UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Vancomycin: Parenteral dosing and serum concentration monitoring in adults

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

INTRODUCTION

Vancomycin is a glycopeptide antibiotic used intravenously for treatment of patients with suspected or proven invasive gram-positive infections, including methicillin-resistant Staphylococcus aureus (MRSA).

Appropriate dosing and administration of vancomycin requires consideration of the infection site, disease severity, patient weight, renal function, and pathogen susceptibility [1,2]. Careful attention to individualizing therapy and use of serum concentration monitoring are important for optimizing vancomycin dosing [3-6].

Issues related to vancomycin dosing and serum concentration monitoring will be reviewed here. Issues related to vancomycin hypersensitivity are discussed separately. (See "Vancomycin hypersensitivity".)

VANCOMYCIN ADMINISTRATION

Clinical approach — The clinical approach to vancomycin dosing is based on the type and severity of infection, patient weight, and renal function [3-7]:

For patients with deep-seated infection (including bacteremia, endocarditis, osteomyelitis, prosthetic joint infection, pneumonia warranting hospitalization, infection involving the central nervous system, and/or critical illness), an initial vancomycin loading dose (25 to 30 mg/kg, rounded to the nearest 250 mg increment) may be administered. Thereafter, intermittent maintenance dosing should be administered to achieve a target serum trough concentration of 15 to 20 mcg/mL [8,9]. (See 'Loading dose' below and 'Target concentrations' below.)

                

