Intermittent vancomycin dosing in noncritically ill adults

For intermittent vancomycin dosing in noncritically ill adults without obesity, an appropriate initial dosage is:

vancomycin intravenously; see Calculated vancomycin maintenance dosages in adults for calculated dosages based on weight and kidney function. vancomycin vancomycin vancomycin

CrCl more than 60 mL/min: 15 mg/kg (actual body weight), rounded up to the nearest 125 mg, up to 2 g, 12-hourly. Maximum daily dose 4 g

CrCl 20 to 60 mL/min: 7.5 mg/kg (actual body weight), rounded up to the nearest 125 mg, up to 1 g, 12-hourly. Maximum daily dose 2 g

CrCl less than 20 mL/min: 15 mg/kg (actual body weight), rounded up to the nearest 125 mg, up to 2 g, as a single dose¹.

For noncritically ill adults with obesity, it is the consensus view of the Antibiotic Expert Group that the initial vancomycin dosage should be the same as that for nonobese patients (as above).

For adults undergoing haemodialysis, see Vancomycin dosing, monitoring and dosage adjustment in adults undergoing dialysis.

Vancomycin monitoring is required if therapy continues for more than 48 hours. The maintenance dosage depends on the vancomycin plasma concentration. Monitoring and dose adjustment is essential for all patients receiving vancomycin to optimise drug exposure and minimise toxicity.

Consider switching to a continuous vancomycin infusion for patients who require higher or more frequent doses (eg patients with obesity, patients with central nervous system infection) or those admitted to an ambulatory antimicrobial therapy service.

Table 1. Calculated vancomycin maintenance dosages in adults[NB1]
Actual body weight: 40 kg or less 41 to 50 kg 51 to 60 kg 61 to 80 kg 81 to 100 kg 101 to 120 kg 121 kg or more
Actual body weight: 40 kg or less
CrCl [NB2]	Suggested dosage
more than 60 mL/minute	15 mg/kg (actual body weight) 12-hourly
20 to 60 mL/minute	7.5 mg/kg (actual body weight) 12-hourly
less than 20 mL/minute and not treated with dialysis	15 mg/kg (actual body weight) as a single dose [NB3]
Actual body weight: 41 to 50 kg
CrCl [NB2]	Suggested dosage
more than 60 mL/minute	750 mg 12-hourly
20 to 60 mL/minute	375 mg 12-hourly
less than 20 mL/minute and not treated with dialysis	750 mg as a single dose [NB3]
Actual body weight: 51 to 60 kg
CrCl [NB2]	Suggested dosage
more than 60 mL/minute	1 g 12-hourly
20 to 60 mL/minute	500 mg 12-hourly
less than 20 mL/minute and not treated with dialysis	1 g as a single dose [NB3]
Actual body weight: 61 to 80 kg
CrCl [NB2]	Suggested dosage
more than 60 mL/minute	1.25 g 12-hourly
20 to 60 mL/minute	625 mg 12-hourly
less than 20 mL/minute and not treated with dialysis	1.25 g as a single dose [NB3]
Actual body weight: 81 to 100 kg
CrCl [NB2]	Suggested dosage
more than 60 mL/minute	1.5 g 12-hourly
20 to 60 mL/minute	750 mg 12-hourly
less than 20 mL/minute and not treated with dialysis	1.5 g as a single dose [NB3]
Actual body weight: 101 to 120 kg
CrCl [NB2]	Suggested dosage
more than 60 mL/minute	1.75 g 12-hourly
20 to 60 mL/minute	875 mg 12-hourly
less than 20 mL/minute and not treated with dialysis	1.75 g as a single dose [NB3]
Actual body weight: 121 kg or more
CrCl [NB2]	Suggested dosage
more than 60 mL/minute	2 g 12-hourly
20 to 60 mL/minute	1 g 12-hourly
less than 20 mL/minute and not treated with dialysis	2 g as a single dose [NB3]
Note: CrCl = creatinine clearance NB1: The dosages in this table are for initial dosing only, up to 48 hours. Subsequent dosage adjustments should be based on plasma concentration monitoring. NB2: Use the Cockcroft–Gault formula or calculator to approximate creatinine clearance. NB3: For adults with creatinine clearance less than 20 mL/minute and not treated with dialysis, a single dose may be given. Measure the plasma concentration 48 hours after the dose. Seek expert advice to determine ongoing doses and dosing interval.

¹ Measure the vancomycin plasma concentration 48 hours after the dose. Seek expert advice to determine ongoing doses and dosing interval.Return