Vancomycin - IV

For normal renal function: 1 g IV every 12 hours; ideally determine the initial regimen with patient-specific pharmacokinetic calculations. The original page lists historical peak 25-40 micrograms/mL and trough 5-15 micrograms/mL targets. These are preserved as historical source targets, not current AUC-guided monitoring advice.

The manufacturer discussion gives 2 g/day as 500 mg every 6 hours or 1 g every 12 hours; age/obesity may require modification. Each dose is administered no faster than 10 mg/min or over at least 60 minutes, whichever takes longer. Recommended concentration no greater than 5 mg/mL; up to 10 mg/mL may be used for selected fluid-restricted patients, with increased infusion-reaction risk. Reactions can occur at any rate/concentration.

Pediatric source dose: 10 mg/kg every 6 hours over at least 60 minutes. Neonates/young infants: 15 mg/kg initially, then 10 mg/kg every 12 hours in the first week and every 8 hours thereafter through age 1 month; infuse over 60 minutes and closely monitor concentrations. Intrathecal/intraventricular safety and efficacy were not assessed; intermittent IV infusion is recommended.

CrCl above 60 mL/min: initially 1 g or 10-20 mg/kg every 12 hours. CrCl 40-60: initially 1 g or 10-20 mg/kg every 24 hours. Below 40: use measured concentrations.

Separate rough Matzke nomogram: 25 mg/kg load (assumed Vd 0.9 L/kg), then 19 mg/kg at these estimated intervals: CrCl 80, every 16-18 hours; 60, every 24; 40, every 36; 30, every 48; 20, every 60; 10, every 96; 5, every 144 hours (6 days).

The source cites Moellering, Krogstad and Greenblatt, Annals of Internal Medicine 1981;94:343. Its daily-dose approximation is about 15 times GFR in mL/min. Listed CrCl mL/min -> vancomycin mg/24 hours:

100 -> 1,545; 90 -> 1,390; 80 -> 1,235; 70 -> 1,080; 60 -> 925; 50 -> 770; 40 -> 620; 30 -> 465; 20 -> 310; 10 -> 155.

Initial dose at least 15 mg/kg, even with mild/moderate impairment. This table is not valid for functionally anephric patients. For them the source gives 15 mg/kg initially and a maintenance requirement of 1.9 mg/kg/day, potentially delivered as 250-1,000 mg every several days. It also reports a historical anuria recommendation of 1 g every 7-10 days.

Adjust for impairment; premature infants and older adults may need greater reductions than expected. Concentrations help optimize therapy, especially in seriously ill patients with changing function. The original assay list includes microbiologic, radioimmunoassay, fluorescence-polarization immunoassay, fluorescence immunoassay and high-pressure liquid chromatography.

Source Cockcroft-Gault: (140 - age) x weight in kg / (72 x serum creatinine in mg/dL), multiplied by 0.85 for females. This is an estimate; the source calls for prompt measured clearance. Serum creatinine must be at steady state. Estimates can overstate actual clearance with declining function (shock, severe heart failure, oliguria), altered muscle-to-body-weight relationships (obesity, liver disease, edema, ascites), debilitation, malnutrition or inactivity.

The source initially says 'not dialyzable' and recommends concentration-guided dosing, then explicitly identifies high-flux HD as an exception, with estimated removal 39% +/- 13%, potentially useful in overdose.

Original supporting citations: Quale JM, O'Halloran JJ, DeVincenzo N, Barth RH. Removal of vancomycin by high-flux hemodialysis membranes. Antimicrobial Agents and Chemotherapy. 1992;36(7):1424-1426. Pai AB, Pai MP. Vancomycin dosing in high flux hemodialysis: a limited-sampling algorithm. American Journal of Health-System Pharmacy. 2004;61:1812-1816.