Vancomycin Dosage

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Usual Adult Dose for Bacterial Infection

15 to 20 mg/kg IV every 8 to 12 hours (2 to 3 g/day); a loading dose of 25 to 30 mg/kg can be considered for seriously ill patients

The manufacturer recommends 500 mg IV every 6 hours or 1 g IV every 12 hours.

Usual Adult Dose for Bacteremia

15 to 20 mg/kg IV every 8 to 12 hours
Duration: 2 to 6 weeks, depending on the nature and severity of the infection

Usual Adult Dose for Bacterial Endocarditis Prophylaxis

For patients allergic to penicillin: 1 g IV once; infusion should be completed within 30 minutes of the start of the procedure

Gentamicin may be added for high-risk patients.

Usual Adult Dose for Endocarditis

Alternate drug for patients who are unable to tolerate penicillin or ceftriaxone, and for oxacillin-resistant staphylococcal strains: 15 to 20 mg/kg IV every 8 to 12 hours with or without other antibiotics depending on the nature of the infection

Duration:
Native valve: 6 weeks
Prosthetic valve: at least 6 weeks

Maximum dose: 2 g/day unless serum concentrations are low (recommended trough: 15 to 20 mcg/mL)

Refer to current published guidelines for detailed recommendations.

Usual Adult Dose for Pseudomembranous Colitis

Clostridium difficile associated diarrhea: 125 mg orally 4 times a day for 10 days
Staphylococcal enterocolitis: 500 to 2000 mg/day given orally in 3 or 4 divided doses for 7 to 10 days

Usual Adult Dose for Enterocolitis

Clostridium difficile associated diarrhea: 125 mg orally 4 times a day for 10 days
Staphylococcal enterocolitis: 500 to 2000 mg/day given orally in 3 or 4 divided doses for 7 to 10 days

Usual Adult Dose for Meningitis

IV: 15 to 20 mg/kg IV every 8 to 12 hours
Duration: 10 to 14 days or at least 1 week after the patient becomes afebrile and cerebrospinal fluid normalizes

Intraventricular, intrathecal: 5 to 20 mg of a preservative-free formulation have been administered up to every 24 hours

Usual Adult Dose for Nosocomial Pneumonia

Hospital-acquired: 15 to 20 mg/kg IV every 8 to 12 hours
Recommended trough levels: 15 to 20 mcg/mL

Initial empiric treatment with broad-spectrum coverage according to the hospital's and/or ICU's antibiogram is recommended if multidrug-resistant organisms are suspected.

Duration: The duration of treatment should be as short as clinically possible (e.g., as little as 7 days) to reduce the risk of superinfections with resistant organisms.

Usual Adult Dose for Pneumonia

Due to methicillin-resistant Staphylococcus aureus (MRSA): 15 to 20 mg/kg IV every 8 to 12 hours
Duration: 7 to 21 days, depending on the nature and severity of the infection

Usual Adult Dose for Osteomyelitis

15 to 20 mg/kg IV every 8 to 12 hours

Duration: 3 to 6 weeks or at least 8 weeks if due to MRSA; oral antibiotics may be required for chronic osteomyelitis for an additional 1 to 2 months

Usual Adult Dose for Febrile Neutropenia

15 mg/kg IV every 12 hours

Duration: Once the patient is stable, afebrile for at least 24 hours, and the absolute neutrophil count is greater than 500/mm3, oral antibiotics may be substituted if antibiotic therapy is to be continued.

Usual Adult Dose for Peritonitis

IV: 15 mg/kg IV every 12 hours
Duration: 14 days, depending on the nature and severity of the infection

Intraperitoneal:
CAPD patients: 15 to 30 mg/kg every 5 to 7 days or 30 to 50 mg/L exchange; dosages may be increased by 25% in nonanuric patients
Duration: 14 to 21 days, depending on the nature and severity of the infection

Usual Adult Dose for Burns - External

15 mg/kg IV every 12 hours

Usual Adult Dose for Prevention of Perinatal Group B Streptococcal Disease

If patient has immediate penicillin hypersensitivity and susceptibility is unknown, testing is not possible, or the isolates are resistant to erythromycin or clindamycin: 1 g IV every 12 hours until delivery

Usual Adult Dose for Sepsis

15 mg/kg IV every 12 hours

Duration: 10 to 14 days, depending on the nature and severity of the infection; longer therapy may be necessary in neutropenic or immunocompromised patients

Usual Adult Dose for Shunt Infection

IV: 15 to 20 mg/kg IV every 8 to 12 hours (up to 2 to 3 g/day)
Intraventricular: 5 to 20 mg of a preservative-free formulation have been administered up to every 24 hours

Usual Adult Dose for Skin or Soft Tissue Infection

15 mg/kg IV every 12 hours
Duration: 10 to 14 days, depending on the nature and severity of the infection

Usual Adult Dose for Surgical Prophylaxis

1 g IV once; infusion should be completed within 30 minutes of the start of the procedure
The dose may be repeated if the procedure lasts longer than 6 hours.

