Vancomycin Dosing and Monitoring of Serum Vancomycin Levels
Infectious Diseases Section Guidelines
VA Greater Los Angeles Healthcare System
(March 2013)
Background:

Traditional recommendations have called for vancomycin trough levels to be less than 10 µg/mL.
However, the recent observation of increasing minimum inhibitory concentrations to vancomycin
among methicillin-resistant Staphylococcus aureus (MRSA) isolates at this and other institutions and
the relatively high failure rate of vancomycin in the treatment of invasive disease has prompted
consideration for increasing goal vancomycin trough levels for select indications.

Under-dosing of vancomycin selects for the induction of S. aureus with decreased susceptibility to
vancomycin (hVISA and VISA).

S. aureus isolates with vancomycin MIC of 2.0 µg/mL, which are usually considered to be
susceptible to vancomycin, have decreased responsiveness to traditional vancomycin dosing
regimens as compared to isolates with lower MICs. Isolates with a vancomycin MIC of > 2.0
should be considered to be resistant to vancomycin. Infectious Diseases should be
consulted to assist in the management of these patients.

While vancomycin nephrotoxicity remains uncommon and is typically reversible, it is becoming more
frequently observed in conjunction with higher vancomycin trough levels and/or prolonged courses
of vancomycin, typically in the presence of other potentially nephrotoxic agents.

Other more infrequent vancomycin toxicities include ototoxicity (often presenting as tinnitus),
phlebitis, and reversible neutropenia or thrombocytopenia.

Penetration of vancomycin into lung and CSF is relatively poor.
Recommendations:
Vancomycin dosing in adults with normal renal function
Dosing regimen
-
15-20 mg/kg as actual body weight (max 2000mg/dose) given every 8-12 hours to achieve
target trough 15-20mcg/ml
-
A loading dose of 25–30 mg/kg (based on actual body weight) should be considered in seriously
ill patients.
*** Vancomycin should be infused over at least 1 hour to minimize infusion related adverse effects.
(For higher dosage, eg. 2g, infusion time should be extended to 2 hours).
Therapeutic drug monitoring:
1.
Vancomycin trough levels should be measured in all patients receiving greater than 48 hours of
vancomycin therapy. Trough serum concentration should be obtained just prior to the next dose at
steady state conditions (usually preceding the fifth dose).
2.
3.
When vancomycin is appropriate therapy, the target trough vancomycin serum levels are as follows:
-
Suspected or proven S. aureus pneumonia: 15 – 20 ug/ml
-
Bacterial meningitis: 15 – 20 ug/ml
-
Endocarditis,osteomyelitis,visceral abscesses, limb and life threatening infections, etc.:15 – 20 ug/ml
-
Bacteremia: 15 – 20 ug/ml
-
Simple cellulitis, UTI, etc: 10 – 15 ug/ml
For the treatment of uncomplicated infections (i.e. goal trough 10 - 15 μg/mL), once the target level
and steady state is achieved, vancomycin trough levels do not need to be repeated for short courses
of therapy (i.e. < 7 days) if the serum creatinine and estimated GFR are stable. Treatment of more
complicated infections where the goal trough is 15 - 20 μg/mL or for longer courses may require
more frequent monitoring.
Vancomycin dosing in Hemodialysis Patients

Spot dose of vancomycin should be given, initial 20mg/kg actual body weight (max 2000mg/dose)
followed with 1000mg redosing when random levels fall below the desired trough level.

The first vancomycin plasma level will be drawn 24 hours after dose initiation or prior to
hemodialysis which ever comes first.

If prehemodialysis vancomycin level is more than 25-30ug/ml, recheck random level 6 to 12 hours
post hemodialysis. Vancomycin random levels should not be measured within 6 hours following
hemodialysis, as vancomycin levels drawn during that time frame may overestimate steady state
levels due to serum concentration rebound following dialysis session.

