VANCOMYCIN HCL (Generic for FIRVANQ)

General Administration Information
For storage information, see the specific product information within the How Supplied section.

Route-Specific Administration

Oral Administration
Oral Solid Formulations
-May be administered with or without food. Swallow whole; do not crush or chew.

Oral Liquid Formulations
Powder for oral solution
-Shake well prior to each administration.
-Measure dosage with a calibrated spoon, cup, or oral syringe.

Reconstitution

-Available as a compounding kit containing 1 bottle of vancomycin powder and 1 bottle of grape-flavored diluent.
-Various bottle sizes are available, which, when reconstituted, produce either a 25 mg/mL or 50 mg/mL vancomycin oral solution. Select the appropriate bottle size/concentration for the individual patient.
-Remove the cap from the bottle containing the vancomycin powder. Tap the top of the induction seal to loosen the powder. Slowly peel back the foil seal.
-Shake the bottle containing grape-flavored diluent for a few seconds prior to removing the cap.
-Open the diluent bottle and empty about half of the contents into the vancomycin powder bottle.
-Replace the cap and shake the mixture vertically for approximately 45 seconds.
-Add the remaining diluent into the vancomycin powder bottle.
-Replace the cap and shake the bottle for approximately 30 seconds.
-Storage after reconstitution: Store under refrigeration at 2 to 8 degrees C (36 to 46 degrees F); do not freeze. Discard any unused solution after 14 days. Keep container tightly closed and protect from light.

Extemporaneous Compounding-Oral
-If a commercial oral product is not available, the vancomycin powder for injection (not including ADD-Vantage vials) may be used for enteral administration. Dilute the appropriate dose in 1 ounce of water. Common flavoring syrups may be added to the solution to improve palatability. Prepare the solution just prior to administration. Administer orally or via a nasogastric tube.



Injectable Administration
-Administer by intravenous infusion; do not administer by rapid IV injection.
-Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Intravenous Administration
Intermittent IV Infusion
Powder Vials for Injection
Reconstitution
-Reconstitute vials with Sterile Water for Injection to yield a 50 mg/mL solution.
--Reconstitute the 250 mg vial with 5 mL of Sterile Water for Injection.
-Reconstitute the 500 mg vial with 10 mL of Sterile Water for Injection.
-Reconstitute the 750 mg vial with 15 mL of Sterile Water for Injection.
-Reconstitute the 1,000 mg vial with 20 mL of Sterile Water for Injection.
-Reconstitute the 1,250 mg vial with 25 mL of Sterile Water for Injection.
-Reconstitute the 1,500 mg vial with 30 mL of Sterile Water for Injection.

-Further dilution is required before administration.
-Storage: Reconstituted vials may be stored in the refrigerator for up to 14 days.

Dilution
-Further dilute the reconstituted solution with a compatible IV solution to a final concentration of 5 mg/mL.
--Dilute the 250 mg reconstituted vial with 50 mL of infusion solution.
-Dilute the 500 mg reconstituted vial with 100 mL of infusion solution.
-Dilute the 750 mg reconstituted vial with 150 mL of infusion solution.
-Dilute the 1,000 mg reconstituted vial with 200 mL of infusion solution.
-Dilute the 1,250 mg reconstituted vial with 250 mL of infusion solution.
-Dilute the 1,500 mg reconstituted vial with 300 mL of infusion solution.

-A final concentration of 5 mg/mL is recommended for administration; however, concentrations of up to 10 mg/mL may be used in patients in need of fluid restriction. Higher concentrations may increase the risk of infusion-related reactions.
-Storage: Solutions diluted with 5% Dextrose Injection or 0.9% Sodium Chloride Injection may be stored in the refrigerator for up to 14 days. Solutions diluted with 5% Dextrose Injection and 0.9% Sodium Chloride Injection, Lactated Ringer's Injection, Lactated Ringer's and 5% Dextrose Injection, Normosol-M, or Isolyte E may be stored in the refrigerator for up to 96 hours.

Bulk Vials for Injection
Reconstitution
-Reconstitute vials with Sterile Water for Injection.
--Reconstitute the 5 g vial with 100 mL of Sterile Water for Injection to yield a 500 mg/10 mL (50 mg/mL) solution.
-Reconstitute the 10 g vial with 95 mL of Sterile Water for Injection to yield a 500 mg/5 mL (100 mg/mL) solution.

-Penetrate the bulk vial once with a suitable sterile dispensing set that allows measured distribution of the contents. Use the entire contents of the bulk vial during reconstitution.
-Further dilution is required before administration.
-Storage: Once penetration of the bulk vial has occurred with the sterile dispensing set, withdrawal of the contents should be done promptly. A maximum of 4 hours from initial penetration may be allowed to complete fluid aliquoting/transferring options before discarding the container.

Dilution
-Further dilute the reconstituted solution with a compatible IV solution to a final concentration of 5 mg/mL. Concentrations of up to 10 mg/mL may be used in patients in need of fluid restriction; higher concentrations may increase the risk of infusion-related reactions.
-Compatible fluids include 5% Dextrose Injection, 0.9% Sodium Chloride Injection, 5% Dextrose Injection and 0.9% Sodium Chloride Injection, Lactated Ringer's Injection, Lactated Ringer's and 5% Dextrose Injection, Normosol-M and 5% Dextrose Injection, or Isolyte E.
-Storage: Specific storage instructions after dilution are not provided in the FDA-approved labeling for bulk products. Use compounded admixtures as soon as feasible. Product labeling for the vancomycin 1 g vials product states that solutions diluted in 5% Dextrose Injection or 0.9% Sodium Chloride Injection are stable for 14 days under refrigeration.

ADD-Vantage IV Solution
Reconstitution
-Reconstitute only with 0.9% Sodium Chloride Injection or 5% Dextrose Injection in the appropriate flexible diluent container provided. For 500 mg vials, use at least a 100 mL diluent container, and for 750 mg and 1 g vials, use only the 250 mL diluent container.
-Remove the protective covers from the top of the vial and vial port. Remove vial cap (do not access with a syringe) and vial port cover. Screw the vial into the vial port until it will go no further to assure a seal. Once vial is sealed to the port, do not remove. To activate the contents of the vial, squeeze the bottom of the diluent container gently to inflate the portion of the container surrounding the end of the drug vial. With the other hand, push the drug vial down into the container telescoping walls of the container and grasp the inner cap of the vial through the walls of the container. Pull the inner cap from the drug vial. Verify the rubber stopper has been pulled out, allowing the drug and diluent to mix. Mix the container contents thoroughly.
-Storage: The admixture solution may be stored for up to 24 hours at room temperature or in the refrigerator for up to 14 days.
-Do not use in series connections with flexible containers.

Pre-mixed Galaxy IV Solution
Preparation
-Thaw frozen containers at room temperature (25 degrees C or 77 degrees F) or under refrigeration (5 degrees C or 41 degrees F). Do not force thaw by immersion in water baths or by microwave irradiation. Check for leaks by squeezing the bag firmly.
-Do not add supplementary medication.
-Contents of the solution may precipitate in the frozen state and should dissolve with little or no agitation once the solution has reached room temperature.
-Storage: The thawed solution is stable for 72 hours at room temperature or 30 days under refrigeration. Do not refreeze thawed product.
-Do not use plastic containers in series connections as this could result in an embolism due to residual air being drawn from the primary container before administration of the fluid from the secondary container is complete.

Flexible bag IV solution
Preparation
-Remove the flexible bag from the aluminum overpouch.
-Do not add supplementary medication.
-Storage: The solution is stable for 28 days at room temperature (up to 25 degrees C or 77 degrees F) after removal from the aluminum overpouch.
-Do not use flexible bags in series connections as this could result in an embolism due to residual air being drawn from the primary container before administration of the fluid from the secondary container is complete.

Intermittent IV Infusion
-Infuse over at least 1 hour to reduce the risk of infusion-related reactions. Larger loading doses may require extended infusion times (at least 2 to 3 hours).
-Infusion rates of 10 to 15 mg/minute are recommended.

Plasmapheresis
-Administer dose after plasmapheresis.

Continuous IV Infusion*
NOTE: Vancomycin is not FDA-approved to be administered by continuous IV infusion.
Reconstitution
-Reconstitution for continuous infusion is not specifically discussed in the literature. Follow manufacturer instructions.

