None
NA
25mg/kg IV loading dose rounded to nearest 250mg.
15mg/kg IV q8-12h maintenance depending on trough goal.
See VANCOMYCIN DOSING NOMOGRAM under Syndromes
For specific dosing and guidance contact Pharmacy
Therapy is UNRESTRICTED for the first 72 hours of therapy after which Infectious Diseases service approval is required for continuation of therapy (see below for exceptions/rules).
Approval may be granted via phone conversation or formal consult and must be reflected in the patient orders section.
The following conditions are also in place:
Nephrologists are authorized to prescribe without I.D. approval for nephrological diseases
Vancomycin may be used for surgical prophylaxis for up to 24 hours post-op in patients with documented penicillin allergy or patients who are known to be MRSA carriers/colonized. (I.D. approval is required for continuation of therapy beyond 24 hours).
Suspected or proven MRSA, coagulase-negative Staphylococcal infections, Enterococcal spp. infections.
General monitoring
1. SCr and urea 2-3 times a week
2. Hydration status
VANCOMYCIN TROUGH CONCENTRATION MONITORING
To be drawn 30 minutes prior to the next dose -- timing dependent upon the following parameters:
Trough concentration recommended if:
Aggressive therapy (i.e., trough concentration 15-20 mg/L)
Concomitant nephrotoxin (e.g., aminoglycosides, NSAIDs, amphotericin)
Serious infection (see below)
Prolonged course of therapy anticipated (greater than 8 days of therapy)
Class III Obesity(BMI greater than or equal to 40 kg/m2)
Unstable Renal Function (either deteriorating or improving)
Renal dysfunction
Altered Volume of Distribution
Therapeutic drug monitoring NOT generally required for anticipated short course of therapy (less than equal to 8 days) AND hemodynamically stable and/or surgical prophylaxis.
Goal Trough 15-20 mg/L if treating:
Central nervous system infection
Deep-seated or sequestered infection (e.g., abscess)
Endocarditis
Osteomyelitis
MRSA pneumonia, skin and soft tissue infection
Bacteremia due to proven or suspected MRSA or MSSA in penicillin-allergic patient
Other infections due to S.Aureus with Vancomycin MIC greater than or equal to 1 mg/L
Goal Trough 10-15 mg/L if treating:
Skin and Soft tissue infection not due to MRSA
Urinary tract infection
Bloodstream or line infections due to Coagulase Negative Staphylococci (CoNS)
Nephrotoxicity
Cytopenias
Rash including Stevens-Johnson Syndrome
Red man syndrome (histamine release- slow down infusion)
Aminoglycosides may potentiate nephrotoxicity.
May enhance neuromuscular blockade of NM blocking agents.
Careful with concomitant nephrotoxins.
Target levels vary widely based upon site of infection and organism.
Consult Infectious Diseases or Pharmacy for target recommendations and dosing assistance.
Antimicrobial class: Glycopeptide
Pregnancy category: C
Average serum half life: 8 hours
Biliary penetration: Moderate
CSF penetration: Moderate
Lung penetration: Therapeutic
Urine penetration: Therapeutic
Route of Elimination: Renal
