The basic principles of using a CONTINUOUS INFUSION of VANCOMYCIN are simple. The two most common drugs used to treat C. difficile are metronidazole (500 mg PO TID) and vancomycin (125 mg PO QID) for 10–14 days. Discover the world's research 20+ million members Method: We conducted a quasi-experimental study in patients who were prescribed intravenous vancomycin. Dosage adjustment must be made in patients with impaired renal function. While its association with acute kidney injury (AKI) has waxed and waned, recent data … Majority of the drugs are primarily metabolized and excreted by hepatobiliary system; hence, liver cell necrosis contributes to impaired drug handling in liver failure while portosystemic shunt can alter drug action in cirrhosis. The glycopeptide antibiotic vancomycin is a mainstay in the treatment of Gram-positive infection. b)Cirrhosis: Decrease Clindamycin total dose by 50%. lack of improvement, increasing stool frequency after 3 days of treatment or new signs of severe C. difficile-associated diarrhoea), switching to oral vancomycin should be considered.1 The recommended oral dose of vancomycin for C. Question 13 from the first paper of 2010 also mentions it on a tangent. Patients received maintenance doses of 1000 mg during the last hour of subsequent dialysis … Bookmark this page and spend a few days here if you need to. Dosage Pediatric patients. (see box 1) Give the loading dose over the specified time as per eTG (Box 2) The maximal liver function capacity (LiMAx) test has been recently introduced as a non-invasive diagnostic tool for determining acute liver failure … SOS is a rare disease with significant morbidity and mortality. Understand basic principles of vancomycin dosing in adults 3. It's really good. 1 Introduction. Initiate the appropriate vancomycin dosing regimen and adjust the dose … Guidelines issued by the Infectious Diseases Society of America in 2006 recommend increasing the vancomycin dosage … The maximum daily dose … We see the start of the infusion at 1200 (yes, of course we know that, since we … Vancomycin doses were 125 mg (one case), 250 mg (three cases), and 500 mg (two cases) every six hours. liver … Add up total dose of vancomycin and reduce by 10-20% Round to nearest 250 mg This will be the recommended starting dose for CI vancomycin o If patient supra- or sub-therapeutic on intermittent therapy: Estimate intermittent dose needed to make therapeutic and reduce by 10-20% Round to nearest 250 mg If vancomycin must be used, an AUC24 of at least 600 should be ensured to achieve efficacy (unfortunately this dose of vancomycin will increase the risk of nephrotoxicity). Take a level before the 4th new dose. Other patient factors, such as age or obesity, may call for modification of the usual daily dose. Is the clearance of the medication significantly altered? Depending on recent doses and drug levels, an additional pre-operative dose may not be necessary. 1)Pen VK: No dose alteration needed. 3. This test is used to monitor levels of the antimicrobial drug vancomycin in the blood. Vancomycin has been traditionally administered as brief intravenous infusions in a dosage of 1 g/12 hours to achieve trough vancomycin levels of 5 to 10 mg/L. Dosage adjustments are recommended when creatinine clearance is below 40 mL/min, see Section 4.2 Dose and Method of Administration. Recommended dose: 25-30 mg/kgIV based on actual body weight, for 1 dose, followed by maintenance dose separated by recommended dosing interval consider capping the loading dose at a maximum of 3g loading doses DO NOT need to be adjusted in patients with renal dysfunction; only maintenance dosing interval requires adjustment Note that this recommendation is … patient was treated with vancomycin (1 gm every 12 hours, with drug monitoring and adjustment to kidney function) and rifampicin (600 mg/day). Pharmacists should be cognizant of recommended drug-dosing alterations for patients with cirrhosis that are necessitated by decreased hepatic and/or renal function. Oral vancomycin: treatment of primary sclerosing cholangitis in children with. Severe ascites = endstage liver disease d) Renal failure… Vancomycin SINGLE Level-(dosing by levels) Original calc . Therefore, the 24h-AUC/MIC ratio is the parameter that correlates with efficacy. Vancomycin is indicated for initial therapy when methicillin-resistant Staphylococci are suspected, but after susceptibility data are