SBUH Guidelines for Adult Vancomycin Empirical Dosing

Glomerular filtration rate Dose b Frequency Monitoring c is recommended for: Target Vancomycin Levels
(eGFR ml/min) a (Round dose to the nearest 250 mg (1) anticipated duration greater than 3 - 5 days
Multiply eGFR (CKD-EPI) in increment; Max 2g per dose or 4g per day) (2) seriously ill patients (3) obese patients (4) patients
ml/min/1.73m2 by BSA/1.73 with decreased renal function (5) daily dose greater than
to convert to ml/min 3.5g or frequency of q6h or q8h
GFR greater than 90 and 15mg- 20 mg /kg based on total body weight Q8H Trough – within 30 minutes prior to the administration of Target Vancomycin Trough
Age 18 to 35 years the 4th dose (For MRSA infections,
GFR greater than 90 and age 15mg- 20 mg /kg based on total body weight Q12H Trough – within 30 minutes prior to the administration of trough level should be
greater than 35 years the 4th dose maintained above
GFR 50 to 90 15mg- 20 mg /kg based on total body weight Q12H Trough – within 30 minutes prior to the administration of 10mcg/ml to minimize
the 4th dose selection of resistance)
GFR 30 to 49 or 15mg- 20 mg /kg based on total body weight Q24H Trough – within 30 minutes prior to the administration of
CVVHD or CVVHDF d the 3rd dose Life threatening and/or
GFR 15 to 29 20 mg /kg based on total body weight Q48H Obtain a random level every 24 hours after dose and re- complicated infections e
dose with 15mg/kg when level falls below 15 - 20 mcg/ml 15 to 20 mcg/ml
GFR less than 15 20mg/kg based on total body weight One time dose Obtain a random level every 24 hours after dose and re-
Other Infections
dose with 15mg/kg when level falls below 15 - 20 mcg/ml
10 to 20 mcg/ml
ESRD on Intermittent HD Load with 20 mg/kg based on total body Re-dosing based Obtain pre-dialysis vancomycin random level prior to the
(Assume 3x per week HD) weight on pre-dialysis 2nd post-load dialysis session and adjust dose accordingly
then give 10 mg/kg based on total body level Target Vancomycin
weight after first dialysis Adjustment based on pre-dialysis level: pre- dialysis level
Pre-dialysis Level (mcg/ml) Dosage Adjustment
Less than 15 Increase by 250 -500 mg 15 to 25 mcg/ml
15 -25 No change
Greater than 25 and less Decrease by 250 – 500 mg
than 30
Greater than 30 Hold vancomycin
a. Exercise judgment when assessing renal function in elderly, patients with extremes in muscle mass or diet, and patients with unstable creatinine
b. For CNS infection, use 15mg/kg/dose q8h for patients with normal renal function.
c. Monitor trough level once a week for patients with stable renal function who have achieved desired trough levels. More frequent monitoring is recommended for patients who have changing
renal function, aggressive dosing (q8h or q6h), or obese patients.
d. For seriously ill patients with GFR 30 - 49 ml/min/1.73m2 or CVVHD/F, load with 15mg- 20mg /kg/dose q12h x 2doses, then 10 mg/kg/dose q12h. Monitor trough level prior to the
administration of the 3rd dose of 10mg/kg/dose q12h
e. Life threatening and/or complicated infections: Pneumonia, Bacteremia, Endocarditis, CNS Infection, Osteomyelitis
References: (1) IDSA/ASHP/IDSP. Therapeutic monitoring of vancomycin in adult patients. Am J Health-Syst Pharm 2009; 66:82-98 (2) Lodise TP et al. Relationship between initial vancomycin
concentration-time profile and nephrotoxicity among hospitalized patients. CID 2009; 49:507-514 (3) ATS/IDSA Guidelines for HAP/VAP. Am J respire Crit Care Med 2005; 171:388-416 (4) IDSA
Practice Guidelines for the management of bacterial meningitis. CID 2004; 39:1267-84. (5) Brown M et al. Weight-based loading of vancomycin in patients on hemodialysis. CID 2011; 53:164-166 (6)
Zelenitsky SA et al. Initial vancomycin dosing protocol to achieve therapeutic serum concentrations in patients undergoing hemodialysis. CID 2012:55; 527-533 (7) Nebraska Medical Center Protocol
Compiled by Melinda Monteforte, Pharm.D., BCPS-ID Reviewed by Infectious Diseases Division, Nephrology Division and Pharmacy. Approved by P&T for use until August 2015