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Alternative approaches to vancomycin dosing for children and adolescents with normal kidney function

Alternative approaches to vancomycin dosing for children and adolescents with normal kidney function
Strategy Initial dose and interval Subsequent dose and interval adjustments
Traditional approach for children >1 month and adolescents Typically 15 mg/kg per dose IV every 6 to 8 hours[1]:
  • Use the every-6-hour interval for serious infections*
  • Maximum daily dose: 4 g/day
Either:
  • Continue initial dose (for most children, particularly if duration of vancomycin is expected to be <3 days)
  • Based on trough-guided serum concentration monitoring for select children (eg, those with renal dysfunction, infective endocarditis, risk factors for altered vancomycin kinetics [eg, fluid overload, critical illness])
AUC-guided approachΔ[2] Generally requires consultation with a clinical pharmacist Based on AUC-guided serum concentration monitoring (generally requires consultation with a clinical pharmacist)
The approach to vancomycin dosing is generally determined at the institutional level. Refer to UpToDate content on invasive staphylococcal infections in children for details of trough-guided and AUC-guided vancomycin dosing and traditional dosing of vancomycin for neonates.
IV: intravenous; AUC: area under the curve; MRSA: methicillin-resistant Staphylococcus aureus.
* Serious infections may include, but are not limited to, infective endocarditis, pneumonia requiring hospitalization, osteomyelitis, central nervous system infection, and infection causing critical illness.
¶ The value of trough-monitoring before achieving steady state (usually on day 2 to 3 of treatment) is uncertain.
Δ Some experts suggest this approach for serious* MRSA infections in children of all ages.
References:
  1. American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed,  Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.876.
  2. Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2020; 77:835.
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