Vancomycin is a glycopeptide antibiotic used to treat infections caused by gram-positive bacteria such as MRSA. This 3-page document provides guidelines on vancomycin dosing and monitoring for different patient populations including neonates, infants, children, and patients with renal impairment. It outlines dosing recommendations according to indication, administration methods, monitoring for toxicity, and renal function-based dosing adjustments.

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Guideline : Vancomycin
MRSA
PRACTICE GUIDELINE
Clinical pharmacy department
Cairo University Hospitals
Prepared by :

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Guideline : Vancomycin
TABLE OF CONTENTS
Background......................................................................................................... 3
Indications.......................................................................................................... 4
Prevalence ...................................................................................................... 5
Neonatel Dose ..................................................................................................... 6
Infants and Children dose .................................................................................... 7
Dosing according to indication ....................................................................... 10
Administration .................................................................................................... 10
Vancomycin Toxicity............................................................................................ 11
Monitoring Parameters................................................................................... 12
Renal function based dosing................................................................................. 14
Appendix 1……………………………………………………………………………………………………… 16
Appendix 2……………………………………………………………………………………………………… 17
Appendix 3……………………………………………………………………………………………… …… 18

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Guideline : Vancomycin
Background
Vancomycin is a glycopeptide antibiotic that has activity against gram positive
organisms including methicillin resistant staphylococcus aureus (MRSA), and some
enterococcus species. It has been shown that higher doses of vancomycin may be
required in some pediatric patients. Patients who are at high risk of developing
infections with MRSA include patients with current or prior skin and soft tissue
infections, musculoskeletal infections, patients treated with frequent courses of
antibiotics, and frequent hospitalizations.
Introduction
Methicillin resistance in S. aureus is defined as an oxacillin minimum inhibitory
concentration (MIC) ≥4 mcg/mL. Isolates resistant to oxacillin or methicillin also
are resistant to all beta-lactam agents
Methicillin resistance is mediated by the mecA gene, which encodes for an
abnormal low-affinity binding protein, PBP-2a, that permits the organism to grow
and divide in the presence of methicillin and other beta-lactam antibiotics

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Guideline : Vancomycin
Indications
Treatment of patients with the following infections or conditions:
 Infections due to documented or suspected methicillin-resistant S. Aureus or beta-
lactam resistant coagulase negative Staphylococcus.
 Serious or life-threatening infections (eg, endocarditis, meningitis, osteomyelitis) due to
documented or suspected staphylococcal or streptococcal infections in patients who are
allergic to penicillins and/or cephalosporins.
 Empiric therapy of infections associated with central lines, hemodialysis shunts, vascular
grafts, prosthetic heart valves .
 Prophylaxis of peritonitis in patients with peritoneal dialysis (PD) catheters undergoing
invasive gastrointestinal procedure, and for the treatment of peritonitis in patients with
peritoneal catheters.
 Treatment of C. Difficile-associated diarrhea and Enterocolitis caused by Staphylococcus
aureus (including methicillin-resistant strains)(oral ).

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Guideline : Vancomycin
Prevalence
Collective antibiogram of respiratory specimens from July – December
ER ICU 4 ICU 6
Augmentin 0% 0% 0%
unasyn 0% 0% 0%
cefoxitin 14% 0% 0%
vancomycin 100% 100% 100%
clindamycin 71% 0% 0%
Eryhromycin 71% 50% 0%
ciprofloxacin 14% 50% 0%
Doxocyclin 28% 50% 0%
Trimrthoprim
/sulphomethoxazole
28% 0% 60%
gentamicine 28% 50% 0%
amikacine 28% 50% 0%
Teicoplanin 43% Not found Not found
Collective antibiogram of wound and pus specimens (ER)
antibiotic Sensitivity
augmentin 0%
unasyn 0%
cefoxitin 0%
vancomycin 100%
clindamycin 33%
erythromycin 33%
ciprofloxacine 0%
doxocyclin 0%
Trimethoprim/ sulphomethoxazole 66%