Usual Pediatric Dose for Bacterial Infection

Less than 7 days, less than 1200 g: 15 mg/kg IV every 24 hours
Less than 7 days, 1200 to 2000 g: 10 to 15 mg/kg IV every 12 to 18 hours
Less than 7 days, greater than 2000 g: 10 to 15 mg/kg IV every 8 to 12 hours

7 days up to 1 month, less than 1200 g: 15 mg/kg IV every 24 hours
7 days up to 1 month, 1200 to 2000 g: 10 to 15 mg/kg IV every 8 to 12 hours
7 days up to 1 month, greater than 2000 g: 10 to 15 mg/kg IV every 6 to 8 hours

1 month to 18 years: 10 to 20 mg/kg IV every 6 to 8 hours (total 40 to 60 mg/kg/day)

The manufacturer recommends an initial dose of 15 mg/kg in neonates, followed by 10 mg/kg every 12 hours for neonates in the first week of life and every 8 hours thereafter up to 1 month of age. The manufacturer recommends 10 mg/kg IV every 6 hours for pediatric patients.

Usual Pediatric Dose for Bacterial Endocarditis Prophylaxis

1 month or older:
For patients allergic to penicillin: 20 mg/kg IV (maximum 1 g) once; infusion should be completed within 30 minutes of the start of the procedure

Gentamicin 1.5 mg/kg (maximum 120 mg) IV or IM may be added for high-risk patients.

Usual Pediatric Dose for Peritonitis

CAPD patients: 30 mg/kg intraperitoneally every 5 to 7 days or 30 mg/L exchange

Usual Pediatric Dose for Pseudomembranous Colitis

1 to 18 years: 40 mg/kg/day orally in 3 or 4 divided doses
Maximum dose: 2 g/day
Duration: 7 to 10 days

Usual Pediatric Dose for Enterocolitis

1 to 18 years: 40 mg/kg/day orally in 3 or 4 divided doses
Maximum dose: 2 g/day
Duration: 7 to 10 days

Usual Pediatric Dose for Surgical Prophylaxis

15 mg/kg IV once, with or without gentamicin; infusion should be completed within 30 minutes of the start of the procedure

Renal Dose Adjustments

Adults:
Dosage should be adjusted in renal insufficiency. Various nomograms and methods have been proposed for determining the dosage in renally impaired patients - reduced doses at fixed intervals or normal doses at prolonged intervals. As vancomycin pharmacokinetics exhibit wide interindividual variability, regimens are ideally based on individualized pharmacokinetic dosing. Vancomycin levels should be monitored in patients with any renal dysfunction.

The following adjustments have been suggested:
CrCl 20 to less than 50 mL/min: Start with 15 to 20 mg/kg every 24 hours
CrCl less than 20 mL/min: Longer intervals are suggested; dosages should be determined by the plasma concentration, estimated clearance, and the patient's condition

The loading dose should not be reduced in seriously ill patients; however, subsequent dose adjustments should be based on renal function and trough serum levels.

The manufacturer recommends that the initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency.

For functionally anephric patients, an initial dose of 15 mg/kg IV is recommended by the manufacturer. Further doses should be individualized based on plasma concentrations.

Liver Dose Adjustments

No adjustment recommended.

Dose Adjustments

Adults: Initial IV dosing should be based on actual body weight. Subsequent dosing should be adjusted based on trough serum vancomycin levels. The manufacturer states that other patient factors (such as age or obesity) may require modification of the usual IV daily dose.

Premature infants: The manufacturer states that longer dosing intervals may be required since vancomycin clearance decreases as postconceptional age decreases.

Precautions

Severe infusion-related reactions, including wheezing, dyspnea, urticaria, pruritus, hypotension, flushing ("red man syndrome") and rarely, cardiac arrest have been associated with rapid administration (over several minutes) of vancomycin. Slow infusion (over 60 minutes) and dilute solutions are recommended to prevent these reactions.

