vancomycin

Adult Dosing .

Dosage forms:  CAP: 125 mg, 250 mg; SOL: 250 mg per 5 mL; INJ: various

Special Note

[dosing clarification]

Info: use AUC-based monitoring for serious infections due to MRSA; consider AUC-based monitoring regardless of infection type if high nephrotoxicity risk, unstable renal fxn, prolonged tx

infections, severe bacterial

[15-20 mg/kg/dose IV q8-12h]

Info: consider start 20-35 mg/kg/dose IV x1 in seriously ill pts, max 3 g/dose; use ABW to calculate dose; adjust dose based on serum levels; consider 20-25 mg/kg/dose IV x1 then 10-15 mg/kg/dose IV q12h in obese pts using ABW, consider 10-12.5 mg/kg/dose IV q12h using ABW if BMI >40 kg/m^2

C. difficile infection

[non-fulminant (off-label)]

Dose: 125 mg PO q6h x10 days; Info: for 1st episode; IV form may be given PO

[fulminant (off-label)]

Dose: 500 mg PO/NG q6h; Info: 1st-line agent; IV form may be given PO; may give w/ metronidazole IV; consider adding vancomycin 500 mg in 100 mL NS retention enema PR q6h if complete ileus

[1st recurrence (off-label)]

Dose: 125 mg PO q6h x10-14 days, then 125 mg PO q12h x7 days, then 125 mg PO qd x7 days, then 125 mg PO q2-3 days x2-8wk; Info: IV form may be given PO; may give 125 mg PO q6h x10 days if metronidazole initial regimen

[2 or more recurrences (off-label)]

Dose: 125 mg PO q6h x10-14 days, then 125 mg PO q12h x7 days, then 125 mg PO qd x7 days, then 125 mg PO q2-3 days x2-8wk; Alt: 125 mg PO q6h x10 days, then rifaximin x20 days; Info: IV form may be given PO

enterocolitis, staphylococcal

[500-2000 mg/day PO divided q6-8h x7-10 days]

Info: IV form may be given PO

pneumonia

[community-acquired]

Dose: 15-20 mg/kg/dose IV q8-12h x7 days; Info: for inpatient tx; refer to IDSA guidelines; consider start 20-35 mg/kg/dose IV x1 in seriously ill pts, max 3 g/dose; use ABW to calculate dose; adjust dose based on serum levels; consider 20-25 mg/kg/dose IV x1 then 10-15 mg/kg/dose IV q12h in obese pts using ABW, consider 10-12.5 mg/kg/dose IV q12h using ABW if BMI >40 kg/m^2

[hospital-acquired or ventilator-assoc.]

Dose: 15-20 mg/kg/dose IV q8-12h x7 days; Info: may extend duration based on clinical response; refer to IDSA guidelines; consider start 20-35 mg/kg/dose IV x1 in seriously ill pts, max 3 g/dose; use ABW to calculate dose; adjust dose based on serum levels; consider 20-25 mg/kg/dose IV x1 then 10-15 mg/kg/dose IV q12h in obese pts using ABW, consider 10-12.5 mg/kg/dose IV q12h using ABW if BMI >40 kg/m^2

endocarditis

[15-20 mg/kg/dose IV q8-12h for at least 4wk]

Info: dose, duration varies w/ pathogen susceptibility, valve type; may be part of multi-drug regimen incl. gentamicin gram positive synergy; refer to AHA guidelines; consider start 20-35 mg/kg/dose IV x1 in seriously ill pts, max 3 g/dose; use ABW to calculate dose; adjust dose based on serum levels; consider 20-25 mg/kg/dose IV x1 then 10-15 mg/kg/dose IV q12h in obese pts using ABW, consider 10-12.5 mg/kg/dose IV q12h using ABW if BMI >40 kg/m^2

anthrax, systemic (off-label)

[60 mg/kg/day IV divided q8h for at least 2wk]

Info: not recommended for CNS anthrax; not 1st-line agent; part of multi-drug regimen; consider start 25-30 mg/kg/dose IV x1 in seriously ill pts, max 3 g/dose; use ABW to calculate dose; adjust dose based on serum levels; consider 20-25 mg/kg/dose IV x1 then 10-15 mg/kg/dose IV q12h in obese pts using ABW, consider 10-12.5 mg/kg/dose IV q12h using ABW if BMI >40 kg/m^2; switch to PO abx for post-exposure prophylaxis if inhalational exposure

endophthalmitis, bacterial (off-label)

[1 mg in 0.1 ml sterile water or saline intravitreally x1]

Info: may be part of multi-drug regimen; refer to institution protocol; may repeat q48h x1

meningitis, bacterial (off-label)

[15-20 mg/kg/dose IV q8-12h]

Info: part of multi-drug regimen; consider start 20-35 mg/kg/dose IV x1 in seriously ill pts, max 3 g/dose; use ABW to calculate dose; adjust dose based on serum levels; consider 20-25 mg/kg/dose IV x1 then 10-15 mg/kg/dose IV q12h in obese pts using ABW, consider 10-12.5 mg/kg/dose IV q12h using ABW if BMI >40 kg/m^2

renal dosing

[IV route]

CrCl 30-60: give usual maint. dose IV q12-24h; CrCl 15-30: give usual maint. dose IV q24h; CrCl <15: give usual maint. dose IV q48h; Info: adjust dose based on serum levels

HD: 25 mg/kg/dose IV x1, then 7.5-10 mg/kg/dose IV 3x/wk after dialysis; consider supplement if next maint. dose not due right after dialysis; PD: not defined; Info: adjust dose based on serum levels; consider incr. HD dose by 25% if next hemodialysis due in 72h; consider incr. HD dose if intradialytic admin.

