal Dosing
Rough estimates (Ideally, base initial regimen on patient-specific pharmacokinetic dosing calculations.):
- [CRCL >60 ml/min]: Start with 1-1.5g see method 1 or 10-20 mg/kg/dose q12h.
- [ 40-60 ]: Start with 1-1.5g see method 1 or 10-20 mg/kg/dose q24h.
- [<40 ]: Start with 1-1.5g see method 1 or 10-20 mg/kg/dose q36 to 48h. May need serum level
Vancomycin: Dose adjustment for renal impairment.
Cockcroft-Gault CrCl estimates (using the creatinine clearance calculator) should be used for drug dosing rather than the automated MDRD eGFR produced by the clinical chemistry laboratory available on NOTIS.
Crcl (ml/min)
Dose
20 – 50
(or >65 yrs if Crcl >50ml/min)
- 1 - 1.5g LD see method 1. then 1g every 24 hours. Check pre dose level before third dose.
- 1-1.5g LD see method 1 and then 1g every 48 hours. Check pre dose level before second dose.
- 1-1.5g LD stat see method 1 (or 15mg/kg up to max 2g). Check level after 4-5 days. ONLY re-dose when level <12mg/L. If deep seated infection when <15mg/L.
1. Vancomycin should be infused intravenously over one hour to avoid blunted peaks especially in the setting of meningitis. It maynot be given IM.
2. Loading dose (optional): An initial loading dose of 15mg/kg may be used to insure immediate attainment of a therapeutic peak concentration (>20 mcg/ml).
3. Maintenance dose: Physicians may order “vancomycin per pharmacy” in addition to using the dosing recommendations below.
Patients > 1 week through 1 month chronological age and >36 weeks post conceptual age (PCA) with normal serum creatinine (SCr ≤ 0.6)*
Indication
Initial Dosing
Pneumonia, endocarditis, meningitis, osteomyelitis
45 mg/kg/day divided every 8 hours
All other indications
30 mg/kg/day divided every 8 hours
*Patients < 1 week of age regardless of gestational age, refer to the NICU guideline.
Patients 1 through 3 months of age and > 36 weeks PCA with normal serum creatinine (SCr < 0.9)
Indication
Initial Dosing
Pneumonia, endocarditis, meningitis, osteomyelitis
60 mg/kg/day divided every 6 hours
All other indications
40-50 mg/kg/day divided every 6 hours
Patients 3 months through 12 years of age with normal renal function (SCr < 0.9)
Indication
Initial Dosing
Pneumonia, endocarditis, meningitis, osteomyelitis
60 mg/kg/day divided every 6 hours
All other indications
40-50 mg/kg/day divided every 6 hours
Patients >12 years of age with normal renal function (SCr <0.9)
Indication
Initial Dosing**
Pneumonia, endocarditis, meningitis, osteomyelitis
60 mg/kg/day divided every 8 hours
Or call pharmacy for a dosage assessment,
especially for obese patients
(Maximum dose = 1250-1500mg every 8-12 hours)
All other indications
40 mg/kg/day divided every 8 hours
**The typical adult maximum dose for adult patients is 1250 - 1500mg every 8 – 12 hours or 4000mg/day. Consider using adult pharmacokinetics in larger and/or older pediatric patients. Refer further to the LBMMC Vancomycin Guideline.
DISCLAIMER
The information contained on this website is for informational purposes only, and should not be used to replace professional medical advice. Visitors to the website are responsible for how they chose to utilize this content.
This information should not be considered complete, nor should it be relied on in diagnosing or treating a medical condition. Content on this website does not contain information on all diseases, ailments, physical conditions or their treatment.
It is best to seek advice and attention from your physician or qualified healthcare professional. Always consult your physician before beginning a new treatment, diet or fitness program.
Walnut HealthCare and the participating hospitals do not endorse nor have responsibility for the contents of any other websites linked to or from www.walnuthealthcare.com or www.walnuthealthcare.org.
Please note that all inpatient pharmacists at the participating hospitals are trained and contiuously recertified before they can use any of the protocols per pharmacy on patients. Per Pharmacy Protocols are those Protocols which are approved by hospital’s P&T committee and to which the pharmacy adheres in order to provide medications to patients in a safe, efficient and ethical manner.