After a discussion at work I’ve been looking to current recommendations for proper vancomycin dosing in the ICU and ER.
Drug monitoring should be performed. Through serum concentrations just before the next dose at steady state are recommended. Steady state is achieved normally just before the fourth dose. The minimum through serum concentration should be above 10mg/L to avoid the resistance and at least moderate concentration at the infection theatre. If you have a MRSA with a Minimal Inhibition Concentration (MIC) of 1mg/L or above minimum through concentrations of 15-20mg/L should be targeted. To achieve optimal through concentrations doses of 15-20mg/kg actual body weight (ABW) should be given every 8-12 hours with normal renal function. In case of a MIC of 2 or above conventional dosing regimes fail. If you have a serious ill patient the authors recommend a loading dose of 25-30mg/kg ABW. Vancomycin Induced Nephrotoxicity is defined as two or three increases in serum creatinine concentrations (0,5mg/dL or 50% above baseline) after several days of therapy. Frequent monitoring is not recommended if there is no risk for renal failure. The authors suggest a weekly monitoring for stable patients. Every patient should receive at least one through serum level and repeated as deemed clinically appropriate.
So dose right, know your MIC.
Rybak, Michael, et al. “Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists.” American Journal of Health-System Pharmacy 66.1 (2009): 82-98.