Bryan Hayes has a great post on ALIEM on proper dosing of vancomycin.
We are very bad at this in the ED
Proper Vancomycin Dosing
- 15-20 mg/kg every 8-12 hours in patients with normal renal function [1]
- In seriously ill patients (eg, sepsis, meningitis, infective endocarditis) with suspected MRSA infection, a loading dose of 25-30 mg/kg may be considered [3]
- Actual body weight should be used
- IDSA recommends a max dose of 2 gm
- In adults, we round to the nearest 250 mg increment
See the post for more and all of the references
Scott Weingart
An ED Intensivist from NY.
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An infusion with regular level checks may be the way to go in critical patients (nosocomial pneumonia, pneumococcal meningitis)
I’m an emergency medicine pharmacist at a hospital in Michigan. I normally do the loading dose with 15-25 mg/kg depending on site of infection and severity of the illness. There are some people at my hospital that use the volume of distribution times the patient weight times the desired peak (30-40). E.x. patient weighs 60 kg, so 0.7*60kg*30 gives a dose of approximately 1250 mg of vancomycin. Does anyone use this method for vancomycin dosing or do most of you go with the weight based dosing of 15-25 mg/kg?
The Vd dosing looks intriguing. Has anyone studied this to see if it results in quicker optimal dosing?
(As an ICU doc – in training) one thing I see a lot of is improper loading of Vancomycin for obese patients with AKI or ARF. Renal dosing is important, of course, but the first dose should of course be the big shabang!
I personally use the patients actual weight up until 2grams.
yep
Here is an example of the strategy: http://www.ncbi.nlm.nih.gov/m/pubmed/24165255/
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More importantly, never exceed an infusion rate of 10mg/min. And remember, it has poor penetration into CSF unless the meninges are inflammed. Even then the max penetration is 30 % only. So if you are giving it for meningitis, increase the dose to 30 mg/kg q12h.
Has anyone heard of Area-under-the-curve/MIC (AUIC) dosing for vancomycin? Optimal killing power for even the most resistant MRSA is attributed w/ AUICs > 400. We try not to overshoot AUICs greater than 700 as these correlate w/ higher incidences of nephrotoxicity, and other adverse effects. I advocate use of a 2-compartment Bayesian approach shooting for AUICs between 400-600. If you decide to use ‘fancier’ PK software like PrecisePK (formerly TDMS2000), then you can check non-steady state levels. AUIC can be calculated by taking the total-daily-dose (TDD) and dividing this by clearance (CrCl in L/hr). Then, you divide this value w/ by your MIC. This, in my opinion is the most practical and most efficient way of dosing vancomycin. Troughs are proven to be POOR surrogate markers for AUC, which was the original assumption the guys who wrote the 2009 IDSA concensus statement made. A beautifully written article on this by Pharmacometrician’s Michael Neely and Roger Jelliffe – a must read.