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Mon Oct 24 00:00:00 GMT 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Barth RH, DeVincenzo N. Use of vancomycin in high-flux hemodialysis: experience with 130 courses of therapy. Kidney Int 1996; 50:929.
  2. Rybak MJ, Lomaestro BM, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adults summary of consensus recommendations from the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Pharmacotherapy 2009; 29:1275.
  3. Matzke GR, McGory RW, Halstenson CE, Keane WF. Pharmacokinetics of vancomycin in patients with various degrees of renal function. Antimicrob Agents Chemother 1984; 25:433.
  4. Moellering RC Jr, Krogstad DJ, Greenblatt DJ. Vancomycin therapy in patients with impaired renal function: a nomogram for dosage. Ann Intern Med 1981; 94:343.
  5. Lake KD, Peterson CD. A simplified dosing method for initiating vancomycin therapy. Pharmacotherapy 1985; 5:340.
  6. Pryka RD, Rodvold KA, Erdman SM. An updated comparison of drug dosing methods. Part IV: Vancomycin. Clin Pharmacokinet 1991; 20:463.
  7. Glatard A, Bourguignon L, Jelliffe RW, et al. Influence of renal function estimation on pharmacokinetic modeling of vancomycin in elderly patients. Antimicrob Agents Chemother 2015; 59:2986.
  8. Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2009; 66:82.
  9. 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.
  10. Howden BP, Ward PB, Charles PG, et al. Treatment outcomes for serious infections caused by methicillin-resistant Staphylococcus aureus with reduced vancomycin susceptibility. Clin Infect Dis 2004; 38:521.
  11. Moellering RC Jr. Monitoring serum vancomycin levels: climbing the mountain because it is there? Clin Infect Dis 1994; 18:544.
  12. Cataldo MA, Tacconelli E, Grilli E, et al. Continuous versus intermittent infusion of vancomycin for the treatment of Gram-positive infections: systematic review and meta-analysis. J Antimicrob Chemother 2012; 67:17.
  13. Hao JJ, Chen H, Zhou JX. Continuous versus intermittent infusion of vancomycin in adult patients: A systematic review and meta-analysis. Int J Antimicrob Agents 2016; 47:28.
  14. Pea F, Viale P. The antimicrobial therapy puzzle: could pharmacokinetic-pharmacodynamic relationships be helpful in addressing the issue of appropriate pneumonia treatment in critically ill patients? Clin Infect Dis 2006; 42:1764.
  15. Reardon J, Lau TT, Ensom MH. Vancomycin loading doses: a systematic review. Ann Pharmacother 2015; 49:557.
  16. Rosini JM, Davis JJ, Muenzer J, et al. High Single-dose Vancomycin Loading Is Not Associated With Increased Nephrotoxicity in Emergency Department Sepsis Patients. Acad Emerg Med 2016; 23:744.
  17. Rosini JM, Laughner J, Levine BJ, et al. A randomized trial of loading vancomycin in the emergency department. Ann Pharmacother 2015; 49:6.
  18. Tsuji BT, Rybak MJ, Lau KL, Sakoulas G. Evaluation of accessory gene regulator (agr) group and function in the proclivity towards vancomycin intermediate resistance in Staphylococcus aureus. Antimicrob Agents Chemother 2007; 51:1089.
  19. Sakoulas G, Eliopoulos GM, Moellering RC Jr, et al. Staphylococcus aureus accessory gene regulator (agr) group II: is there a relationship to the development of intermediate-level glycopeptide resistance? J Infect Dis 2003; 187:929.
  20. Mohr JF, Murray BE. Point: Vancomycin is not obsolete for the treatment of infection caused by methicillin-resistant Staphylococcus aureus. Clin Infect Dis 2007; 44:1536.
  21. Holmes NE, Turnidge JD, Munckhof WJ, et al. Vancomycin AUC/MIC ratio and 30-day mortality in patients with Staphylococcus aureus bacteremia. Antimicrob Agents Chemother 2013; 57:1654.
  22. Hall RG 2nd, Payne KD, Bain AM, et al. Multicenter evaluation of vancomycin dosing: emphasis on obesity. Am J Med 2008; 121:515.
  23. Blouin RA, Bauer LA, Miller DD, et al. Vancomycin pharmacokinetics in normal and morbidly obese subjects. Antimicrob Agents Chemother 1982; 21:575.
  24. Adane ED, Herald M, Koura F. Pharmacokinetics of vancomycin in extremely obese patients with suspected or confirmed Staphylococcus aureus infections. Pharmacotherapy 2015; 35:127.
  25. Hong J, Krop LC, Johns T, Pai MP. Individualized vancomycin dosing in obese patients: a two-sample measurement approach improves target attainment. Pharmacotherapy 2015; 35:455.
  26. Morrill HJ, Caffrey AR, Noh E, LaPlante KL. Vancomycin Dosing Considerations in a Real-World Cohort of Obese and Extremely Obese Patients. Pharmacotherapy 2015; 35:869.
