These recommendations are provided for initial vancomycin dosing as part of the Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines.
Prior to choosing a dosing regimen the clinician should review the patient’s previous vancomycin regimen(s) to determine if information from prior courses of therapy can aid in selecting dosing for a new course of treatment. For patients with less common circumstances e.g. suboptimal baseline renal function, rapidly changing renal function, on dialysis, or congenital heart disease, additional clinical judgment should be exercised. Consult a clinical pharmacist for patient-specific recommendations.
| Patient Age | Recommended Initial Vancomycin Dose | ||
|---|---|---|---|
| < 1 mo | Refer to Neonatal Dosing Guidelines | ||
| 1-2 mo | 15 mg/kg/dose IV q6h | ||
| 3 mo-<12yo | 17.5 mg/kg/dose (initial max 1000 mg/dose) IV q6h | ||
| >=12 yo | 15 mg/kg/dose (initial max 1000 mg/dose) IV q6h | ||
Monitoring During Vancomycin Therapy
Goal Vancomycin Exposure
The ideal target exposure is an Area-Under-The-[Concentration-Time]-Curve (AUC) 400 to 600 mg*hr/L. At both BCH campuses this can be calculated by a clinical pharmacist using software based on information about the patient, the current vancomycin dosing regimen, and a measured level of vancomycin.
This is now preferred over previous trough-based targets because it is more closely associated with the antimicrobial activity of vancomycin against Staphylococcus aureus, and usually can be achieved with a lower dose of vancomycin which may decrease the risk for nephrotoxicity.
Therapeutic Drug Monitoring (TDM)
TDM is essentially defined as checking medication levels, assessing the exposure and adjusting the medication dose if needed.
Only perform TDM if the expected duration of vancomycin is > 48 hours. Unless the patient has a documented MRSA or other resistant gram-positive infection, vancomycin should usually be stopped within 48 hours. If 48 hours or shorter duration is anticipated in a patient with relatively stable volume status and renal function, no levels are indicated.
If using Bayesian software, no need to be at steady state when obtaining levels so can time levels to bundle with other lab draws as well as avoid overnight and evening lab draws when able.
Wait at least 1 hour after the end of vancomycin infusion before obtaining any levels to allow for drug distribution.
Dose Adjustments
Consult a clinical pharmacist for recommendations. Use of Bayesian software to calculate AUC is the preferred approach. When considering the actual vancomycin level, it is important to avoid making a change based on the level alone without considering other information:
Is the level a true trough (drawn within 30 minutes prior to administration of the next dose)?
Is it drawn at steady state?
Calculations based on Bayesian software are preferred for assessment of all levels and particularly for interpretation of levels that are not true steady state troughs based on the above criteria.
Before determining whether dose adjustment is necessary, re-evaluate whether vancomycin should be continued at all.
Re-evaluate kidney function.
Follow-up Monitoring
The frequency of rechecking vancomycin level and serum creatinine should be determined using clinical judgement based on:
Changes in dose
Suboptimal fitting Bayesian model
Significant change in renal function/urine output
Addition of potentially nephrotoxic medications e.g. NSAIDS, contrast, etc.
At minimum, monitoring of vancomycin serum concentrations in stable patients should be repeated once per week.
Reference:
Rybak MJ, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2020;77:835-864.
Pediatric Empiric Antimicrobial Therapy Guidelines
This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites.
These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.
For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK.
The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.