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Guideline : Vancomycin
Neonatel Dose
IV infusion by syringe pump over 60 minutes
Meningitis : 15 mg/ kg per dose
Bacteremia : 10 mg /kg per dose
Dosing interval chart
PMN
(weeks)
PostNatal Interval
(hours)
≤ 29 0 to 14
˃14
18
12
0 to 14
˃14
12
8
37 to 44 0 to 7
˃7
12
8
≥45 ALL 6

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Guideline : Vancomycin
Infant and children dose :
General dosing, susceptible infection
(Empirical)
Age Infection severity Dose Interval Maximum Dose
Infants ≤2 months Mild to moderate
infection
40 to 45
mg/kg/day
6 to 8 hours 2,000 mg/day
Severe infection 45 to 60
mg/kg/day
6 to 8 hours 4,000 mg/day
Infants >2 months Mild to moderate
infection
40 to 45
mg/kg/day
6 to 8 hours 2,000 mg/day
Severe infection 45 to 60
mg/kg/day
6 to 8 hours 4,000 mg/day
Infants 3 months
to Children <2
years
70 mg/kg/day 6 to 8 hours
Children 2 to <12
years
60 mg/kg/day
*Higher doses
may be needed if
SCr < 0.45 mg/dL
70 mg/kg/day
6 to 8 hours
6 to 8 hours

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Guideline : Vancomycin
Dosage according to indication
(proven infection)
Indication Dose/ Frequency (IV) Duration
Bacteremia(MRSA) 15 mg/kg/dose every 6 hours 2 to 6 weeks
(Depending on
severity)
Bone and
joint
infection
Osteomyelitis
(MRSA)
15 mg/kg/dose every 6 hours 4 to 6 weeks
Septic arthritis
(MRSA)
15 mg/kg/dose every 6 hours 3 to 4 weeks
C. difficile-associated diarrhea
Severe or recurrent infection 40 mg/kg/day in 4 divided doses
≥10 day
CNS
infection
Brain abscess,
subdural empyema,
spinal epidural
abscess
15 mg/kg/dose every 6 hours 4 to 6 weeks
Meningitis 5 mg/kg/dose every 6 hours 2 weeks
VP-shunt infection,
ventriculitis (use preservative-free preparation)
10 or 20 mg/day
Endocarditis
(AHA guidelines)
40 mg/kg/day divided every 6 to 12
hours
at least 6 weeks
Prophylaxis
(GI or genitourinary procedures)
20 mg/kg over 1 hour
complete infusion 30 min prior procedure
Enterocolitis
40 mg/kg/day divided every 6 to 8
hours
7 to 10 days
Intra-abdominal infection
complicated (MRSA)
40 mg/kg/day divided every 6 to 8
hours

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Guideline : Vancomycin
Peritonitis
(peritoneal
dialysis)
Prophylaxis Touch contamination of PD line
Intraperitoneal: 25 mg per liter
(known MRSA Colonization)
High-risk gastrointestinal procedures
10 mg/kg administered 60 to 90
minutes before procedure
Treatment Intermittent: Intraperitoneal
 Initial dose: 30 mg/kg in the
long dwell
 subsequent doses: 15
mg/kg/dose every 3 to 5
days during the long dwell
Continuous: Intraperitoneal
 Loading dose: 1,000 mg per
liter of dialysate
 maintenance dose: 25 mg
per liter
Pneumonia (CAP): Infants ≥3
months, Children
60 mg/kg/day divided every 6 hours 7 to 21 days
(HAP) : MRSA 60 mg/kg/day divided every 6 hours 7 to 21 days
Skin and skin structure infections,
complicated
60 mg/kg/day divided every 6 hours 7 to 14 days
*If Complete ileus , rectal enema dosage form may be preferable.