Further vancomycin dose adjustment should be depended on repeated random levels.
*** Target vancomycin levels depend on treatment indications as listed for normal renal function patients
References:
Vancomycin pharmacokinetics, safety and resistance
1.
Moise PA, Forrest A, Bhavnani SM, Birmingham MC, Schentag JJ. Area under the inhibitory curve
and a pneumonia scoring system for predicting outcomes of vancomycin therapy for respiratory infections
by Staphylococcus aureus. Am J Health Syst Pharm 2000; 57:S4–S9.
2.
Rybak MJ. The pharmacokinetic and pharmacodynamic properties of vancomycin. Clin Infect Dis.
2006 ;42:S35-9.
3.
Sakoulas G, Gold HS, Cohen RA, Venkataraman L, Moellering RC, Eliopoulos GM. Effects of
prolonged vancomycin administration on methicillin-resistant Staphylococcus aureus (MRSA) in a
patient with recurrent bacteremia. J Antimicrob Chemother. 2006; 57:699-704.
4.
Sakoulas G, Moellering RC Jr, Eliopoulos GM. Adaptation of methicillin-resistant Staphylococcus
aureus in the face of vancomycin therapy. Clin Infect Dis. 2006; 42:S40-50.
5.
Moise-Broder PA, Forrest A, Birmingham MC, Schentag JJ. Pharmacodynamics of vancomycin
and other antimicrobials in patients with Staphylococcus aureus lower respiratory tract infections.
Clin Pharmacokinet. 2004;43:925-42.
6.
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Antimicrob Chemother 1996; 38:865-9.
7.
Lodise TP, Lomaestro B, Graves J, Drusano GL. Larger vancomycin doses (at least four grams per
day) are associated with an increased incidence of nephrotoxicity. Antimicrob Agents Chemother
2008; 52:1330-6.
Guidelines for vancomycin trough levels
1.
Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis Diagnosis, Antimicrobial Therapy,
and Management of Complications A Statement for Healthcare Professionals From the Committee
on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the
Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and
Anesthesia, American Heart Association—Executive Summary. Circulation. 2005: 111:3167-3184.
2.
Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice
guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004; 39:1267-84.
3.
American Thoracic Society; Infectious Diseases Society of America. Guidelines for the
management of adults with hospital-acquired, ventilator-associated, and healthcare-associated
pneumonia. Am J Respir Crit Care Med. 2005; 171:388-416
4.
Rybak M, Lomaestro, B, Rotchafer JC, Moellering R Jr, Craig W, Billeter M, Dalavosio JR, Levine
DP. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American
Society of Health-System Pharamacists, the Infectious Diseases Society of America, and the Society
of Infectious Diseases Pharmacists. Am J Health-Syst Pharm. 2009; 66:82-98.
Vancomycin dosing with hemodialysis
1.
Mason NA, Neudeck BL, Welage LS, Patel JA, Swartz RD. Comparison of 3 vancomycin dosage
regimens during hemodialysis with cellulose triacetate dialyzers: post-dialysis versus intradialytic
administration. Clin Nephrol. 2003; 60:96-104.
2.
Barth RH, DeVincenzo N. Use of vancomycin in high-flux hemodialysis: experience with 130
courses of therapy. Kidney Int. 1996; 50:929-36.
3.
Crawford BS, Largen RF, Walton T, Doran JJ. Once weekly vancomycin for patients receiving high
flux hemodialysis. Am J Health-Syst Pharm-Vol 65 Jul1, 2008.
4.
Foote EF, Dreitlein WB, Steward CA, Kapoian T, Walker JA, Sherman RA. Pharmacokinetics of
vancomycin when administered during high flux hemodialysis. Clin Nephrol. 1998; 50:51-5.
6.
Ariano RE, Fine A, Sitar DS, Rexrode S, Zelenitsky SA. Adequacy of a vancomycin dosing regimen
in patients receiving high-flux hemodialysis. Am J Kidney Dis. 2005; 46:681-7.
7.
Pai AB, Pai MP. Vancomycin dosing in high flux hemodialysis. Am J Health Syst Pharm 2004
8.
Pallotta KE, Manley HJ. Vancomycin use in patients requiring hemodialysis: A literature review.
Seminars in Dialysis –Vol 21, No1 (Jan-Feb) 2008pp.63-70.
9.
Welage LS, Mason NA, Hoffman EJ, Odeh HR, Dombrouski J, Patel JA, Swartz RD. Influence of
cellulose triacetate Hemodialyzer on vancomycin pharmacokinetics. Journal of the American Society
of Nephrology. Vol6, No4.1995.