Dilution
-Although data are limited, most pediatric studies have used vancomycin concentrations of 5 mg/mL diluted in 5% Dextrose Injection; however, concentrations up to 20 mg/mL have been reported. Higher concentrations may increase the risk of infusion-related reactions.
-Stability: Stability data is limited in pediatric patients. The following data is from adult studies.

--A study used 10 g of vancomycin diluted in 1,000 mL of 5% Dextrose Injection; doses were stored at 4 degrees C until approximately 15 minutes before use. Doses were infused at room temperature for 24 to 48 hours. The concentration of vancomycin in the remaining fluid of the infusion sets was approximately equivalent to the initial concentration (10 g/L).
-Additionally, samples of concentrated solutions (up to 83 g/L) were incubated at increasing temperatures up to 50 degrees C for up to 72 hours. Samples degraded less than 5% when kept for 72 hours at up to 37 degrees C. Samples exposed to 50 degrees C showed more than 7% degradation.


Continuous IV Infusion
-Continuous infusion regimens usually start after an initial loading dose.
-Doses have been administered over 24 hours in pediatric patients.

Intrathecal Administration
NOTE: Vancomycin is not FDA-approved for intrathecal administration.
Reconstitution
-Use preservative-free product.
-A concentration of 10 mg in 1 mL of 0.9% Sodium Chloride Injection has been used.

Intrathecal injection*
-Administer via lumbar puncture.

Other Injectable Administration
Intraventricular Administration*
NOTE: Vancomycin is not FDA-approved for intraventricular administration.
Reconstitution
-Use preservative-free product.
-Concentrations of 10 mg in 1 to 10 mL of 0.9% Sodium Chloride Injection have been used.

Intraventricular injection

-Reports describe varying amounts of CSF aspirated into the syringe containing the vancomycin dose for instillation and potentially followed by a 2 mL flush of 0.9% Sodium Chloride Injection.
-When administered through a ventricular drain, the drain should be clamped for 15 to 60 minutes to allow the antimicrobial solution to equilibrate in the CSF before opening the drain.



Rectal Administration
Extemporaneous Compounding-Rectal
Retention Enema (using powder for injection)
-Very limited data; vancomycin 125 mg in 25 mL of 0.9% Sodium Chloride Injection has been utilized in a case report of a 4-year-old child. Doses of 0.5 to 1 g diluted in 100 to 500 mL of 0.9% Sodium Chloride Injection have been utilized in adults. Careful consideration should be given to the patient's age and size when determining a suitable dose/volume.
-While no specific preparation instructions have been described, preparation of the enema per the instructions associated with each specific powder for injection product would seem warranted.
-Stability should coincide with specific intravenous product labeling.

Instillation
-While guidelines and case reports do not provide specific instillation recommendations for pediatric patients, a method of instilling the dose over 15 minutes with clamping of the tube for 1 to 2 hours has been described in adult patients. Specific patient circumstances (i.e., age and weight of patient) will likely dictate the duration of the dwell.

Intraperitoneal administration of vancomycin has been associated with chemical peritonitis.

Transient or permanent ototoxicity has occurred in patients receiving IV vancomycin. A few dozen cases of hearing loss have been reported. Serial tests of auditory function may be helpful in order to minimize the risk of ototoxicity. Vertigo, dizziness, and tinnitus have been reported rarely.

Nephrotoxicity/renal failure (unspecified), principally manifested by azotemia (increased BUN) or increased serum creatinine (SCr), has been reported with vancomycin. Nephrotoxicity has been reported in 5.4% to 17.2% of pediatric patients receiving vancomycin in retrospective studies. In 1 study (n = 167, ages 1 week to 19 years), patients with high average serum trough concentrations (15 mcg/mL or higher) and those receiving concomitant furosemide in the intensive care unit were significantly more likely to develop nephrotoxicity. However, another study (n = 113, age 0 to 23 years) found no significant difference in the rates of nephrotoxicity in patients with target vancomycin trough concentrations of 15 to 20 mcg/mL (8.8%, mean trough 17.8 mcg/mL) compared to those with target trough concentrations of 5 to 15 mcg/mL (5.4%, mean trough 8.4 mcg/mL). Other factors associated with an increased risk of nephrotoxicity in studies of critically ill pediatric patients include duration of vancomycin therapy, use of extracorporeal membrane oxygenation (ECMO), use of vasopressors, administration of other nephrotoxic drugs, and elevated BUN to SCr ratio before vancomycin therapy. Most episodes of vancomycin-associated acute kidney injury (AKI) develop between 4 and 17 days after initiation of therapy. Many patients, especially those who are critically ill, do not fully recover renal function after AKI. In studies with oral vancomycin in adults, 5% of patients experienced nephrotoxicity (renal failure, renal impairment, and increased serum creatinine). Nephrotoxicity typically occurred within 1 week after completion of treatment. Cases of interstitial nephritis, a hypersensitivity reaction, have also been rarely reported with intravenous vancomycin.

Rapid infusion of vancomycin can cause histamine release. This histamine-release reaction, also known as vancomycin infusion reaction, is characterized by flushing of the face, neck, upper body, arms, and/or back. This may result in anaphylactoid reactions including hypotension, sinus tachycardia, wheezing, dyspnea, urticaria, erythema, pruritus, and rarely cardiac arrest. Rapid infusion may also cause pain and muscle spasm of the chest and back or paresthesias. Symptoms usually resolve within 20 minutes but may last for several hours. Stopping or slowing the infusion rates (i.e., 10 mg/minute or less or infuse over 60 minutes or more), may reduce the incidence or severity of the reaction. Administer intravenous vancomycin through a secure route; the drug is irritating to tissues and may cause pain, tenderness, and necrosis if extravasation occurs. Phlebitis, vasculitis, and other types of injection site reaction have also been reported. Histamine-release reactions have also been reported with the use of oral vancomycin.

Hematologic adverse reactions have been reported with vancomycin. Reversible neutropenia has been reported in pediatric patients receiving vancomycin. In adult patients, neutropenia has been reported to occur 1 week or more after starting vancomycin or after a total dose of more than 25 g IV and has been reported in the literature to occur at rates of 2% to 12%. Prompt reversal of neutropenia occurs when vancomycin is discontinued. Vancomycin-induced thrombocytopenia has also rarely been reported, and, in 1 study in adult patients, was determined to be immune related. One study also reported that, in patients with renal impairment, prolonged thrombocytopenia was observed due to altered clearance of vancomycin. Eosinophilia and reversible agranulocytosis have also been reported rarely.

Severe dermatologic adverse reactions, including toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS), drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), exfoliative dermatitis, and linear IgA bullous dermatosis (LABD), have been reported with vancomycin therapy. Cutaneous signs or symptoms reported include skin rash, mucosal lesions, and blisters. Discontinue vancomycin at the first appearance of signs and symptoms of severe skin reaction.

General adverse reactions associated with IV vancomycin include drug fever and chills. Fever (9%), peripheral edema (6%), and fatigue (5%) have been reported with the use of oral vancomycin in adult patients.

Gastrointestinal adverse events have been reported with the use of oral vancomycin in adult patients and include abdominal pain (15%), vomiting (9%), diarrhea (9%), and flatulence (8%). Nausea was reported in 17% of adult patients receiving oral vancomycin in clinical trials, but has also been reported with the use of IV vancomycin.

Microbial overgrowth and superinfection can occur with antibiotic use. C. difficile-associated diarrhea (CDAD) or pseudomembranous colitis has been reported with vancomycin. If pseudomembranous colitis is suspected or confirmed, ongoing antibacterial therapy not directed against C. difficile may need to be discontinued. Institute appropriate fluid and electrolyte management, protein supplementation, C. difficile-directed antibacterial therapy, and surgical evaluation as clinically appropriate. Urinary tract infection was reported in 8% of adult patients receiving oral vancomycin.

Hypokalemia was reported in 13% of adult patients during clinical trials with oral vancomycin; the incidence in pediatric patients is unknown.

Back pain was reported in 6% of adult patients receiving oral vancomycin in clinical trials.

Hemorrhagic occlusive retinal vasculitis (HORV), including visual impairment (i.e., permanent loss of vision), has occurred in patients receiving intracameral or intravitreal vancomycin during or after cataract surgery. Characteristics of HORV include a delayed onset (up to 3 weeks) of sudden painless decreased vision, intraocular inflammation, intraretinal hemorrhage, retinal vasculitis, vascular occlusion of retinal vessels, and retinal ischemia. The safety and efficacy of vancomycin by the intracameral or intravitreal routes have not been established by adequate and well-controlled trials; prophylactic intraocular vancomycin use during cataract surgery is generally not recommended.

