Practical considerations for vancomycin dosing in hemodialysis patients: Perspectives from the nephrology stewardship pharmacist

Vancomycin remains the principal antibiotic used to treat methicillin-resistant in patients with chronic kidney disease stage 5 utilizing hemodialysis (CKD-5D). The recent guidelines have added comprehensive dosing guidance to assist clinicians optimize vancomycin dosing in this population. The purpose of this review was to elaborate on additional practical and stewardship considerations which clinicians may apply in this unique patient population. Relevant clinical outcome and clinical pharmacokinetic (PK) studies were discussed in this review since the publication of the 2009 version of the vancomycin therapy guidelines. Administering vancomycin during the last 60 - 90 minutes of hemodialysis is preferred to prevent vascular damage and preserve patients' vascular access. All published and pertinent data were included across the study period. Two outcome studies, 13 clinical PK studies, and 2 PK modeling studies were identified and discussed in this review. The used loading doses (LD) in the reviewed studies ranged between 18 and 23 mg/kg (~ 1.5 - 2 g) followed by a maintenance dose (MD) of 8 - 13 mg/kg (~ 1 g) administered in the last hour of dialysis (high flux). This dosing strategy resulted in vancomycin pre-dialysis concentrations of ≥ 13 mg/L and favorable clinical outcomes, particularly in patients with bacteremia and skin and soft tissue infections. Regardless of how high the pre-HD vancomycin concentrations were, vancomycin was not associated with favorable outcomes in patients with deep-seated infections. Vancomycin administration using dialysis access in the last hour of dialysis is suggested. Administering a standard MD would simplify dosing and reduce the risk of errors. Vancomycin dosing is challenging in this patient population.