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Guideline : Vancomycin
Administration :
Route of administration Method of preparation
Oral Using a vial of vancomycin powder for injection
(reconstituted to 50 mg/mL) using water for
injection
Nasogastric tube 1. Stop the enteral feed.
2. Flush the enteral feeding tube with the
recommended volume of water.
3. Reconstitute injection as directed (the
reconstituted solution can be stored in the
fridge for 24 hours for enteral use).
4. Draw the medication solution into an
appropriate size and type of syringe.
5. Flush the medication dose down the feeding
tube.
6. Finally, flush with the recommended volume
of water.
7. Re-start the feed.
Parentral 1. Reconstitute vials with SWFI to a final
concentration of 50 mg/mL.
2. Further dilute the reconstituted solution
to
 A final concentration ≤5 mg/mL
 In fluid restricted patients ,conc 10
mg/mL

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Guideline : Vancomycin
Vancomycin toxicity
Nephrotoxicity:
Risk Factors
 preexisting renal impairment
 concomitant nephrotoxic medication
 dehydration
If multiple sequential (≥2) serum creatinine concentrations demonstrate an increase of 0.5
mg/dL or ≥50% increase from baseline (whichever is greater) in the absence of an alternative
explanation, the patient should be identified as having vancomycin-induced nephrotoxicity .
Discontinue treatment if signs of nephrotoxicity occur; renal damage is usually reversible.
Ototoxicity:
Although rarely associated with monotherapy, is proportional to the amount of drug given and the
duration of treatment.
Tinnitus or vertigo may be indications of vestibular injury and impending bilateral irreversible damage.
Discontinue treatment if signs of ototoxicity occur.
Hypersensitivity reactions:
The most common hypersensitivity reaction is an infusion-related anaphylaxis-like
reaction, known as ‘red man syndrome’.It is common and is related to the
speed of infusion.
• Suggested management of ‘red man syndrome’:
 Stop the infusion.
 Assess for signs of anaphylaxis (i.e. urticaria, stridor, wheeze).
-If these are present, manage as an anaphylactic reaction
 including IM adrenaline. In these cases, vancomycin avoided in the future.
- If no signs of anaphylaxis are present, administer an antihistamine.
 Once symptoms have subsided, the infusion can be re-started at one-half
the original rate.
 Future infusions of vancomycin should be administered over four hours.
Consider pre-medicating with an antihistamine before infusions.

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Guideline : Vancomycin
Vancomycin monitoring parameters
Recommendations for Vancomycin Therapeutic Drug Monitoring (TDM)
Recommended TDM Parameters Recommendation
Optimal monitoring parameter Trough serum vancomycin concentrations are the most
accurate and practical method for monitoring efficacy.
Timing of monitoring Troughs should be obtained just prior to the next dose at
steady-state conditions (just before the fourth dose).
Optimal trough concentration -Minimum serum vancomycin trough concentrations
should always be maintained above 10 mg/L to avoid
development of resistance.
-For a pathogen with an MIC of 1 mg/L, the
minimum trough concentration would have to be at least
15 mg/L to generate the target AUC:MIC of 400.
Optimal trough concentration
complicated infections (bacteremia,
endocarditis, osteomyelitis, meningitis,
and hospital-acquired pneumonia
caused by Staphylococcus aureus)
Vancomycin serum trough concentrations of 15–20 mg/L
are recommended to improve penetration, increase
the probability of obtaining optimal target serum
concentrations, and improve clinical outcomes.

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Guideline : Vancomycin
TDM for Vancomycin-Induced Nephrotoxicity
Variable Recommendation
Definition A minimum of two or three consecutive documented increases
in serum creatinine concentrations (defined as an increase
of 0.5 mg/dL or a ≥50% increase from baseline, whichever is
greater) after several days of vancomycin therapy.
Criteria for monitoring Trough monitoring is recommended for patients receiving
aggressive dosing (i.e., to achieve sustained trough levels of
15–20 mg/L) and all patients at high risk of nephrotoxicity
(e.g., patients receiving concurrent nephrotoxins).
Monitoring is also recommended for patients with unstable
(i.e., deteriorating or significantly improving) renal function
and those receiving prolonged courses of therapy (more
than three to five days).
Frequency of monitoring Frequent monitoring (more than one trough before the fourth dose)
for short course or lower intensity dosing (to attain target trough
concentrations below 15 mg/L) is not recommended.
All patients on prolonged courses of vancomycin (exceeding
three to five days) should have at least one steady-state
trough concentration obtained no earlier than at steady
state (just before the fourth dose) .
There are limited data supporting the safety of sustained
trough concentrations of 15–20 mg/L.
Clinical judgment should guide the frequency of trough monitoring when
the target trough is in this range.
Once-weekly monitoring is recommended or hemodynamically stable
patients.
More frequent or daily trough monitoring is advisable in patients
who are hemodynamically unstable.
TDM for Vancomycin-Induced Ototoxicity
Criteria for monitoring Monitoring for ototoxicity is not recommended for patients receiving
vancomycin monotherapy.
Monitoring should be considered for patients receiving additional ototoxic
agents, such as aminoglycosides.

