Approach to vancomycin dosing in adults undergoing haemodialysis
Therapy with vancomycin may be started during dialysis, or a patient undergoing haemodialysis may present outside of a dialysis session (eg to an emergency department). In cases where the patient presents outside of a dialysis session, do not wait until a dialysis day to initiate therapy.
A loading dose is recommended in haemodialysis patients to ensure rapid attainment of target vancomycin plasma concentrations.
If vancomycin is administered to an adult during high-flux haemodialysis1, use:Allawati, 2020Hui, 2019Lewis, 2021Rybak, 2020Zelenitsky, 2022
vancomycin intravenously (loading dose)vancomycinvancomycinvancomycin
30 mg/kg (actual body weight) rounded up to the nearest 125 mg, as a single dose. Maximum loading dose 3 g
FOLLOWED BY2
vancomycin intravenously (initial maintenance dose)
12.5 mg/kg (actual body weight) rounded up to the nearest 125 mg, as a single dose. Maximum initial maintenance dose 2 g3.
If vancomycin is administered to an adult after high-flux haemodialysis or on a nonhaemodialysis day, useAllawati, 2020Hui, 2019Lewis, 2021Zelenitsky, 2022:
vancomycin intravenously (loading dose)vancomycinvancomycinvancomycin
25 mg/kg (actual body weight) rounded up to the nearest 125 mg, as a single dose. Maximum loading dose 2.5 g
FOLLOWED BY2
vancomycin intravenously (initial maintenance dose)
10 mg/kg (actual body weight) rounded up to the nearest 125 mg, as a single dose. Maximum initial maintenance dose 1.75 g3.
Although vancomycin is removed by haemodialysis, it is desirable to administer vancomycin during haemodialysis because there may be challenges in obtaining intravenous access and a need to preserve veins for future vascular access. Vancomycin is commonly administered during the last 1 to 2 hours of haemodialysis, especially in the outpatient setting. Giving a dose during or after each haemodialysis session usually ensures adequate vancomycin exposure until the end of the interdialytic interval.