Vancomycin is contraindicated in patients who have a history of vancomycin hypersensitivity. Vancomycin solutions containing dextrose may be contraindicated in patients with history of corn hypersensitivity or corn product hypersensitivity.

Use vancomycin with caution in patients with renal disease such as renal failure or renal impairment because it can accumulate. Neonates with immature renal function are also at risk for accumulation. Monitor vancomycin serum concentrations, renal-function tests, and urine output during intravenous therapy, especially when concurrent nephrotoxic agents, such as aminoglycosides, are used. Dosage adjustment may be necessary depending on the degree of renal dysfunction. Although data are limited, literature suggests that the risk of acute kidney injury (AKI) increases as a function of trough, especially when maintained above 15 to 20 mg/L or the daily AUC exceeds 650 to 1,300 mg x hour/L. AUC-guided monitoring may reduce the occurrence of vancomycin-associated AKI. Nephrotoxicity (renal failure), principally manifested by azotemia (increased BUN) or increased serum creatinine, has been reported with vancomycin. Factors associated with nephrotoxicity include increased weight, pre-existing renal dysfunction, critical illness, and concurrent nephrotoxic agents. Many patients, especially those who are critically ill, do not fully recover renal function after AKI. Clinically significant serum concentrations have been reported after oral vancomycin use in some patients with inflammatory disorders of the intestinal mucosa; therefore, serum concentration monitoring may also be beneficial in some patients with renal impairment receiving oral therapy.

Administer each intravenous vancomycin dose over at least 60 minutes. Larger loading doses may require extended infusion times of at least 2 to 3 hours. Infusion rates of 10 to 15 mg/minute are recommended. Too-rapid administration can lead to infusion-related reactions such as 'red man syndrome'. The frequency of infusion-related events may be higher with the concomitant administration of anesthetic agents. In addition, care must be taken to avoid extravasation because vancomycin is extremely irritating to tissues. Avoid intramuscular administration due to severe pain at the injection site. The safety and efficacy of intrathecal administration (intralumbar or intraventricular), intraperitoneal administration, intracameral administration, or intravitreal administration have not been established. Intraperitoneal administration of vancomycin has been associated with peritonitis. Hemorrhagic occlusive retinal vasculitis (HORV), including permanent loss of vision, has occurred in patients receiving intracameral or intravitreal administration of vancomycin during or after cataract surgery (ocular surgery).

Consider pseudomembranous colitis in patients presenting with diarrhea after antibacterial use. Careful medical history is necessary as pseudomembranous colitis has been reported to occur over 2 months after the administration of antibacterial agents. Almost all antibacterial agents, including vancomycin, have been associated with pseudomembranous colitis or C. difficile-associated diarrhea (CDAD) which may range in severity from mild to life-threatening. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.

Transient or permanent ototoxicity has occurred in patients receiving IV vancomycin. It has been reported mostly in patients who have been given excessive doses, who have an underlying hearing impairment or renal dysfunction, or who are receiving concomitant therapy with another ototoxic agent. Serial tests of auditory function may be helpful in order to minimize the risk of ototoxicity.

Due to the sodium content, avoid certain vancomycin products in patients requiring sodium restriction and patients with heart failure. Consult specific product labeling for precise sodium content.

Obesity may be associated with an increased risk of vancomycin-induced nephrotoxicity, partially due to supratherapeutic concentrations resulting from maintenance doses calculated using actual body weight. Monitor vancomycin AUC to adjust dosing.

Serious rash events, including toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS), drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), and linear IgA bullous dermatosis (LABD), have been reported with vancomycin therapy. Cutaneous signs or symptoms reported include skin rash, mucosal lesions, and blisters. Discontinue vancomycin at the first appearance of signs and symptoms of severe skin reaction.

Description: Vancomycin is an intravenous and oral glycopeptide antibiotic. Intravenous vancomycin is indicated for the treatment of septicemia, infective endocarditis, skin and skin structure infections, bone infections, and lower respiratory tract infections. Intravenous vancomycin is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant (beta-lactam-resistant) staphylococci. It is indicated for penicillin-allergic persons, for persons who cannot receive or who have failed to respond to other drugs, including the penicillins or cephalosporins, and for infections caused by vancomycin-susceptible organisms that are resistant to other antimicrobial drugs. Vancomycin is indicated for initial therapy when methicillin-resistant staphylococci are suspected, with subsequent therapy adjustment when susceptibility data are available. Vancomycin disposition is highly variable and individualization of intravenous dosages based on area under the curve (AUC) targets and therapeutic drug monitoring is recommended. Consider factors such as age, weight, renal function, site of infection, and organism susceptibility when determining the dose. Vancomycin disposition in pediatric patients is more variable than in adults due to changes in vancomycin clearance, weight, and age. These changing variables may warrant more intense or frequent therapeutic drug monitoring to optimize dosing and minimize vancomycin toxicity, especially in specific subsets, such as premature neonates, critically ill persons, and persons with malignancy. Oral vancomycin is indicated for the treatment of C. difficile-associated diarrhea (CDAD) and enterocolitis due to S. aureus, including methicillin-resistant S. aureus (MRSA). Parenteral administration of vancomycin is not effective for CDAD or enterocolitis; therefore, vancomycin must be given orally for these infections. Orally administered vancomycin is poorly absorbed and is not effective for other types of infections. To reduce the development of drug-resistant bacteria and maintain the effectiveness of vancomycin and other antibacterial drugs, limit vancomycin use to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. Vancomycin is FDA-approved for use in pediatric patients as young as neonates.

Per the manufacturer, this drug has been shown to be active against most strains of the following microorganisms either in vitro and/or in clinical infections: Actinomyces sp., Bacillus sp., Clostridioides difficile, Clostridium sp., Enterococcus faecalis, Enterococcus faecium, Enterococcus sp., Lactobacillus sp., Listeria monocytogenes, Staphylococcus aureus (MRSA), Staphylococcus aureus (MSSA), Staphylococcus epidermidis, Staphylococcus sp., Streptococcus agalactiae (group B streptococci), Streptococcus bovis, Streptococcus pneumoniae, Streptococcus pyogenes (group A beta-hemolytic streptococci), Viridans streptococci
NOTE: The safety and effectiveness in treating clinical infections due to organisms with in vitro data only have not been established in adequate and well-controlled clinical trials.

This drug may also have activity against the following microorganisms: Corynebacterium jeikeium, Corynebacterium sp.
NOTE: Some organisms may not have been adequately studied during clinical trials; therefore, exclusion from this list does not necessarily negate the drug's activity against the organism.

For the treatment of CNS infections*, including meningitis*, ventriculitis* (including shunt-related infections), brain abscess*, subdural empyema*, spinal epidural abscess*, and septic thrombosis of the cavernous or dural venous sinus*:
-for the treatment of meningitis* and ventriculitis*:
Intravenous dosage:
Neonates 0 to 7 days weighing less than 1.2 kg: 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Neonates 0 to 7 days weighing 1.2 to 2 kg: 15 mg/kg/dose IV every 12 to 18 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Neonates 0 to 7 days weighing more than 2 kg: 15 mg/kg/dose IV every 8 to 12 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Neonates 8 days and older weighing less than 1.2 kg: 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Neonates 8 days and older weighing 1.2 to 2 kg: 15 mg/kg/dose IV every 8 to 12 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Neonates 8 days and older weighing more than 2 kg: 15 mg/kg/dose IV every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Infants 1 to 2 months: 60 mg/kg/day IV divided every 6 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg IV may be considered in critically ill patients. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV may be considered in critically ill patients. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Continuous Intravenous Infusion dosage:
NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.
Neonates: 10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Infants, Children, and Adolescents: 10 to 15 mg/kg/dose (20 mg/kg/dose in critically ill patients) IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 15 to 25 mcg/mL. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (aged 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.
Intrathecal or Intraventricular dosage (preservative-free formulations only):
Infants, Children, and Adolescents: 5 to 20 mg/day intrathecally or intraventricularly; however, most studies have used a 10 or 20 mg dose. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.
-for the treatment of brain abscess*, subdural empyema*, spinal epidural abscess*, and septic thrombosis of the cavernous or dural venous sinus* due to methicillin-resistant S. aureus*:
Intravenous dosage:
Neonates 0 to 7 days weighing less than 1.2 kg: 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat with or without rifampin for 4 to 6 weeks.
Neonates 0 to 7 days weighing 1.2 to 2 kg: 15 mg/kg/dose IV every 12 to 18 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat with or without rifampin for 4 to 6 weeks.
Neonates 0 to 7 days weighing more than 2 kg: 15 mg/kg/dose IV every 8 to 12 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat with or without rifampin for 4 to 6 weeks.
Neonates 8 days and older weighing less than 1.2 kg: 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat with or without rifampin for 4 to 6 weeks.
Neonates 8 days and older weighing 1.2 to 2 kg: 15 mg/kg/dose IV every 8 to 12 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat with or without rifampin for 4 to 6 weeks.
Neonates 8 days and older weighing more than 2 kg: 15 mg/kg/dose IV every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat with or without rifampin for 4 to 6 weeks.
Infants 1 to 2 months: 60 mg/kg/day IV divided every 6 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat with or without rifampin for 4 to 6 weeks.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat with or without rifampin for 4 to 6 weeks.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat with or without rifampin for 4 to 6 weeks.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Treat with or without rifampin for 4 to 6 weeks.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat with or without rifampin for 4 to 6 weeks.
Continuous Intravenous Infusion dosage:
NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.
Neonates: 10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations. Treat with or without rifampin for 4 to 6 weeks.
Infants, Children, and Adolescents: 10 to 15 mg/kg/dose (20 mg/kg/dose in critically ill patients) IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 15 to 25 mcg/mL. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (aged 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years. Treat with or without rifampin for 4 to 6 weeks.