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Guideline : Vancomycin
Vancomycin levels should be monitored in patients with
any renal impairment:
Neonatal dose
Initial dosage recommendations:
Renal function-based dosing:
Scr Gestational age ≤28
weeks
Scr Gestational age >28 weeks
Dose adjustment Dose adjustment
<0.5 mg/dL 15 mg/kg/dose every 12
hours
<0.7 mg/dL 15 mg/kg/dose every 12 hours
0.5 to 0.7
mg/dL
20 mg/kg/dose every 24
hours
0.7 to 0.9
mg/dL
20 mg/kg/dose every 24 hours
0.8 to 1
mg/dL
15 mg/kg/dose every 24
hours
1 to 1.2
mg/dL
15 mg/kg/dose every 24 hours
1.1 to 1.4
mg/dL
10 mg/kg/dose every 24
hours
1.3 to 1.6
mg/dL
10 mg/kg/dose every 24 hours
>1.4 mg/dL 15 mg/kg/dose every 48
hours
1.6 mg/dL 15 mg/kg/dose every 48 hours

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Guideline : Vancomycin
Infants and Children Doses :
Renally adjusted dose recommendations are based on doses of 10 mg/kg/dose
every 6 hours or 15 mg/kg/dose every 8 hours
GFR Dose adjustment
GFR 30 to 50 mL/minute/1.73 m2
10 mg/kg/dose every 12 hours
GFR 30 to 50 mL/minute/1.73 m2
10 mg/kg/dose every 18 to 24 hours
GFR <10 mL/minute/1.73 m2
10 mg/kg/dose; redose based on serum
concentrations
Intermittent hemodialysis 10 mg/kg/dose; redose based on serum
concentrations
Peritoneal dialysis (PD) 10 mg/kg/dose; redose based on serum
concentrations
Continuous renal replacement therapy
(CRRT)
10 mg/kg/dose every 12 to 24 hours;
monitor serum concentrations

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Guideline : Vancomycin
Appendix 1: Governance Information
Document Title Vancomycin prescription and
therapeutic drug monitoring
guideline
Date Issued/Approved:
Date Valid From:
Date Valid to:
Department responsible
(author/owner):
Brief summary of contents: Guidance on the safe and
effective prescribing and
monitoring of intravenous
vancomycin
Executive Director responsible
for Policy:
Names Of Committees
/Consultation:
Antimicrobial Stewardship
Management Committee
Clinical pharmacist approval
Staff approval

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Guideline : Vancomycin
Appendix 2: Version Control Table
Date Summary of Changes Changes Made by
(Name and Job Title)

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Guideline : Vancomycin
Appendix 3. Initial Equality Impact Assessment Form
Name of the policy to be assessed (Provide brief description): Clinical Guideline for
Vancomycin Prescribing and Therapeutic Drug Monitoring
Directorate and service area: Pharmacy Is this a new or existing
Policy?
NEW
Name of individual completing assessment:
1. Policy Aim/ Who is the policy function aimed at? To provide guidance to staff
on the appropriate
prescription and
therapeutic drug
monitoring of vancomycin
therapy
2. Policy Objectives To provide guidance to
RCHT staff on the
prescription and
therapeutic drug
monitoring for vancomycin
therapy
3. Policy – intended Outcomes Safe and effective
prescribing of vancomycin
4. How will you measure the outcome? Six monthly vancomycin
audits
5. Who is intended to benefit from the policy? All prescribers and nurses
administering vancomycin