Vancomycin dose according to crt clearance
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vancomycin dosing renal impairment creatinine clearance
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vancomycin dosing creatinine clearance renal adjustment table 2020 ASHP IDSA guidelines
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Vancomycin Dosing by Creatinine Clearance (CrCl)
Vancomycin is renally eliminated, and its clearance is directly proportional to creatinine clearance. Dosing must be individualized based on CrCl, body weight, and infection severity.
Current Monitoring Standard (2020 ASHP/IDSA/PIDS/SIDP Guidelines)
The 2020 consensus guidelines represent a major shift away from trough-only monitoring toward AUC/MIC-guided dosing:
- Target AUC/MIC: 400-600 mg·h/L (assuming MIC = 1 mg/L by broth microdilution)
- Trough-only targeting (15-20 mcg/mL) is no longer recommended due to increased nephrotoxicity risk
- Bayesian dosing software is preferred to estimate AUC from 1-2 levels
Initial Dosing by Creatinine Clearance
Loading Dose (for serious infections)
- 20-25 mg/kg actual body weight, max 3,000 mg
- Critically ill patients: up to 20-35 mg/kg IV for rapid target attainment
Maintenance Dose - Normal to Mildly Impaired Renal Function
| CrCl (mL/min) | Typical Dose | Interval | Notes |
|---|---|---|---|
| >90 (normal) | 15-20 mg/kg | q8-12h | Total 30-60 mg/kg/day |
| 50-90 | 15-20 mg/kg | q12h | May start at lower end |
| 30-49 | 15-20 mg/kg | q24h | Monitor closely |
| 10-29 | 15-20 mg/kg | q24-48h | Extended intervals |
| <10 (non-dialysis) | 15-20 mg/kg | q48-96h | Level-guided only |
Rule of thumb: Use the CrCl value as the dosing interval in hours - e.g., CrCl 50 → dose every 50 hours (traditional method). This is a rough guide only; individual titration is required.
Standard Adult Dosing (Normal Renal Function)
- Traditional: 1 g IV every 12 hours (~30 mg/kg/day)
- Serious infections (MRSA bacteremia, endocarditis, pneumonia): 45-60 mg/kg/day in 2-3 divided doses, titrated to AUC/MIC 400-600
- Children: 40-60 mg/kg/day in 3-4 divided doses
Special Populations
Hemodialysis (IHD)
- Loading dose: 25 mg/kg (actual body weight)
- Maintenance: 500 mg - 1 g after each dialysis session (typically 3x/week), adjusted by post-dialysis trough levels
- Vancomycin is only partially removed by conventional hemodialysis (~30-40%)
Continuous Renal Replacement Therapy (CRRT)
- Higher doses may be needed - CRRT significantly increases vancomycin clearance by 15-25% compared to IHD
- Typical maintenance: 15-20 mg/kg q24h, but must be guided by AUC monitoring
- Predilution modality increases clearance further
Obesity
- Use actual body weight for loading and maintenance doses
- Max empiric maintenance: 4,500 mg/day
- Frequent early AUC monitoring recommended when doses exceed 4,000 mg/day
Monitoring Parameters
| Parameter | Target |
|---|---|
| AUC/MIC (preferred) | 400-600 mg·h/L |
| Trough (if AUC not available) | 10-20 mcg/mL (serious infections) |
| Peak (not routinely monitored) | Keep <60 mcg/mL to limit ototoxicity |
| First level | Prior to 4th or 5th dose (trough) |
Key Adverse Effects to Monitor with Dose Adjustment
- Nephrotoxicity - most common; risk increases with troughs >15 mg/L
- Ototoxicity - rare with modern preparations; peaks >60 mcg/mL increase risk
- Vancomycin Infusion Reaction (Red Man Syndrome) - not dose-dependent; prevented by slow infusion over 1-2 hours
Practical Takeaway
Clearance of vancomycin is directly proportional to CrCl. Reduce the dose frequency (extend the interval) in renal impairment rather than always reducing the individual dose amount. Always use AUC/MIC-guided monitoring with Bayesian software when available, especially in serious MRSA infections.
- Katzung's Basic and Clinical Pharmacology, 16th Ed., p. 1257
- Lippincott Illustrated Reviews: Pharmacology, p. 970
- ASHP/IDSA/PIDS/SIDP 2020 Vancomycin Consensus Guidelines
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