  27. Kubiak DW, Alquwaizani M, Sansonetti D, et al. An Evaluation of Systemic Vancomycin Dosing in Obese Patients. Open Forum Infect Dis 2015; 2:ofv176.
  28. Vandecasteele SJ, De Bacquer D, De Vriese AS. Implementation of a dose calculator for vancomycin to achieve target trough levels of 15-20 microg/mL in persons undergoing hemodialysis. Clin Infect Dis 2011; 53:124.
  29. Brown M, Polisetty R, Gracely EJ, et al. Weight-based loading of vancomycin in patients on hemodialysis. Clin Infect Dis 2011; 53:164.
  30. Quale JM, O'Halloran JJ, DeVincenzo N, Barth RH. Removal of vancomycin by high-flux hemodialysis membranes. Antimicrob Agents Chemother 1992; 36:1424.
  31. Zelenitsky SA, Ariano RE, McCrae ML, Vercaigne LM. Initial vancomycin dosing protocol to achieve therapeutic serum concentrations in patients undergoing hemodialysis. Clin Infect Dis 2012; 55:527.
  32. Pai AB, Pai MP. Vancomycin dosing in high flux hemodialysis: a limited-sampling algorithm. Am J Health Syst Pharm 2004; 61:1812.
  33. Crew P, Heintz SJ, Heintz BH. Vancomycin dosing and monitoring for patients with end-stage renal disease receiving intermittent hemodialysis. Am J Health Syst Pharm 2015; 72:1856.
  34. Osawa R, Kaka AS. Maculopapular rash induced by oral vancomycin. Clin Infect Dis 2008; 47:860.
  35. Polk RE, Israel D, Wang J, et al. Vancomycin skin tests and prediction of "red man syndrome" in healthy volunteers. Antimicrob Agents Chemother 1993; 37:2139.
  36. Appel GB, Given DB, Levine LR, Cooper GL. Vancomycin and the kidney. Am J Kidney Dis 1986; 8:75.
  37. Bailie GR, Neal D. Vancomycin ototoxicity and nephrotoxicity. A review. Med Toxicol Adverse Drug Exp 1988; 3:376.
  38. Downs NJ, Neihart RE, Dolezal JM, Hodges GR. Mild nephrotoxicity associated with vancomycin use. Arch Intern Med 1989; 149:1777.
  39. Rybak MJ, Albrecht LM, Boike SC, Chandrasekar PH. Nephrotoxicity of vancomycin, alone and with an aminoglycoside. J Antimicrob Chemother 1990; 25:679.
  40. Hidayat LK, Hsu DI, Quist R, et al. High-dose vancomycin therapy for methicillin-resistant Staphylococcus aureus infections: efficacy and toxicity. Arch Intern Med 2006; 166:2138.
  41. Jeffres MN, Isakow W, Doherty JA, et al. A retrospective analysis of possible renal toxicity associated with vancomycin in patients with health care-associated methicillin-resistant Staphylococcus aureus pneumonia. Clin Ther 2007; 29:1107.
  42. Lodise TP, Lomaestro B, Graves J, Drusano GL. Larger vancomycin doses (at least four grams per day) are associated with an increased incidence of nephrotoxicity. Antimicrob Agents Chemother 2008; 52:1330.
  43. Lodise TP, Patel N, Lomaestro BM, et al. Relationship between initial vancomycin concentration-time profile and nephrotoxicity among hospitalized patients. Clin Infect Dis 2009; 49:507.
  44. Rybak MJ, Abate BJ, Kang SL, et al. Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity. Antimicrob Agents Chemother 1999; 43:1549.
  45. Burgess LD, Drew RH. Comparison of the incidence of vancomycin-induced nephrotoxicity in hospitalized patients with and without concomitant piperacillin-tazobactam. Pharmacotherapy 2014; 34:670.
  46. Gomes DM, Smotherman C, Birch A, et al. Comparison of acute kidney injury during treatment with vancomycin in combination with piperacillin-tazobactam or cefepime. Pharmacotherapy 2014; 34:662.
  47. Meaney CJ, Hynicka LM, Tsoukleris MG. Vancomycin-associated nephrotoxicity in adult medicine patients: incidence, outcomes, and risk factors. Pharmacotherapy 2014; 34:653.
  48. Hammond DA, Smith MN, Painter JT, et al. Comparative Incidence of Acute Kidney Injury in Critically Ill Patients Receiving Vancomycin with Concomitant Piperacillin-Tazobactam or Cefepime: A Retrospective Cohort Study. Pharmacotherapy 2016; 36:463.
  49. Karino S, Kaye KS, Navalkele B, et al. Epidemiology of Acute Kidney Injury among Patients Receiving Concomitant Vancomycin and Piperacillin-Tazobactam: Opportunities for Antimicrobial Stewardship. Antimicrob Agents Chemother 2016; 60:3743.
  50. Carreno JJ, Kenney RM, Lomaestro B. Vancomycin-associated renal dysfunction: where are we now? Pharmacotherapy 2014; 34:1259.
  51. Klibanov OM, Filicko JE, DeSimone JA Jr, Tice DS. Sensorineural hearing loss associated with intrathecal vancomycin. Ann Pharmacother 2003; 37:61.
  52. Forouzesh A, Moise PA, Sakoulas G. Vancomycin ototoxicity: a reevaluation in an era of increasing doses. Antimicrob Agents Chemother 2009; 53:483.