[enteral routes]

renal impairment: no adjustment; Info: consider monitoring serum levels if potential for systemic absorption

HD/PD: not defined

[intravitreal route]

renal impairment: not defined

HD/PD: not defined

hepatic dosing

[not defined]

Peds Dosing .

Dosage forms:  CAP: 125 mg, 250 mg; SOL: 250 mg per 5 mL; INJ: various

Special Note

[dosing clarification]

Info: use AUC-based monitoring for serious infections due to MRSA; consider AUC-based monitoring regardless of infection type if high nephrotoxicity risk, unstable renal fxn, prolonged tx

infections, severe bacterial

[neonates <7 days old, <1.2 kg]

Dose: 15 mg/kg/dose IV q24h; Info: adjust dose based on serum levels

[neonates <7 days old, 1.2-2 kg]

Dose: 10-15 mg/kg/dose IV q12-18h; Info: adjust dose based on serum levels

[neonates <7 days old, >2.1 kg]

Dose: 10-15 mg/kg/dose IV q8-12h; Info: adjust dose based on serum levels

[neonates 7 days old and older, <1.2 kg]

Dose: 15 mg/kg/dose IV q24h; Info: adjust dose based on serum levels

[neonates 7 days old and older, 1.2-2 kg]

Dose: 10-15 mg/kg/dose IV q8-12h; Info: adjust dose based on serum levels

[neonates 7 days old and older, >2.1 kg]

Dose: 15-20 mg/kg/dose IV q8h; Info: adjust dose based on serum levels

[1-3 mo]

Dose: 10-15 mg/kg/dose IV q6-8h; Max: 1 g/dose; Info: adjust dose based on serum levels

[4 mo-11 yo]

Dose: 60-80 mg/kg/day divided q6-8h; Max: 100 mg/kg/day; Info: consider start 20 mg/kg/dose IV x1 in obese pts; adjust dose based on serum levels

[12 yo and older]

Dose: 1000 mg IV q12h; Alt: 10-15 mg/kg/dose IV q12h; Info: adjust dose based on serum levels; pts w/ high clearance may require 1200-1500 mg IV q12h or 10 mg/kg/dose IV q8h

C. difficile infection

[non-severe (off-label)]

Dose: 40 mg/kg/day PO divided q6h x10 days; Max: 125 mg/dose; Info: for 1st episode or 1st recurrence; 1st-line agent; IV form may be given PO

[severe or fulminant (off-label)]

Dose: 40 mg/kg/day PO/PR divided q6h x10 days; Max: 500 mg/dose; Info: for 1st episode; 1st-line agent; may give w/ metronidazole IV; IV form may be given PO; may mix IV powder in 100 mL NS retention enema and give PR

[2 or more recurrences (off-label)]

Dose: 10 mg/kg/dose PO q6h x14 days, then 10 mg/kg/dose PO q12h x7-14 days, then 10 mg/kg/dose PO qd x7-14 days, then 10 mg/kg/dose PO q2-3 days x2-8wk; Max: 125 mg/dose; Alt: 10 mg/kg/dose PO q6h x7 days, then 10 mg/kg/dose PO q8h x7 days, then 10 mg/kg/dose PO q12h x7 days, then 10 mg/kg/dose PO qd x7 days, then 10 mg/kg/dose PO q48h x7 days, then 10 mg/kg/dose PO q72h x7 days; 10 mg/kg/dose PO q6h x14 days, then rifaximin x14 days or nitazoxanide x10 days; Info: IV form may be given PO

enterocolitis, staphylococcal

[40 mg/kg/day PO divided q6-8h x7-10 days]

Max: 500 mg/dose, 2000 mg/day; Info: IV form may be given PO

community-acquired pneumonia, severe bacterial

[>3 mo]

Dose: 40-60 mg/kg/day IV divided q6-8h x10-14 days; Info: adjust dose based on serum levels; may switch to appropriate oral regimen when possible to complete course

endocarditis

[40-60 mg/kg/day IV divided q6-12h x4-6wk]

Info: dose, frequency, duration vary w/ pathogen susceptibility, valve type, sx duration; may be part of multi-drug regimen incl. gentamicin gram positive synergy; refer to AHA guidelines; adjust dose based on serum levels

anthrax, systemic (off-label)

[neonates >32 wk gestation]

Dose: 10-20 mg/kg/dose IV q12-48h for at least 2wk; Info: not recommended for CNS anthrax; not 1st-line agent; part of multi-drug regimen; dose, frequency depend on Cr; adjust dose based on serum levels; switch to PO abx x60 days total if inhalational exposure

[1 mo and older]

Dose: 60 mg/kg/day IV divided q8h for at least 2wk; Info: not 1st-line agent; part of multi-drug regimen; adjust dose based on serum levels; switch to PO abx x60 days total if inhalational exposure

endophthalmitis, bacterial (off-label)

[2 yo and older]

Dose: 1 mg in 0.1 ml sterile water or saline intravitreally x1; Info: may be part of multi-drug regimen; refer to institution protocol; may repeat q48h x1

renal dosing

[IV route]

CrCl 10-50: give usual dose IV q12-48h; CrCl <10: give usual dose IV x1, subsequent doses and frequency determined by serum levels; Info: adjust dose based on serum levels

HD/PD: give usual dose IV x1, subsequent doses and frequency determined by serum levels; monitor random level 4-6h after dialysis; Info: adjust dose based on serum levels

[enteral routes]

renal impairment: no adjustment; Info: consider monitoring serum levels if potential for systemic absorption

HD/PD: not defined

[intravitreal route]

renal impairment: not defined

HD/PD: not defined

hepatic dosing

[not defined]