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Suggested approach to parenteral vancomycin dosing in adults who are not receiving hemodialysis*

Suggested approach to parenteral vancomycin dosing in adults who are not receiving hemodialysis*
1. Loading dose for critically ill patient or severe infection: 25 mg/kg (rounded to nearest 250 mg)
2. Initial maintenance dose and interval: Based on target trough, patient weight, and estimated creatinine clearanceΔ as follows:
Creatinine clearance in mL/minute
(Cockcroft Gault equation)Δ
Weight (actual)
50 to 59 kg 60 to 69 kg 70 to 79 kg 80 to 89 kg 90 to 99 kg 100 kg
Severe or deep-seated infection:§ Target trough 15 to 20 mcg/mL
<10 (not receiving hemodialysis)¥ Repeat dose when spot (random) serum concentration ≤20 mcg/mL
10 to 19 (not receiving hemodialysis)¥ 750 mg every 48 hours 1000 mg every 48 hours 1000 mg every 48 hours 1250 mg every 48 hours 1250 mg every 48 hours 1500 mg every 48 hours
20 to 29 500 mg every 24 hours 750 mg every 24 hours 1000 mg every 36 hours 1250 mg every 36 hours 1250 mg every 36 hours 1250 mg every 36 hours
30 to 39 750 mg every 24 hours 750 mg every 24 hours 1000 mg every 24 hours 1250 mg every 24 hours 1250 mg every 24 hours 1250 mg every 24 hours
40 to 49 750 mg every 18 hours 750 mg every 18 hours 1000 mg every 18 hours 1250 mg every 18 hours 1250 mg every 18 hours 1250 mg every 18 hours
50 to 59 750 mg every 18 hours 1000 mg every 18 hours 1000 mg every 18 hours 1250 mg every 18 hours 1250 mg every 18 hours 1500 mg every 18 hours
60 to 69 750 mg every 12 hours 750 mg every 12 hours 1000 mg every 12 hours 1000 mg every 12 hours 1250 mg every 12 hours 1250 mg every 12 hours
70 to 79 750 mg every 12 hours 1000 mg every 12 hours 1000 mg every 12 hours 1250 mg every 12 hours 1250 mg every 12 hours 1500 mg every 12 hours
80 to 89 750 mg every 12 hours 1000 mg every 12 hours 1250 mg every 12 hours 1250 mg every 12 hours 1500 mg every 12 hours 1500 mg every 12 hours
90 to 99 1000 mg every 12 hours 1000 mg every 12 hours 1250 mg every 12 hours 1500 mg every 12 hours 1500 mg every 12 hours 1500 mg every 12 hours
≥100 and <60 years oldΔ 750 mg every 8 hours 750 mg every 8 hours 1000 mg every 8 hours 1250 mg every 8 hours 1250 mg every 8 hours 1250 mg every 8 hours
Nonsevere and superficial infection:§ Target trough 10 to 15 mcg/mL
<10 (not receiving hemodialysis)¥ Repeat dose when spot (random) serum concentration ≤15 mcg/mL
10 to 19 (not receiving hemodialysis)¥ 1000 mg every 72 hours 1250 mg every 72 hours 1250 mg every 72 hours 1500 mg every 72 hours 1500 mg every 72 hours 1750 mg every 72 hours
20 to 29 1000 mg every 48 hours 1000 mg every 48 hours 1250 mg every 48 hours 1500 mg every 48 hours 1500 mg every 48 hours 1750 mg every 48 hours
30 to 39 1000 mg every 36 hours 1000 mg every 36 hours 1250 mg every 36 hours 1500 mg every 36 hours 1500 mg every 36 hours 1750 mg every 36 hours
40 to 49 1000 mg every 24 hours 1000 mg every 24 hours 1250 mg every 24 hours 1250 mg every 24 hours 1500 mg every 24 hours 1500 mg every 24 hours
50 to 59 1000 mg every 24 hours 1250 mg every 24 hours 1250 mg every 24 hours 1500 mg every 24 hours 1500 mg every 24 hours 1750 mg every 24 hours
60 to 69 1000 mg every 18 hours 1250 mg every 18 hours 1250 mg every 18 hours 1500 mg every 18 hours 1500 mg every 18 hours 1750 mg every 18 hours
70 to 79 1000 mg every 18 hours 1250 mg every 18 hours 1250 mg every 18 hours 1500 mg every 18 hours 1500 mg every 18 hours 1750 mg every 18 hours
80 to 89 1000 mg every 18 hours 1250 mg every 18 hours 1250 mg every 12 hours 1250 mg every 12 hours 1500 mg every 12 hours 1500 mg every 12 hours
90 to 99 1000 mg every 12 hours 1000 mg every 12 hours 1250 mg every 12 hours 1500 mg every 12 hours 1500 mg every 12 hours 1500 mg every 12 hours
≥100 and <60 years oldΔ 1000 mg every 12 hours 1000 mg every 12 hours 1250 mg every 12 hours 1500 mg every 12 hours 1500 mg every 12 hours 1500 mg every 12 hours
