No longer a primary target; do NOT push 15–20 to chase AUC
Empiric Dosing (normal renal function, actual body weight)
Phase
Dose
Notes
Loading dose
20–25 mg/kg IV
Consider 25–30 mg/kg in critically ill/septic; many institutions cap ~2–3 g
Maintenance
15–20 mg/kg q8–12h
Titrate to AUC; interval driven by renal function. Estimate with the CrCl calculator
Infusion
≤10–15 mg/min
Doses >1 g over ≥90–120 min to limit infusion reaction
Monitoring
⭐
Bayesian (preferred): 1–2 levels, flexible timing, does not require steady state.
📈
Two-level (no software): post-distribution peak 1–2 h after infusion + trough near end of interval, same interval at steady state.
🔄
Recheck with any significant renal change; for stable inpatients roughly every 3–5 days. Trough-only monitoring is not recommended.
Nephrotoxicity
Item
Detail
VAN-AKI definition
SCr rise ≥0.5 mg/dL or ≥50% from baseline on ≥2 consecutive draws ≥24 h apart
Monitor SCr
Baseline then q48–72h (daily in ICU/unstable)
AUC vs trough
AUC-guided dosing lowers AKI vs trough-only targeting
⚠ The vancomycin + piperacillin-tazobactam AKI signal (older observational data) was not confirmed by the 2023 ACORN randomized trial (no difference vs cefepime) and may partly reflect pseudotoxicity. Consider cefepime/meropenem in high AKI-risk patients, but pip-tazo need not be reflexively avoided.
Red Flags & Pearls
🛑
MIC ≥2 mg/L: vancomycin is a poor choice, consider linezolid, ceftaroline, or daptomycin (daptomycin is inactivated by surfactant, so not for pneumonia).
💊
Oral vancomycin is for C. difficile only, with negligible systemic absorption.
🌪️
CRRT: clearance is highly variable (filter/flow-dependent); AUC monitoring is essential, q24–48h redosing is a common starting point.