National University Hospital Vancomycin Guidelines

This guideline is meant to be a general outline for adult patients in the general ward setting
with relatively stable renal function. Patient populations not applicable for this guideline
include pediatrics, neonates, burns patients, ICU patients and dialysis patients.

Vancomycin Overview
1. Vancomycin is a glycopeptide antibiotic which exhibits time-dependent killing.
2. The AUC (area under serum drug concentration-versus-time curve) to MIC ratio of 400
correlates best with efficacy. For practicality reasons, trough blood levels are used as a
surrogate marker of efficacy.
3. If MIC 1, AUC/MIC 400 can be achieved for most patients.
4. If MIC 2, consult ID and choose alternative agent.
5. Monitoring peak blood levels is NOT recommended as they do not correlate with efficacy
or toxicity.

Initial Empiric Dosing of Vancomycin

1. Determine patients total body weight (TBW)

2. Determine patients creatinine clearance via the Cockcroft-Gault equation
CLm (Creatinine Clearance in males) = [(140-age) X weight / Serum Creatinine in umol/L ] X 1.23
CLf (Creatinine Clearance in females) = CLm X 0.85
In general, use Ideal Body Weight (IBW) in calculation of creatinine clearance
If patients actual weight is less than IBW, use their actual body weight

IBW (male) : 50kg + (2.3) (inches > 60)

IBW (female) : 45.5kg + (2.3)(inches > 60)

3. Estimate initial dosing regimen based on chart below

4. Vancomycin dose is 15mg-20mg/kg based on total body weight, round to nearest 250mg
5. Usual maximum is 2g/dose, consult pharmacist if exceed 2g per dose
6. Consider 20-25mg/kg load for patients with severe infections (eg. Patients presenting with
septic shock, febrile neutropenia)
Consider prolonging infusion to 2 hours and administering antihistamines prior to
dose to minimize Red Mans Syndrome/possible anaphylaxis
Consider splitting dose for loading i.e., 3g given as 2 consecutive doses of 1.5g

Creatinine Clearance (ml/min) Initial dosing

> 50 15mg 20mg/kg/dose q8-q12
30-50 15mg 20mg/kg/dose q24
20-30 15mg 20mg/kg/dose q48
< 20 Dose intermittently based on levels (q2-3
days)

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Therapeutic Drug Monitoring

Infections Target Trough (mcg/ml)

Highly sensitive MRSA (MIC 0.5) in easy to 10-15
reach sites ie. skin and soft tissue infections,
simple urinary tract infections
Pneumonia, meningitis, endocarditis, 15-20
osteomyelitis, bacteremia, septic arthritis,
intra-abdominal infections

1. Trough levels should be obtained within 30minutes before next scheduled dose
2. Obtain troughs prior to 3rd or 4th dose of new regimen or when estimated to be at steady state
based on estimated drug clearance and half- life.
3. Consider checking trough prior to 2nd dose for q48h regimens
4. Consider checking trough prior to 3rd dose for q24h regimens
5. In general, administer scheduled dose only after an expected vancomycin level returns. When in
doubt, to clarify with ward pharmacist
6. Once target trough attained, repeat trough weekly, or earlier if renal function changes
significantly or if nephrotoxic drugs are concomitantly used (i.e., amphotericin, aminoglycosides,
etc.)
7. Serum vancomycin trough level monitoring is recommended for:
a. Patients receiving therapy > 3 days
b. Morbidly obese patients
c. Patients with renal dysfunction
d. Patients with a fluctuating volume of distribution (e.g., oncology patients, ICU patients,
dialysis patients, post-surgery patients)
e. High risk of nephrotoxicity (e.g., Concurrent nephrotoxic drugs like aminoglycosides)
8. Trough monitoring is NOT needed for:
a. Surgical prophylaxis (expected duration < 3 days)
b. Mild skin and soft tissue infections (SSTIs)in patients with normal renal function and who
are NOT morbidly obese with dose of 1g q12h (eg. Using vancomycin for patients with
SSTIs who are allergic/intolerant to beta-lactams)
c. Patients on oral vancomycin regimens for Clostridium difficile

Dosing Adjustments based on true trough levels (i.e., levels within 30min before next dose)
Trough Level Adjustments
< 10 Increase dose by 500mg or 50% of dose (whichever is greater) at same interval.
If renal function improves, can consider shortening interval
10-15 Within goal : no change
If below goal : increase dose by 250mg -500mg + keep same interval OR if at
20mg/kg/dose can consider reduced dose with more frequent dosing
15 20 Within goal : no change
If above goal : decrease dose by 250mg 500mg and keep interval , if renal
function worsens, consider extending interval
> 20 Hold dose and recheck in 12-24 hours, when in goal range, resume at extended
interval/lower dose.

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Administration Guidelines

Dose Infusion time

1000mg 1 hour
1250mg 1500mg 1.5 hours
1750mg 2000mg 2 hours
Infusion-related adverse events are rate and concentration dependent
If patient is unable to tolerate usual infusion rates due to Red Mans Syndrome, adverse
effects may be minimized with reducing infusion rates to 10mg/minute
If patient has issues with thrombophlebitis, suggest to increase the dilution volume.
Vancomycin infusion concentrations are usually kept to 5mg/ml ie. 500mg in 100ml
diluent
In fluid-restricted patients with central line access, 10mg/ml may be used

Prepared by: Ms Hooi Pik Yee (Pharmacy), Mr. Yeoh Siang Fei (Pharmacy), Dr. Caroline Tee
(Pharmacy), Dr. Grant Sklar (Pharmacy) and Dr. Dale Fisher (Medicine) Date: February 2014

References

1. Cockcroft D, Gault MD. Prediction of creatinine clearance from serum creatinine. Nephron,
16:31-41, 1976

2. Rybak M et al. Therapeutic monitoring of vancomycin in adult patients: A consensus review of

the American Society of Health-System Pharmacists, the
Infectious Diesese Society of American and the Society of Infectious Disease Pharmacists; Am J
Health-Syst Pharm. 2009;66:82-98

3. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society
of america for the treatment of methicillin-resistant Staphylococcus aureus infections in
adults and children. Clin Infect Dis 2011; 52:e18

4. Moellering Jr. RC. Editorial: Monitoring serum vancomycin levels: climbing the
mountain because it is there? Clin Infect Dis 1994;18:544-6.

5. Product Information: Vancocin(R) HCl, vancomycin injection USP. Baxter Healthcare

Corporation, Deerfield, IL, 2003