Guidance on use of vancomycin in adults (age >16 years)
This guideline is not for use in patients with end stage renal disease or those on haemofiltration.
1. VANCOMYCIN LOADING INFUSION
The loading dose is based on actual body weight; doses are capped to avoid overdosing in severely
obese patients.
The loading dose does not depend on creatinine clearance.
Actual body weight (ABW)
Dose
Volume of
NaCl 0.9% or
glucose 5%
Duration of
infusion (max
rate 10 mg/min)
<40 kg
750 mg
250 ml
1.5 hours
40 – 59 kg
1000 mg
250 ml
2 hours
60 – 90 kg
1500 mg
500 ml
3 hours
> 90 kg
2000 mg
500 ml
4 hours
2. VANCOMYCIN MAINTENANCE INTERMITTENT INFUSION
Maintenance doses depend on creatinine clearance, and not on weight.
Give the first maintenance infusion 12, 24 or 48 hours after the loading infusion according to the table
below:
VANCOMYCIN INTERMITTENT INFUSION - INITIAL DOSAGE GUIDELINES
CrCl (ml/min)
Dose, vol. of NaCl
Dose Interval (after
Time after loading
0.9% or glucose 5%
start of loading
dose for first trough
(max conc 5mg/ml)
dose)
sample
& duration (max rate
10 mg/min)
< 20
500 mg in 250 ml
48 hours
48 hours
over 1 hour
20 - 29
500 mg in 250 ml
24 hours
48 hours
over 1 hour
30 - 39
750 mg in 250 ml
24 hours
48 hours
over 1.5 hours
40 - 54
500 mg in 250 ml
12 hours
24 hours
over 1 hour
55 - 74
750 mg in 250 ml
12 hours
24 hours
over 1.5 hours
75 - 89
1000 mg in 250 ml
12 hours
24 hours
over 2 hours
90 - 110
1250 mg in 500 ml
12 hours
24 hours
over 2.5 hours
>110
1500 mg in 500 ml
12 hours
24 hours
over 3 hours
For some 12 hourly regimens the daily dose can be split into 3 equal doses and given 8 hourly.
This approach is especially useful for patients who require daily doses of 3000 mg or higher.
3. MONITORING OF VANCOMYCIN CONCENTRATIONS
• Concentrations are meaningless unless the dose and sample time are recorded accurately.
• Take a trough sample at the end of the dosage interval
o In patients on a 48 hourly regimen, take a level just before the first maintenance dose (i.e. at 48
hours after the start of the loading dose infusion)
o For all other patients, take a trough sample just before the second maintenance dose
Target trough concentration: 10 – 15 mg/L
A target trough concentration of 15 – 20 mg/L may be required for deep seated infections, such as
sub-acute bacterial endocarditis (SBE), discitis, etc.
If a patient is seriously ill or failing to respond to vancomycin discuss with Microbiology.
4. ADJUSTMENT OF VANCOMYCIN
Always check that the dosage history and sampling time are appropriate before interpreting the result.
•
Seek advice from Pharmacy or Microbiology if you need help to interpret the result.
Vancomycin concentration
Suggested dose change & further monitoring
<10 mg/L
Increase dose by one dose band (see table below)
Take a trough level after 24 hours and again 24 hours
later to check the new dose is suitable. Do not increase
the dose before the second sample result.
10 – 20 mg/L
Maintain the present dose
Resample every 2 days if renal function stable or daily if
renal function deteriorating.
>20 mg/L
Stop
Resample every 24 hours until <20 mg/L then restart at
one dose band lower (see table below).
Take a trough level 24 hours after restarting and again 24
hours later to check the new dose is suitable
VANCOMYCIN DOSE BANDING
For dosage adjustment in response to levels
Dose, volume of sodium chloride 0.9% or glucose
5% (max conc 5mg/ml) & duration (max rate 10
mg/min)
500 mg in 250 ml over 1 hour
500 mg in 250 ml over 1 hour
750 mg in 250 ml over 1.5 hours
500 mg in 250 ml over 1 hour
750 mg in 250 ml over 1.5 hours
1000 mg in 250 ml over 2 hours
1250 mg in 500 ml over 2.5 hours
1500 mg in 500 ml over 3 hours
1000 mg in 250 ml over 2 hours
1250 mg in 500 ml over 2.5 hours
1500 mg in 500 ml over 3 hours
Dose Interval
48 hours
24 hours
24 hours
12 hours
12 hours
12 hours
12 hours
12 hours
8 hours
8 hours
8 hours
References
Thomson AH, Staatz CE, Tobin CM, Gall M, Lovering AM. Development and evaluation of vancomycin dosage
guidelines designed to achieve new target concentrations. Journal of Antimicrobial Chemotherapy
doi:10.1093/jac/dkp085
Rybak M, Lomaestro B, Rotschafer JC, Moellering Jr R, Craig W et al. Therapeutic monitoring of vancomycin in adult
patients; A consensus review of the American Society of Health System Pharmacists, the Infectious Diseases Society of
America, and the Society of infectious Diseases Pharmacists. Am J Health Syst Pharm. 2009;66:82-98