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Vancomycin

Combinations; Vancomycin/ Ceftriaxone- See below

Dosage; Usual dosage range:

Oral

125mg every 6 hours for 10-14 days,

Child 5mg/kg every 6 hours, over 5 years, half adult dose

Note: Oral paediatric dose is lower than that on product literature but is adequate.

By intravenous infusion,

1-1.5g every 12 hours;

Elderly over 65 years, 500mg every 12 hours or 1g once daily;

Child over 1 month, 15mg/kg every 8 hours (max. 2g daily).

Initial intravenous dosing should be based on actual body weight;

subsequent dosing adjusted based on serum trough vancomycin concentrations.

I.V.: 2-3 g/day (or 30-60 mg/kg/day) in divided doses every 8-12 hours

Note: Dose requires adjustment in renal impairment

Oral: 500-2000 mg/day in divided doses every 6 hours

Combinations; Vancomycin/ Ceftriaxone= See below

Vancomycin/ ceftriaxone brands

Indication-specific dosing: Vancomycin

Catheter-related infections: Antibiotic lock technique (Mermel, 2009): 2 mg/mL ± 10 units heparin/mL or 2.5 mg/mL ± 2500 or 5000 units heparin/mL or 5 mg/mL ± 5000 units heparin/mL (preferred regimen); instill into catheter port with a volume sufficient to fill the catheter (2-5 mL). Note: May use SWFI/NS or D5W as diluents. Do not mix with any other solutions. Dwell times generally should not exceed 48 hours before renewal of lock solution. Remove lock solution prior to catheter use, then replace.

C. difficile -associated diarrhea (CDAD): Oral:

Manufacturer recommendations: 500-2000 mg/day in 3-4 divided doses for 7-10 days (usual dose: 125-500 mg every 6 hours)

IDSA guideline recommendations: Severe infection: 125 mg 4 times/day for 10-14 days; Severe, complicated infection: 500 mg 4 times/day with or without concurrent I.V. metronidazole. May consider vancomycin retention enema (in patients with complete ileus) (Cohen, 2010).

Complicated infections in seriously-ill patients: I.V.: Loading dose: 25-30 mg/kg (based on actual body weight) may be used to rapidly achieve target concentration; then 15-20 mg/kg/dose every 8-12 hours (Rybak, 2009)

Enterocolitis (S. aureus): Oral 500-2000 mg/day in 3-4 divided doses for 7-10 days (usual dose: 125-500 mg every 6 hours)

Endophthalmitis (unlabeled use): Intravitreal: Usual dose: 1 mg/0.1 mL NS instilled into vitreum; may repeat administration if necessary in 3-4 days, usually in combination with ceftazidime or an aminoglycoside. Note: Some clinicians have recommended using a lower dose of 0.2 mg/0.1 mL, based on concerns for retinotoxicity.

Hospital-acquired pneumonia (HAP): I.V.: 15-20 mg/kg/dose every 8-12 hours (American Thoracic Society [ATS], 2005 guidelines; Rybak, 2009)

Meningitis:

I.V.: 30-60 mg/kg/day in divided doses every 8-12 hours (Rybak, 2009) or 500-750 mg every 6 hours (with third-generation cephalosporin for PCN-resistant Streptococcus pneumoniae)

Intrathecal, intraventricular (unlabeled route): 5-20 mg/day

MRSA infections: I.V.:

Bacteremia (Liu, 2011): 15-20 mg/kg/dose every 8-12 hours for 2-6 weeks depending on severity

Brain abscess, subdural empyema, spinal epidural abscess (Liu, 2011): 15-20 mg/kg/dose every 8-12 hours for 4-6 weeks (some experts combine with rifampin)

Complicated skin and skin structure infections (Liu, 2011): 15-20 mg/kg/dose every 8-12 hours for 7-14 days

Endocarditis, native valve (Liu, 2011): 15-20 mg/kg/dose every 8-12 hours for 6 weeks

Endocarditis, prosthetic valve (Liu, 2011): 15-20 mg/kg/dose every 8-12 hours for at least 6 weeks (combine with rifampin for the entire duration of therapy and gentamicin for the first 2 weeks)

Meningitis (Liu, 2011): 15-20 mg/kg/dose every 8-12 hours for 2 weeks (some experts combine with rifampin)

Osteomyelitis (Liu, 2011): 15-20 mg/kg/dose every 8-12 hours for a minimum of 8 weeks (some experts combine with rifampin)

Pneumonia (Liu, 2011): 15-20 mg/kg/dose every 8-12 hours for 7-21 days depending on severity

Septic arthritis (Liu, 2011): 15-20 mg/kg/dose every 8-12 hours for 3-4 weeks

Septic thrombosis of cavernous or dural venous sinus (Liu, 2011): 15-20 mg/kg/dose every 8-12 hours for 4-6 weeks (some experts combine with rifampin)

Prophylaxis against infective endocarditis:

Dental, oral, or upper respiratory tract surgery: 1 g 1 hour before surgery. Note: AHA guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur

GI/GU procedure: 1 g plus 1.5 mg/kg gentamicin 1 hour prior to surgery. Note: As of April 2007, routine prophylaxis no longer recommended by the AHA.

Susceptible (MIC ≤1 mcg/mL; Rybak, 2009) gram-positive infections: 15-20 mg/kg/dose (usual: 750-1500 mg) every 8-12 hours. Note: If MIC ≥2 mcg/mL, alternative therapies are recommended.