For the treatment of serious gram-positive infections, including lower respiratory tract infections (LRTIs) such as community-acquired pneumonia (CAP), nosocomial pneumonia, and pleural empyema*:
-for the treatment of nonspecific lower respiratory tract infections (LRTIs):
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider a loading dose of 20 to 35 mg/kg IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider a loading dose of 20 to 35 mg/kg IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose IV loading dose (Max: 3,000 mg/dose), followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider a loading dose of 20 to 35 mg/kg IV (Max: 3,000 mg/dose) in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose IV loading dose (Max: 3,000 mg/dose), followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Continuous Intravenous Infusion dosage*:
NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.
Neonates: 10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations.
Infants, Children, and Adolescents: 10 to 15 mg/kg/dose (20 mg/kg/dose in critically ill patients) IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (aged 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.
-for the treatment of community-acquired pneumonia (CAP):
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours for at least 7 days; adjust dose based on target PK/PD parameter. Consider a loading dose of 20 to 35 mg/kg IV in critically ill patients.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider a loading dose of 20 to 35 mg/kg IV in critically ill patients.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose IV loading dose (Max: 3,000 mg/dose), followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider a loading dose of 20 to 35 mg/kg IV (Max: 3,000 mg/dose) in critically ill patients.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose IV loading dose (Max: 3,000 mg/dose), followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter.
Continuous Intravenous Infusion dosage*:
NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.
Neonates: 10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL for at least 7 days. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations.
Infants, Children, and Adolescents: 10 to 15 mg/kg/dose (20 mg/kg/dose in critically ill patients) IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL for at least 7 days. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (aged 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.
-for the treatment of nosocomial pneumonia:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours for at least 7 days; adjust dose based on target PK/PD parameter. A loading dose of 20 to 35 mg/kg IV may be considered in critically ill patients.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose IV loading dose (Max: 3,000 mg/dose), followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose IV loading dose (Max: 3,000 mg/dose), followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter.
Continuous Intravenous Infusion dosage*:
NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.
Neonates: 10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL for at least 7 days. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations.
Infants, Children, and Adolescents: 10 to 15 mg/kg/dose (20 mg/kg/dose in critically ill patients) IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL for at least 7 days. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (aged 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.
-for the treatment of hospital-acquired or postprocedural pleural empyema*:
Intravenous dosage:
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for at least 2 weeks after drainage and defervescence as part of combination therapy.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for at least 2 weeks after drainage and defervescence as part of combination therapy.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for at least 2 weeks after drainage and defervescence as part of combination therapy.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max 3,000 mg/dose) IV in critically ill patients. Treat for at least 2 weeks after drainage and defervescence as part of combination therapy.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for at least 2 weeks after drainage and defervescence as part of combination therapy.
Continuous Intravenous Infusion dosage*:
Infants, Children, and Adolescents: 10 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 15 to 25 mg/L. Treat for at least 2 weeks after drainage and defervescence as part of combination therapy. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.

For the treatment of infective endocarditis:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours is recommended by the American Academy of Pediatrics (AAP). The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing interval of vancomycin may need to be extended in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours is recommended by the American Academy of Pediatrics (AAP). The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing interval of vancomycin may need to be extended in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours is recommended by the American Academy of Pediatrics (AAP). The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing interval of vancomycin may need to be extended in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours is recommended by the American Academy of Pediatrics (AAP). The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing interval of vancomycin may need to be extended in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours is recommended by the American Academy of Pediatrics (AAP). The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing interval of vancomycin may need to be extended in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours is recommended by the American Academy of Pediatrics (AAP). The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours. The dosing interval of vancomycin may need to be extended in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.
Infants: 60 mg/kg/day IV divided every 6 hours in combination with appropriate antimicrobial therapy depending on causative microorganism is recommended by guidelines. A loading dose of 20 to 25 mg/kg IV may be considered in seriously ill patients. Adjust dosage based on serum concentrations. The FDA-approved dosage for pediatric patients is 40 mg/kg/day IV divided every 6 hours.
Children and Adolescents: 40 to 60 mg/kg/day IV divided every 6 to 12 hours is recommended by guidelines. Adjust dosage based on serum concentrations. A loading dose of 20 to 25 mg/kg IV may be considered in seriously ill patients. The FDA-approved dosage for pediatric patients is 40 mg/kg/day IV divided every 6 hours. Guidelines recommend gentamicin plus ampicillin; sulbactam with or without vancomycin for culture-negative, community-acquired native valve endocarditis (NVE) or late (more than 1 year after surgery) prosthetic valve endocarditis (PVE); alternately, vancomycin plus gentamicin may be used. Treat for 4 to 6 weeks for NVE and for 6 weeks with rifampin for PVE. Vancomycin plus gentamicin, cefepime, and rifampin (if prosthetic material is present) is recommended for culture-negative nosocomial endocarditis associated with vascular cannulae or early (less than 1 year after surgery) PVE; treat for 4 to 6 weeks, with a longer course for PVE. For endocarditis due to relatively penicillin-resistant streptococci, including enterococci, vancomycin, in combination with gentamicin for the first 2 weeks or the entire course for enterococci, is recommended as an alternative; vancomycin is also an alternative for streptococcal endocarditis highly susceptible to penicillin. For streptococcal endocarditis, treat for 4 weeks for NVE and 6 weeks for PVE; treat for 6 weeks for NVE and PVE due to enterococci. Vancomycin, with or without gentamicin for the first 3 to 5 days, is recommended for methicillin-resistant S. aureus endocarditis; vancomycin, with or without gentamicin for the first 3 to 5 days, is an alternative for staphylococcal endocarditis susceptible to or resistant to penicillin G. Add rifampin (for the entire course) plus gentamicin (for the first 2 weeks of therapy) for staphylococcal PVE. For native valve staphylococcal endocarditis susceptible to oxacillin, treat for 4 to 6 weeks. For native valve staphylococcal endocarditis resistant to oxacillin or prosthetic valve staphylococcal endocarditis, treat for at least 6 weeks.

