Vancomycin (IV)

Criteria & Principles

The policy for vancomycin dosing by Pharmacy as set forth by the Clinical and Patient Care Services (CPCS) and Antimicrobial Stewardship and Evaluation Team (ASET) is available here.

Adjustment of Dose & Administration

Indication-Specific Adjustment

Selecting Method of Dosing

Initial Empiric Dosing

1. In critically ill patients or patients with suspected severe infections, calculate a loading dose of 20-25 mg/kg with TBW, up to a max single dose of 3 g.
2. Refer to Appendix B. Initial Vancomycin Dosing in the vancomycin policy for patient-specific dosing equations.
3. Vancomycin dosing in dialysis can be found under the "Renal Adjustment" section or in Table B2 of the vancomycin policy
4. Doses will be rounded to the nearest 250 mg increment.

AUC/MIC-based Dosing

1. Refer to Appendix C. AUC-based Dosing and Therapeutic Drug Monitoring in the DUH vancomycin policy for detailed information and equations.
2. Appropriate timing of peak and trough levels can be found under the Serum Concentration Monitoring section.

Renal Adjustment

Empiric Vancomycin Dosing in Renal Replacement Therapy

Vancomycin Dose Adjustments in Hemodialysis

Serum Concentration Monitoring

Clinical Situations to Obtain Serum Trough Concentrations

• Patients likely to receive vancomycin beyond 72 hours
• Patients with rapidly changing renal function
• Concomitant administration of nephrotoxic medication (i.e. aminoglycosides, amphotericin B, IV contrast dye, vasopressors, ACE inhibitors, loop diuretics, NSAIDS, etc.)
• Patients requiring higher than usual doses (>40-50 mg/kg/day) or every 6-8 hour frequency of vancomycin
• Altered volume of distribution (i.e. morbidly obese BMI ≥ 40)
• Special populations (ICU status, pregnancy, BMI < 18 or ≥ 40, burns >20%, liver failure, cystic fibrosis, or transplantation history)

Goal Vancomycin Targets

Timing of Serum Peak and Trough Concentrations

Trough-only monitoring

Peak and Trough monitoring

Drug-Specific Information

Peripheral line concentrations must not exceed 5 mg/mL of compatible diluent. Central line concentrations may be up to 10 mg/mL of compatible diluent.  See piperacillin-tazobactam page for additional compatibility.

Vancomycin infusion reaction may occur if the infusion is too rapid. It is not an allergic reaction, but may be characterized by hypotension and/or a maculopapular rash appearing on the face, neck, trunk, and/or upper extremities. If this should occur, slow the infusion rate. Reactions are often treated with antihistamines and (less frequently) steroids. 

General Notes

1. Up-to-date cost information, click here 
2. IV antimicrobials outpatient (OPAT) dosing, click here
3. Obesity dosing weight recommendations here
4. Helpful drug-drug interaction check website here 
5. When dosing guidance is provided it is important to note the following:

Fixed (ie non weight-based) doses in adults are historically based on a 70 kg patient. Specific disease states or individual patients may warrant dosages that differ from the above recommendations. Since product-specific criteria for dose adjustment based on creatinine clearance exist, consult product information regarding specific recommendations for dosage adjustment based on estimated creatinine clearance.