* This nomogram was developed and validated based on trough targets at Duke University; it is designed to guide determination of initial empiric dose and interval of intravenous (IV) vancomycin in hospitalized adults who are not receiving hemodialysis. Excluded patients included those who exhibit highly variable vancomycin pharmacokinetics (eg, critically ill, burn injured >20 percent body surface, rapidly changing renal function, pregnant, liver failure/ascites, extremes of weight, acutely post-transplant, cystic fibrosis). In general, the clinical utility of nomograms is limited since it is not possible to account for all patient-specific variables. Use of vancomycin dosing nomograms typically produces steady-state serum concentrations within the targeted range in approximately 44 to 76 percent of patients.[1] Ideally, the approach to vancomycin dosing approach at a particular institution should be guided by a nomogram developed and validated at that institution, to best reflect the regional patient population.  
¶ We give a loading dose for patients with known or suspected severe Staphylococcus aureus infection; this includes (but is not limited to) bacteremia, endocarditis, osteomyelitis, prosthetic joint infection, pneumonia warranting hospitalization, infection involving the central nervous system, or infection causing critical illness.[2] This nomogram was developed with a 25 mg/kg loading dose. In general, we administer a vancomycin loading dose of 20 to 35 mg/kg, based on actual body weight, rounded to the nearest 250 mg increment and not exceeding 3000 mg; within this range, we use a higher dose for critically ill patients. We typically use a loading dose of no more than 2 grams in older patients and patients with risk factors for acute kidney injury. 
Δ Creatinine clearance estimates provided by the Cockcroft Gault equation may overestimate renal clearance of vancomycin in patients with low muscle mass and in older adults (eg, ≥60 years). Consider more conservative (ie, less frequent) initial dosing in those patients and/or the use of an alternate method of renal function assessment. A calculator for determination of creatinine clearance by Cockcroft Gault equation is available in UpToDate.
◊ For patients who weigh up to 125% of their ideal body weight (IBW), vancomycin dosing is based on actual body weight. For patients who weigh more than 125% of their ideal body weight, an adjusted dosing weight is used for scaling initial maintenance dose. A calculator is available in UpToDate to determine ideal body weight and adjusted dosing weight. Individual maintenance doses over 2 grams per dose or 4 grams per day should only be given on documentation of sub-therapeutic serum concentrations due to concern for renal injury. The above nomogram has not been validated in patients weighing more than 100 kg. Refer to topic discussion for approach to initial dosing of vancomycin in patients weighing more than 100 kg.
§ A target serum trough concentration of 15 to 20 mcg/mL is warranted for patients with severe or deep-seated infection (such as bacteremia, endocarditis, osteomyelitis, prosthetic joint infection, pneumonia warranting hospitalization, infection involving the central nervous system, or infection causing critical illness). A target trough of 10 to 15 mcg/mL is warranted for patients with nonsevere infection (such as soft tissue infection).
¥ In patients with advanced renal disease (eg, creatinine clearance [CrCl] <29 mL/minute and not receiving dialysis) or unstable renal function, the dosing following the initial vancomycin dose can be determined by measurement of timed "spot" (non-steady state) levels. Refer to UpToDate topic discussion for detail.
Reference:
  1. Elyasi S, Hossein K. Vancomycin dosing nomographs targeting high serum trough levels in different populations: pros and cons. Eur J Clin Pharmacol 2016; 72:777.
  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.
Adapted from: Duke University Hospital Adult Pharmacokinetics Policy, Department of Pharmacy (June 2014). Courtesy of Richard H Drew, PharmD.
Graphic 60466 Version 13.0

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