For the treatment of pseudomembranous colitis due to C. difficile infection:
-for the treatment of initial episode of pseudomembranous colitis due to C. difficile infection and first recurrence in patients previously treated with metronidazole:
Oral dosage:
Infants, Children, and Adolescents: 10 mg/kg/dose (Max: 125 mg/dose) PO 4 times daily for 10 days as a first or second line therapy. The FDA-approved dose is 40 mg/kg/day (Max: 2 g/day) PO divided 3 to 4 times daily for 7 to 10 days.
-for the treatment of fulminant pseudomembranous colitis due to C. difficile infection:
Oral dosage:
Infants, Children, and Adolescents: 10 mg/kg/dose (Max: 500 mg/dose) PO 4 times daily for 10 days; consider adding metronidazole IV.
Rectal dosage*:
Infants, Children, and Adolescents: Rectal vancomycin is suggested as adjunctive therapy; however, very limited dosing data are available. A case report in a 4-year-old boy with toxic megacolon due to C. difficile infection describes the use of rectal vancomycin 125 mg in 25 mL of 0.9% Sodium Chloride Injection 4 times daily for 1 month. Decompression of the megacolon may also be beneficial. A rectal vancomycin dose of 500 mg in 100 mL of 0.9% Sodium Chloride Injection every 6 hours is recommended in adults. Other dosing regimens have been described in case reports in adults including 500 mg every 4 hours and 1 g every 8 to 12 hours. These doses/volume (i.e., 500 mg in 100 mL of 0.9% Sodium Chloride Injection) may be acceptable for older children and adolescents of appropriate weight.
-for the treatment of first recurrence of pseudomembranous colitis due to C. difficile infection in patients initially treated with vancomycin, metronidazole, or fidaxomicin:
Oral dosage:
Infants, Children, and Adolescents: 10 mg/kg/dose (Max: 125 mg/dose) PO 4 times daily for 10 days.
-for the treatment of second/subsequent episodes of pseudomembranous colitis due to C. difficile infection:
Oral dosage:
Infants, Children, and Adolescents: 10 mg/kg/dose (Max: 500 mg/dose) PO 4 times daily for 10 days followed by rifaximin for 20 days, or 10 mg/kg/dose (Max: 125 mg/dose) PO 4 times daily for 10 to 14 days, then 10 mg/kg/dose (Max: 125 mg/dose) PO 2 times daily for 1 week, then 10 mg/kg/dose (Max: 125 mg/dose) PO once daily for 1 week, then 10 mg/kg/dose (Max: 125 mg/dose) PO every 2 to 3 days for 2 to 8 weeks.

For surgical infection prophylaxis*:
Intravenous dosage:
Infants, Children, and Adolescents: 15 mg/kg IV as a single dose within 120 minutes prior to the surgical incision. No intraoperative redosing and a duration of prophylaxis less than 24 hours for most procedures are recommended by clinical practice guidelines. A longer prophylaxis duration of 48 hours for certain cardiothoracic procedures is controversial. Clinical practice guidelines recommend vancomycin as alternate therapy for patients with beta-lactam allergy underoing cardiothoracic, hernia repair, neurosurgical, orthopedic, clean urologic, vascular, heart or lung transplantation, and plastic surgery procedures. Vancomycin is also recommended in combination with another appropriate antimicrobial (i.e., aminoglycoside, aztreonam, or fluoroquinolone) as alternate therapy for patients with beta-lactam allergy undergoing gastroduodenal, biliary tract, urologic with prosthesis, and abdominal transplantation procedures.

For the treatment of intraabdominal infections*, including peritonitis*, appendicitis*, intraabdominal abscess*, neonatal necrotizing enterocolitis*, and peritoneal dialysis-related peritonitis*:
-for the treatment of complicated community-acquired, healthcare-acquired, or hospital-acquired intraabdominal infections* with adequate source control:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days as part of combination therapy. Vancomycin is an option for necrotizing enterocolitis.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days as part of combination therapy. Vancomycin is an option for necrotizing enterocolitis.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days as part of combination therapy. Vancomycin is an option for necrotizing enterocolitis.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days as part of combination therapy. Vancomycin is an option for necrotizing enterocolitis.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days as part of combination therapy. Vancomycin is an option for necrotizing enterocolitis.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days as part of combination therapy. Vancomycin is an option for necrotizing enterocolitis.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. A loading dose of 20 to 35 mg/kg IV may be considered in seriously ill patients. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg IV may be considered in seriously ill patients. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose IV loading dose (Max: 3,000 mg/dose), followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg IV (Max: 3,000 mg/dose) may be considered in seriously ill patients. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose IV loading dose (Max: 3,000 mg/dose), followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
Continuous Intravenous Infusion dosage:
Neonates: 10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations. Treat for 7 to 10 days as part of combination therapy. Vancomycin is an option for necrotizing enterocolitis.
Infants, Children, and Adolescents: 10 to 15 mg/kg/dose (20 mg/kg/dose in critically ill patients) IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mg/L. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (aged 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
-for the treatment of uncomplicated intraabdominal infections*:
Intravenous dosage:
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours. A loading dose of 20 to 35 mg/kg IV may be considered in seriously ill patients. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day). Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg IV may be considered in seriously ill patients. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose IV loading dose (Max: 3,000 mg/dose), followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day). Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day). Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg IV (Max: 3,000 mg/dose) may be considered in seriously ill patients. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose IV loading dose (Max: 3,000 mg/dose), followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day). Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.
-for the treatment of peritoneal dialysis-related peritonitis*:
Intermittent Intraperitoneal dosage*:
Infants, Children, and Adolescents: 30 mg/kg/dose intraperitoneally once, then 15 mg/kg/dose every 3 to 5 days; adjust dose based on serum concentrations and redose when less than 15 mcg/mL. Treat for 14 to 21 days.
Continuous Intraperitoneal dosage*:
Infants, Children, and Adolescents: 1,000 mg/L intraperitoneal loading dose, followed by 25 mg/L in each dialysate exchange. Treat for 14 to 21 days.

For the treatment of anthrax*:
-for the treatment of cutaneous anthrax* without aerosol exposure or signs and symptoms of meningitis:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy.
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours for 7 to 10 days or until clinical criteria for stability are met; adjust dose based on target PK/PD parameter. May consider step-down to oral therapy.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 7 to 10 days or until clinical criteria for stability are met; adjust dose based on target PK/PD parameter. May consider step-down to oral therapy.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 7 to 10 days or until clinical criteria for stability are met; adjust dose based on target PK/PD parameter. May consider step-down to oral therapy.
-for the treatment of cutaneous anthrax* with aerosol exposure and without signs and symptoms of meningitis:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 7 to 10 days or until clinical criteria for stability are met; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
-for the treatment of systemic anthrax* without aerosol exposure, including those with signs and symptoms of meningitis, as part of combination therapy:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy.
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for at least 14 days; may consider step-down to oral therapy.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for at least 14 days; may consider step-down to oral therapy.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for at least 14 days; may consider step-down to oral therapy.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Treat for at least 14 days; may consider step-down to oral therapy.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for at least 14 days; may consider step-down to oral therapy.
-for the treatment of systemic anthrax* with aerosol exposure, including those with signs and symptoms of meningitis, as part of combination therapy:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for at least 14 days; may consider step-down to oral therapy.
Immunocompromised Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for at least 14 days; may consider step-down to oral therapy.
Immunocompromised Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for at least 14 days; may consider step-down to oral therapy.
Immunocompromised Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Treat for at least 14 days; may consider step-down to oral therapy.
Immunocompromised Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Treat for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for at least 14 days; may consider step-down to oral therapy.
Immunocompromised Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.

For the treatment of bacteremia and sepsis:
-for the treatment of bacteremia:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Continuous Intravenous Infusion dosage*:
NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.
Neonates: 10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia.
Infants, Children, and Adolescents: 10 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 15 to 25 mcg/mL. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia.
-for the treatment of sepsis:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. Neonates younger than 37 weeks gestational age were excluded from guideline scope. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. Neonates younger than 37 weeks gestational age were excluded from guideline scope. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. Neonates younger than 37 weeks gestational age were excluded from guideline scope. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Continuous Intravenous Infusion dosage*:
NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.
Neonates: 10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. Neonates younger than 37 weeks gestational age were excluded from guideline scope.
Infants, Children, and Adolescents: 10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.

For the treatment of bone and joint infections, including osteomyelitis, infectious arthritis*, and infectious bursitis*:
-for the treatment of osteomyelitis due to methicillin-resistant S. aureus:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours for at least 4 to 6 weeks; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.
Continuous Intravenous Infusion dosage*:
NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.
Neonates: 10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations.
Infants 1 to 2 months: 10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.
Infants, Children, and Adolescents 3 months to 17 years: 10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.
-for the treatment of infectious arthritis* due to methicillin-resistant S. aureus:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours for at least; adjust dose based on target PK/PD parameter. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
Continuous Intravenous Infusion dosage*:
NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.
Neonates: 10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations.
Infants 1 to 2 months: 10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.
Infants, Children, and Adolescents 3 months to 17 years: 10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.
-for the treatment of infectious bursitis* due to methicillin-resistant S. aureus:
Intravenous dosage:
Children 1 to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 2 to 3 weeks; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.
Obese Children 1 to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 2 to 3 weeks; adjust dose based on target PK/PD parameter. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 2 to 3 weeks; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 2 to 3 weeks; adjust dose based on target PK/PD parameter. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.
Continuous Intravenous Infusion dosage:
NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.
Children and Adolescents: 10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL for 2 to 3 weeks. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.

