Vancomycin Dosing for Patients with Renal Impairment

Initial Dosing Strategy

A loading dose is particularly important in serious infections to quickly achieve target concentrations, according to the American College of Critical Care Medicine 2, 1

Dosing frequency should be reduced to two or three times weekly in patients with significant renal insufficiency, while maintaining the per-dose amount at 12-15 mg/kg, as recommended by the American Thoracic Society and the Infectious Diseases Society of America 3, 4

Trough concentrations should be measured prior to the fourth or fifth dose at steady state, as suggested by the American College of Clinical Pharmacy 1
For serious infections, target trough concentrations of 15-20 mg/L, according to the Infectious Diseases Society of America 4, 1
For less severe infections, trough concentrations of 10-15 mg/L are generally adequate, as recommended by the American College of Clinical Pharmacy 1

For patients on hemodialysis, administer vancomycin after dialysis to avoid premature removal of the drug, as recommended by the American Thoracic Society 3

Using standard nomograms without individual pharmacokinetic adjustments may not achieve target concentrations in all patients, according to the American College of Clinical Pharmacy 1
Failing to obtain steady-state concentrations can lead to inaccurate dose adjustments, as suggested by the American College of Clinical Pharmacy 1
Reducing the per-dose amount rather than extending the interval between doses may reduce efficacy due to vancomycin's concentration-dependent bactericidal effect, as recommended by the American Thoracic Society 3
Not considering the vancomycin MIC when setting target trough concentrations—alternative therapies should be considered when MIC is ≥2 mg/L, according to the American College of Clinical Pharmacy 1