GENERAL: Guidelines applicable to young "healthy" adult population only

Target Serum Levels: Peak: 25 - 40 mcg/ml

� � � � � � � � � � � � � � � � � � �Trough 5 - 10 mcg/ml

DOSE: Vancomycin is dosed based on total body weight (TBW)

� � � � � � � Dose: 12 - 15mg/kg (maximum 2 gm) interval determined by creatinine clearance

� � � � � � � � - Usual adult dose: 1 gm q 12 hrs

� � � � � � � � - After calculation, round the dose to the nearest 250mg

Suggested Adult dose:
Weight (Kg) *	Dose	Infusion rate
> 120 kg	1.5 gm	90 min
100 - 120 kg	1.25gm	90 min
60 - 100 kg	1 gm	60 min
40 - 60 kg	750 mg	60 min
25 - 40 kg	500 mg	60 min

� �* Use adjusted body weight if morbidly obese (maximum dose 2 gm); subsequent dosing based on serum concentrations

Dosing Interval
CrCl (ml/min)	Dosing interval: (hrs)
> 100	12
70 - 99	18
50 - 69	24
30 - 49	48
< 30	Dose based on trough concentrations (redose when < 10 - 15 mcg/ml)

� � �Note: Hemodialysis does not appreciably remove vancomycin

� � �CAVH & CAVHD removes vancomycin--monitor concentrations more frequently

Monitor:

- Concentration times: Peak = 1 hour after 1 hour infusion; trough within 30 minutes prior to next dose

- No need to monitor concentrations for empiric therapy (if anticipated duration of therapy < 72 hours)

- Less serious infections: Trough concentration only after third dose

- Co-administration with nephrotoxic drugs (i.e. aminoglycoside): peak & trough after every third dose

- Serious infection: Peak & trough concentrations after third dose following initiation or adjustment of therapy

- For dosing intervals > 48 hours, the second dose may be appropriate for monitoring serum concentrations

- If patient is stable, monitor vancomycin concentrations every five to seven days.

- Serum creatinine concentrations should be measured initially and periodically

- Note: If peak concentrations are satisfactory, dosing adjustment may not be required for trough levels between 10 - 15 mcg/ml

Contact the clinical pharmacist for assistance with any dose initiation or change

�Dose Adjustments based on concentrations: Make only one adjustment at a time (i.e. dose or interval)
Concentration	Too high	Too low
Peak	Lower the dose	Increase the dose
Trough	Increase the dosing interval	Dependent upon the peak concentration

EQUATIONS Weight: Ideal Body Weight (IBW)

� � � � � � � � � � � � � � � � �IBW: Males (kg) = 50 + (2.3 X inches of height > 60 inches)

� � � � � � � � � � � � � � � � �IBW: Females (kg) = 45 + (2.3 X inches of height > 60 inches)

� � � � � � Adjusted body weight (ABW) = IBW + 0.4 (Total weight - IBW)

Creatinine Clearance (ml/min): CrCl (males)= (140 - age) IBW (kg) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �ScrX72� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

� � � � � � � � � � � � � � � � �� � � � � ��� CrCl (Female) = CrCl (Male) X 0.85

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Last modified: �7/8/1997