Table 5.

Approaches to reduce vancomycin nephrotoxicity

Recommendation	Comment
Weight based dosing of 15–20 mg/kg	Use actual body weight and combine with therapeutic drug monitoring. Consider nomograms in patients with renal insufficiency
Consider a loading dose of 25–30 mg/kg for severe infections (bacteremia, endocarditis, pneumonia, osteomyelitis, meningitis)	There is no evidence of increased nephrotoxicity with a loading dose
Use intermittent rather than continuous administration	Continuous infusion has limited evidence for reducing toxicity and is cumbersome to use
Do not obtain peak vancomycin concentrations	Peak concentrations do not predict efficacy or toxicity
Maintain trough concentration 10–15 mg/L for non–severe infections	>15 mg/L correlates weakly with improved efficacy, but at the expense of a clear association with toxicity
Maintain tough concentrations 15–20 mg/L for serious infections	Increased potential toxicity balanced against severity of infection
Consider cessation of vancomycin should AKI develop after at least 2 days of therapy	Effective but not nephrotoxic alternatives exist e.g., daptomycin for MRSA bacteremia/endocarditis or linezolid for MRSA pneumonia
Tailor duration of therapy to efficacy and not to prevent nephrotoxicity	Duration of therapy should be directed to microbiologic control. Toxicity may increase with prolonged therapy, but evidence base is weak
Concomitant use with piperacillin‐tazobactam or an aminoglycoside should be paired with TDM and ongoing assessment of need for concurrent therapy	There is moderate evidence of synergistic toxicity to be balanced against potential need for efficacy
TDM should be used in patients at high risk for toxicity, prolonged therapy or impaired renal function	Toxicity in patients with limited comorbidities treated for less than 10 days is very uncommon
Obtain TDM before the fourth dose after starting or adjusting therapy if stable renal function	Assumptions linking trough levels to AUC are based upon a steady state concentration