Your patient is an 83 y/o woman who presents with sepsis secondary to pneumonia.
She had
received IV antibiotics approximately 2 weeks. The team wants to start her on vancomycin, but
needs you to recommend a dose.
Her weight is 60 kg, her SCr is 0.9 mg/dL and she is 5’6”. Please design a dosing regimen with
monitoring recommendations for the team.
First loading dose 1,500 mg IVPG in 250 mL NS over 60 mins once
Maintenance dose 1,000 mg IVPG in 250 mL NS over 60 mins q24h
Duration of therapy 7-21 days
Monitor vanco trough level: 15-20 mg/L
MOA: Glycopeptide inhibits cell wall synthesis by interfering with cross-linking in the
development of peptidoglycan, leading to cell wall lysis, different from beta-lactams
G+ coverage
o Staphylococcus
S. aureus
o Streptococcus
o Enterococcus
o Empiric or definitive therapy for MRSA/enterococcus
Complicated SSTIs
Osteomyelitis
Pneumonia
Bone/joint infection
Meningitis
PK/PD of vanco
o Time-dependent killing
Killing activity doesn’t change with increasing concentrations
o Bactericidal
o Hydrophilic
Good penetration to blood, liver, kidney (urine), soft tissue in nondiabetic
pts
Poor penetration to eye, lung, CSF
o Elimination
Primarily excreted unchanged via kidneys via glomerular filtration
80-90% recovered unchanged in urine within 24 hours
Dose adjustments necessary for renal insufficiency
o AUC 0-24 /MIC
Area under the serum concentration vs. time curve for 0-24 hours (AUC24)
has emerged as the preferred method for monitoring vancomycin
therapy in patients with staphylococcal bacteremia, endocarditis, and
invasive infection.
Administration
o IV in D5W or NS
Do not administer IM
Rectal/PO only for c. difficile diarrhea
o Maximum concentration: 5 mg/mL
o Over 1g, infuse over 2 hours
Patient CrCl calculation
Ideal body weight (IBW) (women) = 45.5 kg + 2.3 kg x (height, in - 60)
IBW = 59.3 kg, TBW= 60 kg
o BMI= 21 kg/m2
o Use IBW to calculate CrCl
(140-age) * weight / SCr * 72 (*0.85 if female)
o (140-83)*59.3*0.85/0.9*72 = 44.3 mL/min
Elimination rate constant: Ke = 0.00083 * CrCl + 0.0044 = 0.042 hr-1
Vd (nonobese) = 0.7 L/kg * TBW = 0.7* 60 = 42 L
T1/2 = 0.693/Ke = 16.5 h
Steady state 4T1/2-5T1/2 = 66-83.5 h
Loading dose = 25-35 mg/kg (TBW) round to the nearest 250 mg
1,500 -2,100 mg -> 1,500 mg
Maintenance dose = 15-20 mg/kg (TBW)
900 – 1,200 mg -> 1,000 mg
Dosing interval: q24h
Goal trough 15-20 mg/L for pneumonia
