See also

Antimicrobial guidelines

Key points

1. Administer vancomycin intravenously (IV) over at least 1 hour. Rapid infusion may cause vancomycin infusion reaction (see Adverse Effects section below)
2. Vancomycin levels are required to ensure that the target therapeutic range is achieved (see Therapeutic Drug Monitoring sections below) 
3. Continuous infusions of vancomycin in infants aged 0 to 90 days are associated with earlier and improved attainment of target concentrations compared with intermittent dosing 

Dose

Continuous infusion

Infants 0-90 days of age

Loading dose 15 mg/kg/dose IV (over 1 hour) followed by continuous infusion:

* >60 to the upper limit of normal for serum creatinine. For children with moderate to severe renal impairment, seek specialist advice for dosing

Infants and children >90 days of age

Seek specialist advice

Switching from intermittent vancomycin dosing to continuous infusion:

• Commence at dose equivalent to total daily dose administered in previous 24-hour period
  • Continuous infusion can be commenced immediately after last intermittent dose is given
  • Loading dose is not required
    

Initiating vancomycin treatment with a continuous infusion:

• Give loading dose 20-30 mg/kg over 1 hour, followed by continuous infusion
• Usual starting dose is 60 mg/kg/day
  

Therapeutic drug monitoring
Target steady state level:

• 15–25 mg/L (0-90 days of age)
• 20-25 mg/L (>90 days of age)
• Collect sample for steady state vancomycin level approximately 18-30 hours after start of infusion (with routine bloods where possible)
• If steady state level is within target range, continue vancomycin infusion and repeat steady state level 18-30 hours after first level

Dose adjustment
If steady state level is outside therapeutic range, adjust dose according to the following formula:

Adjusted dose (mg/day) = last maintenance dose (mg/day) x (target level/last vancomycin level)

Eg if a 3 kg infant is prescribed 50 mg/kg/day and has a vancomycin level of 13 mg/L, the adjusted dose = 150 mg x (20/13) = 230 mg/day

The maximum total daily dose should not exceed 80 mg/kg/day 

Intermittent dosing

Infants 0-90 days of age

Individualised dosing and therapeutic drug monitoring (TDM) with calculation of area under the curve (AUC) are to be done using Vanc App online calculators: 

• Vancomycin Intermittent Dosing Calculator
• Vancomycin AUC Calculator

Seek specialist advice for dosing and TDM for the following infants, for whom the Vanc app calculators are not intended to be used:

• PMA <25 weeks
• Weight <500 grams
• Renal impairment
• Receiving extracorporeal membrane oxygenation or renal replacement therapy

The Vanc App calculator was developed by researchers at MCRI in collaboration with RCH and is based on a published population pharmacokinetic model

Dosing
Individualised dosing using Vancomycin Intermittent Dosing Calculator, based on the infant’s

• Postmenstrual age (PMA) in weeks (same as corrected gestational age)
• Weight (kg)
• Serum creatinine (micromol/L)
• Target trough concentration (mg/L) (default 15 mg/L)

Therapeutic drug monitoring
An AUC of 400-650 mg/L.h is the therapeutic target for vancomycin. The AUC should be calculated each time a vancomycin trough level is measured

Calculate the AUC via Vancomycin AUC Calculator, based on:

• PMA (weeks)
• Weight (kg)
• Serum creatinine (micromol/L)
• Dose (mg) and dosing interval (hours)
• Trough level taken at least 24 hours after commencing vancomycin or adjusting dose

Initial vancomycin trough levels should be taken (and an AUC calculated) according to the following:

• Trough level samples are to be taken approximately 30 minutes before the dose is due
• For inpatients with normal renal function, the next dose of vancomycin should be given at the scheduled time before the level is known

Vancomycin levels should be repeated (and AUC calculated) until there are 2 consecutive AUCs within target range (400-650 mg/L.h). After this, vancomycin levels (and AUC calculation) can be repeated every 3 days or whenever there is a significant change in bodyweight, serum creatinine or if the dose has been adjusted

Dose adjustment
If AUC is outside therapeutic range (ie <400 mg/L.hr or >650 mg/L.h), adjust dose according to the following formula:

Adjusted dose (mg/day) = last maintenance dose (mg/day) x (target AUC/last AUC)

A default target AUC of 500 mg/L.h (midpoint of 400-650 mg/L.h) should be used

Eg if a 3 kg infant with PMA 40 weeks is prescribed 50 mg 8 hourly (50 mg/kg/day) and has an AUC of 700 mg/L.h, the adjusted dose = 150 mg x (500/700) = 107 mg/day = 36mg 8 hourly (the dose interval should not change)

The maximum total daily dose should not exceed 80mg/kg/day

Infants and children >90 days of age

Dosing
Usual starting dose: 15 mg/kg/dose (maximum 750 mg) every 6 hours

• In children with severe sepsis, consider a loading dose of 30 mg/kg (maximum 1500 mg). The next dose is then given 6 hours after the loading dose
• Use actual body weight for dose calculations, including obese patients, up to the maximum recommended doses
• For children with moderate to severe renal impairment, seek specialist advice for initial dosing

Therapeutic drug monitoring – trough level
Target trough level: 10-15 mg/L (15-20 mg/mL for severe infections) 

• Trough level samples are to be taken approximately 30 minutes before the dose is due
• For inpatients with normal renal function, the next dose of vancomycin should be given at the scheduled time before the level is known

Vancomycin levels should be repeated until there are two consecutive levels within target range. After this, vancomycin levels can be repeated every 3 days or whenever there is a significant change in bodyweight, serum creatinine or if the dose has been adjusted

Dose adjustment
If vancomycin level is outside therapeutic range, adjust dose according to the following formula:

Adjusted dose (mg/day) = last maintenance dose (mg/day) x (target level/last vancomycin level) 

Eg if a 15 kg child is prescribed 225 mg 6 hourly and has a vancomycin level of 23 mg/L, the adjusted dose = 900 mg x (15/23) = 587 mg/day

The maximum total daily dose should not exceed 80mg/kg/day 

Administration

Dilute to 5 mg/mL or weaker and infuse over at least 60 minutes (maximum rate 10 mg/minute) 

Concentrations up to 10 mg/mL may be administered via a central line if necessary. The risk of infusion reactions is increased with higher concentrations (see Adverse effects below)

Adverse effects

Vancomycin is potentially nephrotoxic and ototoxic, especially when used in combination with other nephrotoxic or ototoxic agents (eg aminoglycosides) and in renal impairment
Rapid infusion may cause vancomycin infusion reaction (previously referred to as red man syndrome):

• flushing or rash on upper body and neck
• muscle spasm of chest and back
• fever
• hypotension
• itch

These features develop quickly and usually subside within an hour, but may persist for several hours in some cases

If symptoms of vancomycin infusion reaction occur:

• Cease infusion
• Check dose and infusion rate
• Wait for symptoms to resolve
• Further dilute infusion if possible
• Resume infusion at a reduced rate
• Document adverse reaction in patient notes and update their Allergies and Adverse Drug Reaction details
• Infuse subsequent doses over 90-120 minutes and consider administration of an antihistamine before future doses

Consider consultation with local paediatric team when

• Child with renal impairment
• Unable to achieve vancomycin AUC or trough level within the target range

Consider transfer when

Child requiring care beyond the level of comfort of the local hospital

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650

Last updated July 2023