For the treatment of skin and skin structure infections, including cellulitis, erysipelas, skin abscesses, furunculosis, carbuncle, burn wound infection, necrotizing infections, and pyomyositis:
-for the treatment of nonpurulent skin infections, such as cellulitis or erysipelas:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 5 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 5 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 5 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 5 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 5 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 5 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Infants, Children, and Adolescents: 40 to 60 mg/kg/day IV divided every 6 hours (Max: 2,000 mg/dose) for 5 to 14 days; adjust dose based on target PK/PD parameter.
-for the treatment of purulent skin infections, such as furunculosis, carbuncle, skin abscess:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Infants, Children, and Adolescents: 40 to 60 mg/kg/day IV divided every 6 hours (Max: 2,000 mg/dose) for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter.
-for the treatment of complicated skin infections, such as traumatic wound infection, burn wound infection, and infected ulcers:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 7 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 7 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 7 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 7 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 7 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 7 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Infants, Children, and Adolescents: 60 mg/kg/day IV divided every 6 hours (Max: 2,000 mg/dose) for 7 to 14 days; adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
-for the treatment of necrotizing infections of the skin, fascia, and muscle:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
-for the treatment of pyomyositis:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

For the treatment of enterocolitis due to Staphylococcus aureus:
Oral dosage:
Infants, Children, and Adolescents: 40 mg/kg/day (Max: 2 g/day) PO given in 3 to 4 divided doses for 7 to 10 days.

For the treatment of neonatal mastitis:
Intravenous dosage:
Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours.
Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours.
Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours.
Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours.
Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL: 20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours.
Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL: 20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours.
Infants 1 to 2 months: 40 to 60 mg/kg/day IV divided every 6 hours.

For the adjunctive treatment of severe diphtheria*:
Intravenous dosage:
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Use in combination with IV penicillin G and a macrolide as an adjunct to diphtheria antitoxin.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Use in combination with IV penicillin G and a macrolide as an adjunct to diphtheria antitoxin.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Use in combination with IV penicillin G and a macrolide as an adjunct to diphtheria antitoxin.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Use in combination with IV penicillin G and a macrolide as an adjunct to diphtheria antitoxin.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Use in combination with IV penicillin G and a macrolide as an adjunct to diphtheria antitoxin.

For bacterial infection prophylaxis* after penetrating central nervous system trauma:
Intravenous dosage:
Infants 1 to 2 months: 60 mg/kg/day IV divided every 6 hours plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg IV may be considered in critically ill patients. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV may be considered in critically ill patients. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.

For the treatment of acute exacerbations of bronchiectasis*:
Intravenous dosage:
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours for 14 days; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 days; adjust dose based on target PK/PD parameter.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 days; adjust dose based on target PK/PD parameter.

For the treatment of epiglottitis*:
Intravenous dosage:
Infants 1 to 2 months: 45 to 60 mg/kg/day IV divided every 6 to 8 hours for 5 to 10 days; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients.
Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 5 to 10 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients.
Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 5 to 10 days; adjust dose based on target PK/PD parameter.
Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 5 to 10 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients.
Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 5 to 10 days; adjust dose based on target PK/PD parameter.

Therapeutic Drug Monitoring:
AUC-Guided Therapeutic Drug Monitoring
-There are limited data in children correlating vancomycin AUC therapeutic drug monitoring and efficacy outcomes; therefore, monitoring recommendations are derived from data in adults.-Until additional data are available, the AUC target used in adults (i.e., 400 to 600 mg x hour/L) appears to be the most appropriate initial target for vancomycin exposures in all pediatric populations.
-Frequent or daily monitoring may be prudent for hemodynamically unstable patients. Once-weekly monitoring may be appropriate for hemodynamically stable patients.
-Target exposure should be achieved early during therapy, preferably within the first 24 to 48 hours; early monitoring is recommended when doses exceed 2,000 to 3,000 mg/day in pediatric patients.
-The specific recommendations for therapeutic monitoring in older children also apply for neonates.-AUC-guided therapeutic dosing and monitoring, preferably with Bayesian estimation, can best achieve the target vancomycin exposure likely required for successful treatment of a methicillin-resistant S. aureus (MRSA) infection for all neonates, regardless of gestational and chronologic age.-Regardless of the dosing model used, therapeutic drug monitoring in the neonate is essential due to the rapid maturation of renal function over the first weeks of life.

-A lower AUC/MIC target may be reasonable for neonatal S. epidermis infections.


-Guideline recommendations for vancomycin AUC/MIC ratio targets are only applicable to infections due to MRSA.-Vancomycin AUC/MIC ratio efficacy targets are primarily derived from studies of MRSA bacteremia, and recommendations are extrapolated for other invasive MRSA infections (i.e., endocarditis, meningitis, pneumonia, osteomyelitis).-Use caution when extrapolating recommendations to pathogens other than MRSA or noninvasive MRSA infections, as there is a lack of data to guide appropriate targets.


-For intermittent IV infusion vancomycin, Bayesian-derived AUC-guided monitoring using software programs is preferred based on the collection of 1 or 2 vancomycin concentrations with at least 1 trough. However, it is preferred to obtain 2 serum concentrations (i.e., 1 to 2 hours post-infusion and at the end of the dosing interval) to estimate the AUC.-A second approach relies on the collection of 2 vancomycin concentrations obtained near steady-state, a post-distributional peak concentration at 1 to 2 hours after the infusion and a trough at the end of the dosing interval, preferably during the same dosing interval and utilizing first-order pharmacokinetic equations to estimate the AUC.

-For continuous IV infusion vancomycin, the AUC may be calculated by multiplying the steady-state concentration by a factor of 24.
-Independent of MRSA infection, vancomycin therapeutic drug monitoring is recommended for persons at high risk for nephrotoxicity (e.g., critical illness and receiving concurrent nephrotoxins), persons with unstable renal function, and those receiving more than 3 to 5 days of therapy.
-Data suggest that the risk of acute kidney injury (AKI) increases as the AUC increases, especially when the daily AUC exceeds 650 to 1,300 mg x hour/L. AUC-guided monitoring may reduce the occurrence of vancomycin-associated AKI vs. trough serum concentration monitoring.-To minimize AKI risk, maintain vancomycin exposure below an AUC of 800 mg x hour/L; avoid vancomycin doses of 100 mg/kg/day given the projected median AUC exceeds this threshold at this dose.


Serum Concentration-Guided Therapeutic Drug Monitoring
-Trough only monitoring is no longer recommended for MRSA infections.
-Data on optimal vancomycin troughs for treatment success in pediatric patients are limited. Therefore, most recommendations are derived from data in adult patients. Guidelines generally recommend target trough concentrations of 15 to 20 mcg/mL for the treatment of complicated infections (endocarditis, osteomyelitis, meningitis, and nosocomial pneumonia).
-For continuous IV infusion, steady-state vancomycin concentrations of 15 to 25 mg/L are suggested.
-Although limited, data suggest that the risk of AKI increases as a function of trough, especially when maintained above 15 to 20 mg/L.

Maximum Dosage Limits:
-Neonates
0 to 7 days: 20 mg/kg/day IV per FDA-approved product labeling; however, doses should be individualized based on patient age, weight, indication for use, and serum drug concentration monitoring.
8 days and older: 30 mg/kg/day IV per FDA-approved product labeling; however, doses should be individualized based on patient age, weight, indication for use, and serum drug concentration monitoring.
-Infants
40 mg/kg/day IV/PO per FDA-approved product labeling; however, initial doses up to 60 mg/kg/day IV are recommended off-label for severe infections. Individualize IV dosage to patient age, weight, indication for use, and serum drug concentration monitoring.
-Children
40 mg/kg/day IV and 2 g/day PO per FDA-approved product labeling; however, initial doses up to 60 mg/kg/day IV are recommended off-label for severe infections. Individualize IV dosage to patient age, weight, indication for use, and serum drug concentration monitoring.
-Adolescents
40 mg/kg/day IV and 2 g/day PO per FDA-approved product labeling; however, initial doses up to 60 mg/kg/day IV are recommended off-label for severe infections. Individualize IV dosage to patient age, weight, indication for use, and serum drug concentration monitoring.