  53. Brummett RE. Ototoxicity of vancomycin and analogues. Otolaryngol Clin North Am 1993; 26:821.
  54. Brummett RE, Fox KE, Jacobs F, et al. Augmented gentamicin ototoxicity induced by vancomycin in guinea pigs. Arch Otolaryngol Head Neck Surg 1990; 116:61.
  55. de Hoog M, van Zanten BA, Hop WC, et al. Newborn hearing screening: tobramycin and vancomycin are not risk factors for hearing loss. J Pediatr 2003; 142:41.
  56. Rodvold KA, Blum RA, Fischer JH, et al. Vancomycin pharmacokinetics in patients with various degrees of renal function. Antimicrob Agents Chemother 1988; 32:848.
  57. Skhirtladze K, Hutschala D, Fleck T, et al. Impaired target site penetration of vancomycin in diabetic patients following cardiac surgery. Antimicrob Agents Chemother 2006; 50:1372.
  58. Cruciani M, Gatti G, Lazzarini L, et al. Penetration of vancomycin into human lung tissue. J Antimicrob Chemother 1996; 38:865.
  59. Lin Wu FL, Liu SS, Yang TY, et al. A Larger Dose of Vancomycin Is Required in Adult Neurosurgical Intensive Care Unit Patients Due to Augmented Clearance. Ther Drug Monit 2015; 37:609.
  60. Moise-Broder PA, Forrest A, Birmingham MC, Schentag JJ. Pharmacodynamics of vancomycin and other antimicrobials in patients with Staphylococcus aureus lower respiratory tract infections. Clin Pharmacokinet 2004; 43:925.
  61. Casapao AM, Lodise TP, Davis SL, et al. Association between vancomycin day 1 exposure profile and outcomes among patients with methicillin-resistant Staphylococcus aureus infective endocarditis. Antimicrob Agents Chemother 2015; 59:2978.
  62. Song KH, Kim HB, Kim HS, et al. Impact of area under the concentration-time curve to minimum inhibitory concentration ratio on vancomycin treatment outcomes in methicillin-resistant Staphylococcus aureus bacteraemia. Int J Antimicrob Agents 2015; 46:689.
  63. Rybak MJ. The pharmacokinetic and pharmacodynamic properties of vancomycin. Clin Infect Dis 2006; 42 Suppl 1:S35.
  64. Lodise TP, Drusano GL, Zasowski E, et al. Vancomycin exposure in patients with methicillin-resistant Staphylococcus aureus bloodstream infections: how much is enough? Clin Infect Dis 2014; 59:666.
  65. Kullar R, Davis SL, Levine DP, Rybak MJ. Impact of vancomycin exposure on outcomes in patients with methicillin-resistant Staphylococcus aureus bacteremia: support for consensus guidelines suggested targets. Clin Infect Dis 2011; 52:975.
  66. Jeffres MN, Isakow W, Doherty JA, et al. Predictors of mortality for methicillin-resistant Staphylococcus aureus health-care-associated pneumonia: specific evaluation of vancomycin pharmacokinetic indices. Chest 2006; 130:947.
  67. Pai MP, Neely M, Rodvold KA, Lodise TP. Innovative approaches to optimizing the delivery of vancomycin in individual patients. Adv Drug Deliv Rev 2014; 77:50.
  68. Steinmetz T, Eliakim-Raz N, Goldberg E, et al. Association of vancomycin serum concentrations with efficacy in patients with MRSA infections: a systematic review and meta-analysis. Clin Microbiol Infect 2015; 21:665.
  69. Prybylski JP. Vancomycin Trough Concentration as a Predictor of Clinical Outcomes in Patients with Staphylococcus aureus Bacteremia: A Meta-analysis of Observational Studies. Pharmacotherapy 2015; 35:889.
  70. Patel N, Pai MP, Rodvold KA, et al. Vancomycin: we can't get there from here. Clin Infect Dis 2011; 52:969.
  71. Haeseker M, Croes S, Neef C, et al. Evaluation of Vancomycin Prediction Methods Based on Estimated Creatinine Clearance or Trough Levels. Ther Drug Monit 2016; 38:120.
  72. Moise PA, Sakoulas G, Forrest A, Schentag JJ. Vancomycin in vitro bactericidal activity and its relationship to efficacy in clearance of methicillin-resistant Staphylococcus aureus bacteremia. Antimicrob Agents Chemother 2007; 51:2582.
  73. Sakoulas G, Moise-Broder PA, Schentag J, et al. Relationship of MIC and bactericidal activity to efficacy of vancomycin for treatment of methicillin-resistant Staphylococcus aureus bacteremia. J Clin Microbiol 2004; 42:2398.
  74. Lodise TP, Graves J, Evans A, et al. Relationship between vancomycin MIC and failure among patients with methicillin-resistant Staphylococcus aureus bacteremia treated with vancomycin. Antimicrob Agents Chemother 2008; 52:3315.
  75. Sakoulas G, Gold HS, Cohen RA, et al. Effects of prolonged vancomycin administration on methicillin-resistant Staphylococcus aureus (MRSA) in a patient with recurrent bacteraemia. J Antimicrob Chemother 2006; 57:699.