Vancomycin - Renal dosing

Usual Dosing (Adults)

Susceptible infections: (normal renal function) 1 gram IV q12h. Ideally, base initial regimen on patient-specific pharmacokinetic dosing calculations.
Therapeutic levels: Peak: 25-40 mcg/ml; Trough: 5-15 mcg/mL.

DOSAGE AND ADMINISTRATION
Infusion-related events are related to both concentration and rate of administration of vancomycin. Concentrations of no more than 5 mg/mL and rates of no more than 10 mg/min are recommended in adults (see also age-specific recommendations). In selected patients in need of fluid restriction, a concentration up to 10 mg/mL may be used; use of such higher concentrations may increase the risk of infusion-related events. Infusion-related events may occur, however, at any rate or concentration.

Patients with Normal Renal Function
Adults: The usual daily intravenous dose is 2 g divided either as 500 mg every six hours or 1 g every 12 hours. Each dose should be administered at no more than 10 mg/min, or over a period of at least 60 minutes, whichever is longer. Other patient factors, such as age or obesity, may call for modification of the usual daily dose.

Pediatric Patients: The usual intravenous dosage of vancomycin is 10 mg/kg per dose given every six hours. Each dose should be administered over a period of at least 60 minutes.

Infants and Neonates: In neonates and young infants, the total daily intravenous dosage may be lower. In both neonates and infants, an initial dose of 15 mg/kg is suggested, followed by 10 mg/kg every 12 hours for neonates in the first week of life and every eight hours thereafter up to the age of one month. Each dose should be administered over 60 minutes. Close monitoring of serum concentrations of vancomycin may be warranted in these patients.

The safety and efficacy of vancomycin administration by the intrathecal (intralumbar or intraventricular) route have not been assessed.

Intermittent infusion is the recommended method of administration.

Renal Dosing

Rough estimates (Ideally, base initial regimen on patient-specific pharmacokinetic dosing calculations.):

[CRCL >60 ml/min]:
Start with 1 g or 10-20 mg/kg/dose q12h.
[ 40-60 ]:
Start with 1 g or 10-20 mg/kg/dose q24h.
[<40 ]:
Determine by serum level monitoring.

Alternatively:
Matzke Nomogram (rough estimates):
Initial dose: 25 mg/kg (based on Vd of 0.9L/kg), followed by 19 mg/kg at estimated interval given below:

[80]: q16-18h.
[60]: q24h.
[40]: q36h
[30]: q48h
[20]: q60h
[10]: q96h
[5 ]: q144h (6 days).

Patients with Impaired Renal Function and Elderly Patients
Dosage adjustment must be made in patients with impaired renal function. In premature infants and the elderly, greater dosage reductions than expected may be necessary because of decreased renal function. Measurement of vancomycin serum concentrations can be helpful in optimizing therapy, especially in seriously ill patients with changing renal function. Vancomycin serum concentrations can be determined by use of microbiologic assay, radioimmunoassay, fluorescence polarization immunoassay, fluorescence immunoassay, or high-pressure liquid chromatography.

If creatinine clearance can be measured or estimated accurately, the dosage for most patients with renal impairment can be calculated using the following table. The dosage of vancomycin per day in mg is about 15 times the glomerular filtration rate in mL/min:

DOSAGE TABLE FOR VANCOMYCIN
IN PATIENTS WITH IMPAIRED RENAL FUNCTION
(Adapted from Moellering et al) Moellering RC, Krogstad DJ, Greenblatt DJ: Vancomycin therapy in patients with impaired renal function: A nomogram for dosage. Ann Intern Med 1981;94:343.
Creatinine Clearance		Vancomycin Dose
mL/min		mg/24 h
100		1545
90		1390
80		1235
70		1080
60		925
50		770
40		620
30		465
20		310
10		155

The initial dose should be no less than 15 mg/kg, even in patients with mild to moderate renal insufficiency.

The table is not valid for functionally anephric patients. For such patients, an initial dose of 15 mg/kg of body weight should be given in order to achieve prompt therapeutic serum concentrations. The dose required to maintain stable concentrations is 1.9 mg/kg/24 h. In patients with marked renal impairment, it may be more convenient to give maintenance doses of 250 to 1000 mg once every several days rather than administering the drug on a daily basis. In anuria, a dose of 1000 mg every 7 to 10 days has been recommended.

When only serum creatinine concentration is known, the following formula (based on sex, weight, and age of the patient) may be used to calculate creatinine clearance. Calculated creatinine clearances (mL/min) are only estimates. The creatinine clearance should be measured promptly.

Creatinine clearance for males =	[140-age (years)]× [body wt (kg)] 72 × [serum creatinine (mg/dL)]
Creatinine clearance for females =	[140-age (years)]× [body wt (kg)]× 0.85 72 × [serum creatinine (mg/dL)]

The serum creatinine must represent a steady state of renal function or the estimated value for creatinine clearance will not be valid. Such a calculated clearance is an overestimate of actual clearance in patients with conditions: (1) characterized by decreasing renal function, such as shock, severe heart failure, or oliguria; (2) in which a normal relationship between muscle mass and total body weight is not present, such as in obese patients or those with liver disease, edema, or ascites; and (3) accompanied by debilitation, malnutrition, or inactivity.

Hemodialysis

Not dialyzable. Determine by serum level monitoring. Exception:
Vancomycin is removed by high-flux hemodialysis and this may be a useful treatment modality in overdose cases. Estimated extraction (Percent/fraction removed): 39% +/- 13%

1) Quale JM, O'Halloran JJ, DeVincenzo N, and Barth RH.
Removal of vancomycin by high-flux hemodialysis membranes.
Antimicrob Agents Chemother. 1992 July; 36(7): 1424–1426.

2) Pai AB, Pai MP. Vancomycin dosing in high flux hemodialysis: a limited-sampling algorithm. Am J Health Syst Pharm 2004; 61: 1812–1816

Disclaimer

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