Patients with Hepatic Impairment Dosing
Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.

Patients with Renal Impairment Dosing
Patients with impaired or changing renal function require dosage adjustments of intravenous vancomycin; however, specific recommendations for non-neonatal pediatric patients are not available. In these patients, it may be prudent to administer an initial loading dose and then monitor serum concentrations and redose accordingly.

Neonates
The American Academy of Pediatrics (AAP) recommends the following dosing schedule based on serum creatinine (SCr) concentration :
28 weeks gestation and younger

less than 0.5 mg/dL: 15 mg/kg/dose IV every 12 hours.
0.5 to 0.7 mg/dL: 20 mg/kg/dose IV every 24 hours.
0.8 to 1 mg/dL: 15 mg/kg/dose IV every 24 hours.
1.1 to 1.4 mg/dL: 10 mg/kg/dose IV every 24 hours.
more than 1.4 mg/dL: 15 mg/kg/dose IV every 48 hours.

Older than 28 weeks gestation

less than 0.7 mg/dL: 15 mg/kg/dose IV every 12 hours.
0.7 to 0.9 mg/dL: 20 mg/kg/dose IV every 24 hours.
1 to 1.2 mg/dL: 15 mg/kg/dose IV every 24 hours.
1.3 to 1.6 mg/dL: 10 mg/kg/dose IV every 24 hours.
more than 1.6 mg/dL: 15 mg/kg/dose IV every 48 hours.

Intermittent hemodialysis
After an initial dose of 15 mg/kg IV, use serum vancomycin concentrations to guide further dosing. Vancomycin is not significantly removed during a standard intermittent hemodialysis session using conventional cuprophane membranes. In general, hemodialysis removes varying degrees of vancomycin, a 1,500-Dalton molecule, depending on the type of filter used. Low-flux membranes do not significantly remove vancomycin, leading to the traditional once-weekly dosing of vancomycin. If high-flux polysulfone dialysis membranes are used, more significant amounts of vancomycin may be removed (26% to 50%) and a supplemental dose after dialysis may be necessary. Consider hemodialysis filter type when determining vancomycin clearance. Due to redistribution of vancomycin after the high-flux dialysis procedure, base dosage supplementation on serum concentrations obtained at least 12 hours after the end of the procedure.

Continuous renal replacement therapy (i.e., CAVH, CVVH, CVVHD, CVVHDF)
Definitive dosage recommendations have not been established. Vancomycin clearance during continuous renal replacement therapy (CRRT) depends on the specific type of CRRT used, including continuous arteriovenous hemofiltration (CAVH), continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), and continuous venovenous hemodiafiltration (CVVHDF). Clearance also depends on the sieving coefficient (SC) for vancomycin for the filter membranes, the CRRT ultrafiltrate rate, the patient's residual renal function, the volume of distribution, the fraction of drug unbound to plasma proteins, and the duration of the CRRT per day. In general, there may be 50% to 60% of the vancomycin dose removed during CRRT. Approach dosing recommendations with caution as the CRRT methods may vary between institutions. Consider additional patient and disease-state factors and guide dosing by individual patient vancomycin serum concentrations.

Peritoneal dialysis
Clearance of vancomycin by intermittent peritoneal dialysis is highly variable; when administering vancomycin intravenously, supplemental dosing may be necessary to maintain adequate serum concentrations.

*non-FDA-approved indication

Monograph content under development

Mechanism of Action: Vancomycin is bactericidal and appears to exert its effect by binding to the precursor units of bacterial cell walls, inhibiting their synthesis. It specifically binds with the D-alanyl-D-alanine terminus of the peptide precursor units, inhibiting peptidoglycan polymerase and transpeptidation reactions. This prevents cross-linking of the cell wall peptidoglycan during the second stage of cell synthesis. The net result is an alteration of bacterial cell wall permeability and cell death. In addition, RNA synthesis is inhibited. Vancomycin is not active in vitro to gram-negative organisms, mycobacteria, of fungi.

Vancomycin exhibits 'concentration-independent killing' in which there is saturation of the bacterial killing rate once the drug concentrations approach the minimum inhibitory concentration (MIC). An AUC/MIC ratio of 400 or more is necessary to achieve clinical effectiveness with vancomycin. In PK/PD models applicable to human methicillin-resistant S. aureus (MRSA) infection, bactericidal activity (i.e., a 1- to 2-log reduction in bacterial inoculum in the animal model) is achieved when the vancomycin AUC/MIC ratio approximates or exceeds 400. Additionally, in vitro data suggest that an AUC of less than 400 potentiates the emergence of MRSA resistance and vancomycin-intermediate S. aureus strains.

Most strains of S. aureus, S. epidermidis, Streptococcus sp., and Corynebacterium sp. are susceptible to vancomycin. Vancomycin is particularly useful against penicillin- and methicillin-resistant staphylococcal infections and for treating other gram-positive infections in beta-lactam-allergic patients. However, there are a few case reports of S. aureus strains that are insensitive to vancomycin. While, traditionally, vancomycin has been used to treat enterococcal infections, there is a significant resistance rate in these organisms. Vancomycin-resistant enterococci (VRE) rates up to 12.1% have been reported in bloodstream isolates and up to 25% of ICU enterococcal infections. Synergistic bactericidal effects can be achieved when vancomycin is combined with aminoglycosides against gram-positive organisms, but this increases possible toxicity. Vancomycin is useful against a wide variety of clinical infections due to these pathogens. When given orally, vancomycin is also useful in treating C. difficile.

The susceptibility interpretive criteria for vancomycin are delineated by pathogen. The MICs are defined for S. aureus and Lactobacillus sp. as susceptible at 2 mcg/mL or less, intermediate at 4 to 8 mcg/mL, and resistant at 16 mcg/mL or more. The MICs are defined for Enterococcus sp. and Staphylococcus sp. other than S. aureus as susceptible at 4 mcg/mL or less, intermediate at 8 to 16 mcg/mL, and resistant at 32 mcg/mL or more. However, reports suggest that S. aureus isolates with vancomycin MICs of 1 to 2 mcg/mL may be less likely to be successfully treated with vancomycin. The MICs are defined for Bacillus sp. (excluding B. anthracis) as susceptible at 4 mcg/mL or less. The MICs are defined for Corynebacterium sp., Lactococcus sp., Micrococcus sp., and R. mucilaginosa as susceptible at 2 mcg/mL or less. The MICs are defined for beta-hemolytic Streptococcus sp., Streptococcus sp. Viridans group, S. pneumoniae, Gemella sp., Abiotrophia sp., Granulicatella sp., and Aerococcus sp. as susceptible at 1 mcg/mL or less.

While vancomycin has been a predominant agent to treat gram-positive infections, increasing resistance has started to limit its utility. Vancomycin-resistant enterococci (VRE) is the most common resistant pathogen. There are 6 types of reported vancomycin resistance in enterococci (VanA, VanB, VanC, VanD, VanE, and VanG). Of these, 5 types are acquired resistance, while VanC is an intrinsic resistance found in E. gallinarum and E. casseliflavus. The most common type is VanA resistance. Once exposed to an inducer, like vancomycin, transcription of the enzymes that make the cell-wall precursors is altered. There is an increase in the cell-wall precursors ending in D-alanyl-D-lactate, to which vancomycin has a low binding affinity, and a decrease in the D-alanyl-D-alanine cell-wall precursors, to which vancomycin has a high binding affinity. This results in decreased binding of vancomycin to the receptor sites of the enterococcal cell wall. The genes for this resistance can potentially be spread to other bacteria via plasmids. Exposure to IV and oral vancomycin, antianaerobic antibiotics, and other broad-spectrum antibiotics have all been associated as factors contributing to VRE. S. aureus is another concerning organism with increasing resistance to vancomycin. Strains of vancomycin-intermediate S. aureus (VISA), heterogeneous vancomycin-intermediate S. aureus (hVISA), and vancomycin-resistance S. aureus (VRSA) have been described in the literature. Strains of VISA have shown an unusually thickened cell wall that prevents drug penetration. The cell wall also contains dipeptides that bind vancomycin. Fully resistant strains, VRSA, have acquired VanA resistance similar to Enterococcus sp. Guidelines suggest that exposure to vancomycin trough serum concentrations of less than 10 mg/L may produce S. aureus strains with VISA-like characteristics.

Pharmacokinetics: Vancomycin is administered intravenously for the treatment of systemic bacterial infections and orally for the treatment of some GI infections such as pseudomembranous colitis and enterocolitis. Vancomycin is not administered intramuscularly due to severe pain at the injection site.

