eGFR (ml/min/1.73 m²)

Actual bodyweight (kg)

<60

60 - 80

81 - 100

>100

>90

750 mg q8

1000 mg q8

1250 mg q8

1500 mg q8

50 - 90

750 mg q12

1000 mg q12

1250 mg q12

1500 mg q12

15 - 49

750 mg q24

1000 mg q24

1250 mg q24

1500 mg q24

<15 or RRT

750 mg ×1

1000 mg ×1

1250 mg ×1

1500 mg ×1

Therapeutic drug monitoring

1. For patients dosed every 8 - 12 hours, check trough 30 minutes prior to 4th dose

2. For patients dosed every 24 hours, check trough 30 minutes prior to 3rd dose

Patients with eGFR < 15, continuous RRT, or unstable renal function

1. Give a one-time dose per nomogram

2. Check a random vancomycin level 24 hours after the dose

3. If random level is <20 mcg/mL, repeat dose

4. If random level is >20 mcg/mL, do not redose, repeat random level in 12 hours

Patients on intermittent hemodialysis

1. Give a one-time dose per nomogram

2. Check a random vancomycin level 2 hours after hemodialysis

3. If random level is <20 mcg/mL, repeat dose

4. If random level is >20 mcg/mL, do not redose, repeat level after next dialysis