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Vancomycin dosing and serum concentration monitoring in adults

Richard H Drew, PharmD, MS, FCCP
Section Editor
David C Hooper, MD
Deputy Editor
Elinor L Baron, MD, DTMH


Vancomycin is a glycopeptide antibiotic used for treatment of patients with suspected or proven invasive gram-positive infections, including methicillin-resistant Staphylococcus aureus (MRSA). Appropriate dosing requires consideration of the infection site, patient weight, renal function, and pathogen susceptibility [1,2]. Therefore, careful attention to individualizing therapy and prudent use of serum concentration monitoring (when indicated) will assist in selecting the appropriate dose [3-6].

Vancomycin pharmacokinetics, pharmacodynamics, dosing, use of serum concentration monitoring, and adverse effects will be reviewed here. Vancomycin hypersensitivity is discussed separately. (See "Vancomycin hypersensitivity".)


Vancomycin undergoes limited absorption when administered orally and is therefore restricted to parenteral administration for the treatment of systemic infections. It is distributed widely to various tissues and body fluids, with a volume of distribution ranging from 0.4 to 1 L/kg [7]. Penetration of vancomycin may vary by site and concomitant disease states. For example, limited cerebrospinal fluid penetration may be enhanced by the presence of inflamed meninges. The favorable penetration of vancomycin into skin tissues may be significantly impaired in patients with diabetes [8]. Vancomycin penetration into lung epithelial lining fluid is limited relative to that of simultaneous serum concentration (the ratio of lung tissue to serum concentration is about 0.25) [9]. Vancomycin's primary route of elimination is via renal excretion of unchanged drug. The rate of elimination is directly related to creatinine clearance [3].


In vitro and animal model studies describing vancomycin pharmacodynamics indicate the rate of killing depends primarily upon time of concentration exceeding the organism's minimum inhibitory concentration (MIC). The area under the time concentration curve (AUC; AUC:MIC ratio) is the best predictor of efficacy in these models [2,10].

Data to characterize the pharmacodynamic properties of vancomycin against methicillin-resistant S. aureus (MRSA) in humans are limited. Some studies suggest that a ratio of AUC to MIC of ≥400 may be desirable, although this AUC/MIC target may not be reliably achieved with standard dosing in many patients who have serious S. aureus infections due to isolates with MIC value >1 mcg/mL [11-14]. The target exposure is affected by the time and method used to determine the AUC and the method utilized to determine the MIC of the causative pathogen [15].


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Literature review current through: Sep 2016. | This topic last updated: Dec 17, 2014.
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