Affected cytochrome P450 isoenzymes: none


-Route-Specific Pharmacokinetics
Oral Route
Oral bioavailability of vancomycin is too low to treat systemic infections. Serum concentrations after oral administration are often undetectable even when inflammatory lesions are present. Patients with pseudomembranous colitis, however, may develop detectable serum concentrations after oral administration, especially if they have renal impairment. Due to poor oral bioavailability, oral doses of vancomycin are excreted mainly in the feces with urinary recovery not exceeding 0.76% of the dose.

Intravenous Route
The distribution half-life of vancomycin in adults is approximately 0.5 to 1 hour. After intravenous administration of 1,000 mg (15 mg/kg) over 1 hour, vancomycin plasma concentrations reach a peak of approximately 63 mcg/mL and fall to about 23 mcg/mL 2 hours after infusion, and 8 mcg/mL 11 hours after the end of the infusion. Multiple doses of 500 mg infused over 30 minutes produces mean serum concentrations of approximately 49 mcg/mL at the end of the infusion, 19 mcg/mL 2 hours after the infusion, and 10 mcg/mL 6 hours after the infusion. Vancomycin serum concentrations are highly variable and depend on many patient factors including age, size, fluid status, infection source/type, and renal function. Systemically administered vancomycin is distributed into most body tissues and fluids including pericardial fluid, pleural fluid, ascitic fluid, synovial fluid, urine, peritoneal dialysis fluid, and atrial appendage tissue. Concentrations obtained in tissues and fluids are variable and somewhat dependent on the degree of inflammation present. The volume of distribution coefficient is reported by the manufacturer as 0.3 to 0.43 L/kg; however, literature reports give a range of 0.2 to 1.9 L/kg. Unless the meninges are inflamed, there is little diffusion into CSF (0 to 3.45 mg/L) with corresponding CSF to serum ratios of 0 to 0.18. Inflamed meninges improve penetration into the CSF with reported concentrations of 6.4 to 11.1 mg/L with corresponding CSF to serum ratio of 0.36 to 0.46. Vancomycin is about 55% (range: 44% to 82%) bound to serum protein in healthy volunteers with normal renal function. There is no apparent metabolism of vancomycin. Excretion is mainly by glomerular filtration, with about 80% of the drug excreted in 24 hours in the urine and only small amounts excreted in the feces. In patients with normal renal function, vancomycin has a serum half-life of about 4 to 6 hours. Mean plasma clearance is approximately 0.058 L/kg/hour and mean renal clearance is approximately 0.048 L/kg/hour.

Other Route(s)
Peritoneal Route
Approximately 60% of an intraperitoneal vancomycin dose is absorbed systemically in 6 hours. Serum concentrations of approximately 10 mcg/mL are achieved by an intraperitoneal dose of 30 mg/kg.

Rectal Route (Retention Enema)
Similar to oral administration, patients with pseudomembranous colitis may develop detectable serum concentrations after rectal administration of retention enemas. Patients with renal impairment may be at a higher risk of systemic absorption.


-Special Populations
Pediatrics
Vancomycin pharmacokinetics vary significantly among pediatric patients. Inter-patient variability and changes in renal function development result in more variability in pharmacokinetic parameters in pediatric patients compared to adults.

Neonates
The volume of distribution at steady state, total body clearance, and elimination half-life in neonates of varying gestational ages have been reported as 0.38 to 0.97 L/kg, 0.63 to 1.5 mL/minute/kg, and 3.5 to 10 hours, respectively. Vancomycin disposition in neonates is highly variable and is dependent on various factors including postconceptional age, weight, and renal function. Neonates, especially premature neonates, have a larger volume of distribution and lower total clearance compared to infants, children, and adolescents. These differences can be attributed to larger proportions of body water and immature renal function, which change as the neonate matures. Vancomycin penetration into the CSF was reported as 26% to 68% in 3 neonates after IV doses of 20 mg/kg every 18 to 24 hours for suspected or documented meningitis.

Neonates Receiving Extracorporeal Membrane Oxygenation (ECMO)
The pharmacokinetics of vancomycin in neonatal patients on extracorporeal membrane oxygenation (ECMO) have been described. Mean volume of distribution, clearance, and half-life were 0.45 to 1.1 L/kg, 0.65 to 0.78 mL/minute/kg, and 8.29 to 16.9 hours, respectively, in neonates receiving IV vancomycin doses of 10 to 20 mg/kg at intervals of 8 to 24 hours.

Infants, Children, and Adolescents
In a pharmacokinetic study involving 78 pediatric patients younger than 18 years of age, the mean calculated volume of distribution at steady state, total plasma clearance, and elimination half-life were 0.43 L/kg, 1.7 mL/minute/kg, and 3.9 hours, respectively. A smaller pharmacokinetic study reported a volume of distribution of 0.595 to 0.964 L/kg, total plasma clearance of 50 to 81 mL/minute/1.73 m2, and elimination half-life of 4.1 hours in 16 infants 1 to 12 months of age. In the same study, volume of distribution, total plasma clearance, and elimination half-life were reported as 0.538 to 0.818 L/kg, 131 to 163 mL/minute/1.73 m2, and 2.2 to 3 hours, respectively, for 18 children 1 to 12 years of age. In general, adolescent patients can demonstrate varied vancomycin pharmacokinetics with clearance values similar to that of younger children (fast clearance) or approaching those of adults. Increased monitoring may be necessary in these patients to determine an appropriate dosing regimen.

Renal Impairment
Pharmacokinetic properties of vancomycin are altered in patients with renal insufficiency. Vancomycin clearance is reported to be reduced by 30% to 70% in pediatric patients with mild or moderate impairment compared with matched controls having normal renal function. The average elimination half-life in anephric adult patients is 7.5 days. The FDA-approved labeling states that vancomycin is not effectively removed by hemodialysis or peritoneal dialysis; however, there may be increased clearance with hemoperfusion and hemofiltration.

Hemodialysis
In general, hemodialysis removes varying degrees of vancomycin, a 1,500-Dalton molecule, depending on the type of filter used. Low flux membranes do not remove much vancomycin, leading to the traditional once-weekly dosing of vancomycin. However, higher flux filters remove significant amounts of vancomycin; therefore, hemodialysis filter type should be considered when determining vancomycin clearance.

Continuous Renal Replacement Therapy (CRRT)
Vancomycin clearance during continuous renal replacement therapy (CRRT) depends on the specific type of CRRT used. Clearance also depends on the sieving coefficient (SC) for vancomycin for the filter membranes, which has been reported in the literature as approximately 0.6 to 0.86. Additionally, the CRRT ultrafiltrate rate, the patient's residual renal function, the volume of distribution, the fraction of drug unbound to plasma proteins, and the duration of the CRRT per day all play a role in the clearance of vancomycin during CRRT. In general, there may be 50% to 60% of the vancomycin dose removed during CRRT.

Peritoneal Dialysis
One study assessing the disposition of vancomycin in pediatric patients receiving peritoneal dialysis found dialysis clearance of 2.46 mL/minute/1.73 m2 during long-dwell and 3.09 mL/minute/1.73 m2 during short-dwell, which accounted for 25% and 32% of total body clearance, respectively.

Other
Patients with Cancer
Mean pharmacokinetic parameters reported in 28 pediatric cancer patients aged 9 months to 13 years included volume of distribution 0.63 L/kg, clearance 2.55 mL/minute/kg, and half-life 2.95 hours.

Patients with Cystic Fibrosis
Estimated pharmacokinetic parameters for vancomycin in pediatric patients with cystic fibrosis (n = 67, mean age 12.1 +/- 5.3 years) were similar to other pediatric populations. The estimated volume of distribution and clearance were 0.63 L/kg and 1.33 mL/minute/kg, respectively. In this study, vancomycin clearance increased with increasing body weight.

Patients with CNS Shunt Infections
Vancomycin penetration into the CSF ranged from 0.77% to 18% in 6 pediatric patients aged 9 months to 21 years receiving doses of 10 to 20 mg/kg/dose IV every 6 to 12 hours for documented or suspected shunt infections.

Patients receiving Plasmapheresis
A single one-volume plasmapheresis session does not remove a clinically important amount of vancomycin. However, it is recommended to administer doses after plasmapheresis to ensure that the drug infusion and extravascular distributive phase are complete prior to initiation of the next plasmapheresis session.