Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

VANCOMYCINUsual DoseAdult: 1 g Q12H IV (15 mg/kg) OR 125 mg Q6H PO (UWHC cost/day IV $8.12; PO $3.09)At UW, the IV formulation is being used for in hospital oral use.The UWHC cost for a comparable PO dose given as capsules is $73.38.Pediatric:** 40 mg/kg/day IV in divided doses Q6H OR 10-50 mg/kg/day PO in divided doses Q6H.Meningitis 60 mg/kg/day in divided doses Q6H.ICU Dosing: Loading dose of 15-25 mg/kg; Maintenance dose of 10 mg/kg Q8HNote: Dose using IBW. For obese patients (BMI>30 kg/m 2 ) use a dosing weight(DW) = 0.4 (ABW-IBW) + IBW.(IBW=Ideal Body Weight; ABW=Actual Body Weight)Indications1. Major Gram-positive infections, especially bacteremia or endocarditis, in patients with serious penicillin allergy. Empirictherapy with vancomycin should be promptly discontinued in patients whose cultures are negative for beta-lactamaseproducingGram-positive organisms.2. Methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant coagulase-negative Staphylococcus orampicillin-resistant enterococci infections only. Not for colonization.3. Drug for Clostridium difficile colitis. Vancomycin is only effective orally for C difficile colitis. Metronidazole is thedrug of first choice unless the patient is moderately ill (but can take oral medications), has not responded to metronidazoleor is allergic to metronidazole.4. Bacteremia or endocarditis with beta-lactam resistant Corynebacterium species (especially C jeikeium).5. Surgical prophylaxis in patients who are allergic to penicillin, are colonized with methicillin-resistant S aureus or inpatients requiring repeat surgical interventions, especially through the previous incision. Ideally dosed as a singlepreoperative dose and NOT continued for more than 24 hours following surgery.6. Cardiovascular or orthopedic prophylaxis when prosthetic material is being implanted. Ideally dosed as a singlepreoperative dose and NOT continued for more than 24 hours following surgery.7. Bacterial endocarditis prophylaxis (see Appendix A).8. Serious infections with Streptococcus pneumonia including meningitis when given in combination with ceftriaxone untilpenicillin susceptibility documented.9. Treatment of intraventricular shunt infections in combination with rifampin and/or removal of shunt material.CommentsDose adjustment required for renal impairment. See renal dosing guideline on uconnect.Vancomycin is still a reliable antibiotic for many MRSA infections, or for methicillin-resistant coagulase-negativeStaphylococcus. Vancomycin is not absorbed orally. To avoid histamine-like reactions, which are not true allergicreactions, administer the drug no faster than over 60 minutes. Pre-operative doses may begin 2 hours before the plannedincision time in the OR. Vancomycin infusions should not be administered during patient transport. Trough concentrationsare required only for pharmacokinetic dosing in renal failure, burn and obese patients; suspected toxicity; or suspectedinefficacy. The unit pharmacist will assist with pharmacokinetic dosing (See Serum Drug Concentration MonitoringProtocol [Appendix G] or on uconnect) Consider dosing at 15 mg/kg/day in obese patients or see Appendix H.See Vancomycin Serum Concentration Monitoring [Appendix H] or on uconnect.Trough: 15 minutes to 30 minutes prior to next dose. Monitor long-term therapy by following the serum creatinineconcentrations.Vancomycin use topically or for irrigations is discouraged. Excess use of vancomycin can promote spread of vancomycinresistantenterococci. Organisms with intermediate vancomycin susceptibility have been reported, most commonly inpatients on long-term vancomycin therapy.