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What adjustments should be made for administering vancomycin to patients receiving hemodialysis?
It is important to load patients receiving dialysis with 15 to 20 mg/kg based on ABW. Maintenance doses will depend on the dialysis membrane used during hemodialysis.
Vancomycin Administration in Patients Undergoing Dialysis
HEMODIALYSIS (HD) (HIGH FLUX) | CONTINUOUS VENOVENOUS HEMOFILTRATION (HD, HEMODIAFILTRATION) | PERITONEAL | |
|---|---|---|---|
| Loading dose | 15–20 mg/kg dose based on actual body weight (ABW) Note: Not to exceed 1500 mg May consider 20 mg/kg in severe infections (i.e., meningitis, severe sepsis, endocarditis, osteomyelitis, and hospital-acquired pneumonia [HAP]) | 15–20 mg/kg dose based on ABW Note: Not to exceed 1500 mg May consider 20 mg/kg in severe infections (i.e., meningitis, severe sepsis, endocarditis, osteomyelitis, HAP) | Not necessary |
| Maintenance dose (postdialysis) | <75 kg: 500 mg after HD for predialysis level <20 >75 kg: 1000 mg after HD for predialysis level <20 | 10–15 mg/kg every 24 h Note: May consider higher doses in patients who are obese not to exceed 1500 mg Intravenous (IV) q24h | IP (intraperitoneal): 30 mg/kg loading dose 15 mg/kg every 3–5 days Note: Patients that are not anuric may need to adjust dosing frequency because there is residual kidney function IV: 15–20 mg/kg per dose |
| Serum level monitoring | Draw serum level prior to the second HD session, then get random levels with am labs on HD days only (or q48 h) Note: Subsequent serum levels should be drawn prior to every or every other HD session | Draw serum level prior to the second or third dose (approximately 24 h after last dose) Note: May draw random daily levels with am labs | IP: Draw serum trough level 72 h after loading dose IV: Draw serum trough level 48–72 h after initial dose |
| Dosing based on serum levels | If pre-HD level is: >20: hold dose 10–20: give dose after HD (based on weight) <10: administer another loading dose after HD | If serum level is: >20: hold dose 10–20: continue with q24h dosing <10: 15–20 mg/kg loading dose → consider more frequent dosing or increasing the dose | If level is: >20: hold dose <20: administer anot |