Dosing: Pediatric

(For additional information see "Vancomycin: Pediatric drug information")

Usual dosage range: Infants >1 month and Children: I.V.: 10-15 mg/kg every 6 hours

Indication-specific dosing:

C. difficile -associated diarrhea (CDAD): Infants >1 month and Children: Oral: 40 mg/kg/day in 3-4 divided doses added to fluids for 7-10 days (maximum: 2000 mg/day)

Enterocolitis (S. aureus): Infants >1 months and Children: Oral: 40 mg/kg/day in 3-4 divided doses added to fluids for 7-10 days (maximum: 2000 mg/day)

Meningitis: Infants >1 month and Children:

I.V.: 15 mg/kg every 6 hours (Tunkel, 2004)

Intrathecal, intraventricular (unlabeled route): 5-20 mg/day (Tunkel, 2004)

MRSA infections: I.V.:

Bacteremia (Liu, 2011): Children: 15 mg/kg/dose every 6 hours for 2-6 weeks depending on severity

Brain abscess, subdural empyema, spinal epidural abscess (Liu, 2011): Children: 15 mg/kg/dose every 6 hours for 4-6 weeks (some experts combine with rifampin)

Complicated skin and skin structure infections (Liu, 2011): Children: 15 mg/kg/dose every 6 hours for 7-14 days

Endocarditis, native valve (Liu, 2011): Children: 15 mg/kg/dose every 6 hours for 6 weeks

Endocarditis, prosthetic valve (Liu, 2011): Children: 15 mg/kg/dose every 6 hours for at least 6 weeks

Meningitis (Liu, 2011): Children: 15 mg/kg/dose every 6 hours for 2 weeks (some experts combine with rifampin)

Osteomyelitis (Liu, 2011): Children: 15 mg/kg/dose every 6 hours for 4-6 weeks

Pneumonia (Liu, 2011): Children: 15 mg/kg/dose every 6 hours for 7-21 days depending on severity

Septic arthritis (Liu, 2011): Children: 15 mg/kg/dose every 6 hours for minimum of 3-4 weeks

Septic thrombosis of cavernous or dural venous sinus (Liu, 2011): Children: 15 mg/kg/dose every 6 hours for 4-6 weeks (some experts combine with rifampin)

Prophylaxis against infective endocarditis: Children:

Dental, oral, or upper respiratory tract surgery: 20 mg/kg/dose administered 1 hour prior to the procedure. Note: American Heart Association (AHA) guidelines recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur.

GI/GU procedure: 20 mg/kg (plus gentamicin 1.5 mg/kg) administered 1 hour prior to surgery. Note: Routine prophylaxis no longer recommended by the AHA.

Susceptible (MIC ≤1 mcg/mL; Rybak, 2009) gram-positive infections: Infants >1 month and Children: 10 mg/kg every 6 hours (manufacturer recommendations) or 15 mg/kg every 6 hours (Liu, 2011). Note: If MIC ≥2 mcg/mL, alternative therapies are recommended.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Renal Impairment

Vancomycin levels should be monitored in patients with any renal impairment:

Clcr >50 mL/minute: Start with 15-20 mg/kg/dose (usual: 750-1500 mg) every 8-12 hours

Clcr 20-49 mL/minute: Start with 15-20 mg/kg/dose (usual: 750-1500 mg) every 24 hours

Clcr <20 mL/minute: Will need longer intervals; determine by serum concentration monitoring

Note: In the critically-ill patient with renal insufficiency, the initial loading dose (25-30 mg/kg) should not be reduced. However, subsequent dosage adjustments should be made based on renal function and trough serum concentrations.

Poorly dialyzable by intermittent hemodialysis (0% to 5%); however, use of high-flux membranes and continuous renal replacement therapy (CRRT) increases vancomycin clearance, and generally requires replacement dosing.

Intermittent hemodialysis (IHD) (administer after hemodialysis on dialysis days): Following loading dose of 15-25 mg/kg, give either 500 mg to 1 g or 5-10 mg/kg after each dialysis session. (Heintz, 2009). Note: Dosing dependent on the assumption of 3 times/week, complete IHD sessions.

Redosing based on pre-HD concentrations:

<10 mg/L: Administer 1g after HD

10-25 mg/L: Administer 500-750 mg after HD

>25 mg/L: Hold vancomycin

Redosing based on post-HD concentrations: <10-15 mg/L: Administer 0.5-1 g

Peritoneal dialysis (PD):

Administration via PD fluid: 15-30 mg/L (15-30 mcg/mL) of PD fluid

Systemic: Loading dose of 1 g, followed by 500 mg to 1 g every 48-72 hours with close monitoring of levels

Continuous renal replacement therapy (CRRT) (Heintz, 2009; Trotman, 2005): Drug clearance is highly dependent on the method of renal replacement, filter type, and flow rate. Appropriate dosing requires close monitoring of pharmacologic response, signs of adverse reactions due to drug accumulation, as well as drug concentrations in relation to target trough (if appropriate). The following are general recommendations only (based on dialysate flow/ultrafiltration rates of 1-2 L/hour and minimal residual renal function) and should not supersede clinical judgment:

CVVH: Loading dose of 15-25 mg/kg, followed by either 1 g every 48 hours or 10-15 mg/kg every 24-48 hours

CVVHD: Loading dose of 15-25 mg/kg, followed by either 1 g every 24 hours or 10-15 mg/kg every 24 hours

CVVHDF: Loading dose of 15-25 mg/kg, followed by either 1 g every 24 hours or 7.5-10 mg/kg every 12 hours

Note: Consider redosing patients receiving CRRT for vancomycin concentrations <10-15 mg/L.