Related Experiment Video
Updated: May 29, 2026
A Reference Broth Microdilution Method for Dalbavancin In Vitro Susceptibility Testing of Bacteria that Grow Aerobically
Published on: September 9, 2015
Impact of a hospitalwide increase in empiric pediatric vancomycin dosing on initial trough concentrations
Adam Frymoyer1, B Joseph Guglielmo, Stephen D Wilson
1Division of Clinical Pharmacology, Department of Medicine, University of California-San Francisco, San Francisco, California 94143-0503, USA. adam.frymoyer@ucsf.edu
Insights
Increasing the vancomycin starting dose to 60 mg/kg/day in children with suspected invasive methicillin-resistant Staphylococcus aureus (MRSA) infections reduced low initial trough levels. This higher dose did not increase toxic levels, but did not consistently reach target concentrations.
Area of Science:
- Pediatric Infectious Diseases
- Pharmacokinetics and Pharmacodynamics
- Antimicrobial Stewardship
Background:
- Invasive methicillin-resistant Staphylococcus aureus (MRSA) infections in children require effective vancomycin therapy.
- Optimizing vancomycin dosing is crucial to achieve therapeutic trough concentrations and minimize toxicity.
- Previous dosing recommendations may not consistently achieve target trough levels in pediatric populations.
Purpose of the Study:
- To assess the impact of increasing the vancomycin starting dose from 45 to 60 mg/kg/day on initial trough concentrations in pediatric patients.
- To evaluate the safety and efficacy of the higher vancomycin dose in children with suspected invasive MRSA infections.
Main Methods:
- Retrospective medical record review at a tertiary care children's hospital.
- Analysis of 182 children (1 month-12 years) with normal renal function treated with vancomycin.
- Comparison of initial vancomycin trough concentrations between a low-dose (45 mg/kg/day) and high-dose (60 mg/kg/day) group.
Main Results:
- The mean initial vancomycin trough level increased from 7 ± 5 μg/ml to 9 ± 5 μg/ml (p<0.001) with the higher dose.
- The percentage of patients with trough levels < 5 μg/ml significantly decreased from 38% to 17% (p<0.001).
- No significant increase in potentially toxic trough levels (> 20 μg/ml) was observed (2% vs 2%, p=0.9).
Conclusions:
- Increasing the vancomycin starting dose to 60 mg/kg/day effectively reduces the incidence of subtherapeutic initial trough levels in children.
- The higher dose was not associated with an increased risk of toxicity.
- Further comparative effectiveness studies are warranted to optimize vancomycin dosing regimens and clinical outcomes in pediatric MRSA infections.
Study Objective:
To evaluate the impact of a hospitalwide increase in the recommended vancomycin starting dose from 45 to 60 mg/kg/day on initial vancomycin trough concentrations in children suspected of having an invasive methicillin-resistant Staphylococcus aureus (MRSA) infection.
Design:
Retrospective medical record review.
Setting:
Dedicated children's hospital located in a tertiary care, academic medical center.
Patients:
A total of 182 children aged 1 month-12 years with normal renal function who had suspected MRSA infections treated with vancomycin during two different starting dose recommendation periods: 45 mg/kg/day divided every 8 hours during July 2006-June 2007 (low-dose group [88 children]) and 60 mg/kg/day divided every 6 hours during July 2008-June 2009 (high-dose group [94 children]).
Measurement And Main Results:
Data on patient demographics, vancomycin doses, and initial vancomycin trough concentrations were collected. No significant demographic differences were noted between patients in the low-dose and high-dose groups. The mean ± SD initial vancomycin trough level increased from 7 ± 5 μg/ml in the low-dose group to 9 ± 5 μg/ml in the high-dose group (p<0.001). The percentage of patients with an initial trough level less than 5 μg/ml declined from 38% (33/88 children) in the low-dose group to 17% (16/94 children) in the high-dose group (p<0.001), whereas the percentage of patients with an initial trough concentration in the potentially adverse range (> 20 μg/ml) did not change between the two groups (2% vs 2%, p=0.9). Less than 14% (13/94 children) achieved a trough level in the range of 15-20 μg/ml in the high-dose group.
Conclusion:
An increase in the recommended vancomycin starting dose to 60 mg/kg/day decreased the likelihood of an initial low vancomycin trough level (< 5 μg/ml), with no increase in the proportion of patients with trough levels in a potentially toxic range. The 60-mg/kg/day dose did not consistently achieve a vancomycin trough of 15-20 μg/ml, a goal suggested by some experts for adults. Comparative effectiveness studies are needed to directly evaluate vancomycin dosing regimens and clinical outcomes for children with invasive MRSA infections.
Related Concept Videos
01:26Pharmacokinetics in Pediatric Patients: Drug Excretion
01:15Determination of Multiple Dosing Parameters: Steady-State, Minimum and Maximum Concentrations
01:29Drug Dosing: Infants and Children
01:24Pharmacokinetics in Pediatric Patients: Drug Metabolism
01:20Estimation of k and VD of Aminoglycosides
01:17Pharmacokinetics in Pediatric Patients: Drug Distribution