Vancomycin IV solutions containing dextrose may be contraindicated in patients allergic to corn or corn products.

Vancomycin has been associated with thrombophlebitis, which may be minimized by slow administration of dilute solutions and rotating infusion sites.

Ototoxicity has occurred during parenteral vancomycin therapy and generally has been associated with excessive vancomycin dosages, patients with underlying hearing loss, or concomitant therapy with other ototoxic agents.

Renal dysfunction has resulted in high, prolonged vancomycin serum concentrations and increased risk of vancomycin-associated toxicity. Dosage adjustments are required for patients with renal dysfunction and elderly patients who are receiving IV vancomycin.

Close monitoring of serum levels of vancomycin may be warranted in premature infants, pediatric patients, and elderly patients.

Monitoring patients for the development of ototoxicity and nephrotoxicity is recommended: Serial, vestibular, audiometric, and renal function tests (creatinine clearance, BUN, urinalysis for proteinuria, decreased specific gravity, casts, and cells) should be performed before and during therapy.

Clostridium difficile associated diarrhea (CDAD) has been reported with almost all antibiotics and may potentially be life-threatening. Therefore, it is important to consider this diagnosis in patients who present with diarrhea following vancomycin therapy. Mild cases generally improve with discontinuation of the drug, while severe cases may require supportive therapy and treatment with an antimicrobial agent effective against C difficile. Hypertoxin producing strains of C difficile cause increased morbidity and mortality; these infections can be resistant to antimicrobial treatment and may necessitate colectomy.

Reversible neutropenia has been reported. Leukocyte counts should be periodically monitored in patients who are receiving prolonged vancomycin therapy or concomitant drugs that may cause neutropenia.

As vancomycin is irritating to tissues, it should be given IV and extravasation should be avoided. IM administration and extravasation have caused pain and necrosis.

Peritoneal administration of vancomycin has been associated with chemical peritonitis.

Due to rapid increases in vancomycin resistance, the Hospital Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control guidelines recommend limiting use to the following indications: Serious infections by beta-lactam resistant gram-positive organisms, gram-positive infections in patients with severe beta-lactam hypersensitivity, antibiotic-associated colitis that is potentially life-threatening or nonresponsive to metronidazole, endocarditis prophylaxis for high-risk patients, and surgical prophylaxis in facilities with high rates of MRSA or MRSE infections.

Dialysis

Hemodialysis: The amount of drug removed varies widely depending on the type of membrane, filtration method, filtration rate, sieving coefficient, and/or dialysate flow rate. Vancomycin is not significantly removed (0% to 5%) during conventional hemodialysis with cellulose or cuprophane filters. However, significant clearance has been reported with high flux dialyzers (e.g., polysulfone, polyacrylonitrile, polymethylmethacrylate membranes), and during continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), and continuous venovenous hemodiafiltration (CVVHDF), resulting in subtherapeutic vancomycin levels. Vancomycin concentrations should be routinely monitored and dosage should be individualized.

Peritoneal dialysis: About 60% of an intraperitoneal dose of vancomycin given during peritoneal dialysis is absorbed systemically in 6 hours. Serum levels of 10 mcg/mL are achieved by intraperitoneal injection of 30 mg/kg of vancomycin. IV vancomycin is not effectively removed by peritoneal dialysis.

The following adjustments have been suggested:
Adults:
Intermittent HD (3 times/week, complete sessions): Loading dose of 15 to 25 mg/kg followed by 500 mg to 1 g or 5 to 10 mg/kg after each dialysis session

CAPD:
Administration via CAPD fluid: 15 to 30 mg/L of CAPD fluid
Systemic: Loading dose of 1 g IV followed by 500 mg to 1 g IV every 48 to 72 hours with close monitoring of levels

Other Comments

In adults, IV vancomycin should be infused at no more than 10 mg/minute or over at least 60 minutes, whichever is longer. In pediatric patients and neonates, IV vancomycin should be infused over at least 60 minutes.

Initial IV dosing for adults should be based on actual body weight.

Minimum serum vancomycin trough concentrations should be maintained above 10 mcg/mL to avoid resistance development. For organisms with an MIC of 1 mcg/mL, the minimum trough level should be at least 15 mcg/mL. Vancomycin serum trough concentrations of 15 to 20 mcg/mL are recommended for complicated infections (bacteremia, endocarditis, osteomyelitis, meningitis, and hospital-acquired pneumonia caused by Staphylococcus aureus).

Alternative treatment is recommended if MIC is 2 mcg/mL or greater.

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