available, therapy should be adjusted accordingly. The dosage of vancomycin hydrochloride for injection per day in mg is about 15 times the glomerular filtration rate in mL/min (see following table). Can also use similarly for staphylococcal enterocolitis. Keywords Augmented renal clearance, neurosurgery, vancomycin, therapeutic drug monitoring, renal func- ... Liver disease 0 0 Kidney disease … Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection and monitor renal function Dosage adjustment … -External drain output 150 to 200 mL/day: Increase the dose by … General rules for Vancomycin Monitoring Aim for pre-dose (trough) level: 10-15 mg/L. I found these 2. studies - Ann. The usual intravenous dosage of vancomycin is 10 mg/kg per dose … Even dosage of a medicine cleared by the kidney should be adjusted based on creatinine clearance, even in patients with liver disease. 12 Patients who should be considered for a loading dose include those who are critically-ill, those receiving renal replacement therapy, or those receiving a continuous infusion of vancomycin. A fixed loading dose (1 g of intravenous vancomycin) given at the end of initial HD, and 0.5–1 g maintenance dose after subsequent dialysis provides adequate pre-HD drug level in 96% of patients (5–20 ug/ml) [Decker et al. The trough level of vancomycin was 10-15 g/mL with a … Both prescription and over-the-counter medications can cause hepatotoxicity through a variety of mechanisms. However, it is increasingly clear that the trough level is an inadequate measurement of vancomycin exposure. MIC 1.5 ug/mL is intermediate. The higher ... response failure due to under-dose vancomycin … Liver cirrhosis is the end result of several mechanisms of liver inflammation caused by chronic liver disease, genetic disease… 2)Amoxicillin: No dose adjustment. For vancomycin and the aminoglycosides, a pharmacokinetic consult will be performed by the pharmacist, and the ordering physician will be contacted for dosage changes unless ordered as “pharmacy to dose.” ... by the liver and adjustments are not required. -External drain output 100 to 150 mL/day: Once a day. Yet CKD alters vancomycin pharmacokinetics, making precise dosing a challenge. The dose is usually given once a day, in the morning, but it can be given twice a day (morning and lunchtime) for additional diuresis. Critical Care Pharmacy Resident Due to a lack of reliable liver function tests, it is difficult to obtain sufficient data guiding clinicians in TGC dose adjustment in critically ill patients with liver dysfunction. 2006 Jun;40(6):1186-9. The frequency of VOD varies greatly, from 1-2% in centers performing pediatric BMT for thalassemia to over 50% in some centers doing BM … possible, specific dosage recommendations for patients with hepatic dysfunction. It is slowly bactericidal with a mechanism of action that consists of binding to peptidoglycan precursors and thus Pediatric Patients: The usual intravenous dosage of vancomycin is 10 mg/kg per dose given every six hours. Note: Criteria for disease severity is based on expert opinion and should not replace clinical judgment. Vancomycin prophylaxis should be considered for patients with known … Use Cases. VANCOMYCIN DOSING. Recently, a novel approach for dosing vancomycin in patients undergoing intermittent hemodialysis was highlighted in a report by Vandecasteele et al.2 A vancomycin dose calculator was developed and assessed for its accuracy in achieving trough concentrations of 15-20 mg/L in 18 patients requiring intermittent hemodialysis. Conclusion: In patients with cirrhosis, there was a high incidence of supratherapeutic vancomycin serum concentrations despite the fact that dosing was significantly less than that suggested by the published Kullar nomogram. Furthermore, the practice of waiting until the fourth dose … Avoid in renal insufficiency if alternatives. Consider omitting dose based on the level: - If vancomycin trough level is 20-25mg/L, give new dosage regime without omitting any doses. Cockcroft-Gault CrCl estimates (using the creatinine clearance calculator) should be used for drug dosing rather than the automated MDRD eGFR produced by the clinical chemistry laboratory available on NOTIS. The recommended vancomycin dose is 125 mg every 6 hours for 10 days for the first episode of non-severe CDI. Check a vancomycin level at 24-48 hours post-dose or with am labs on the day of the next hemodialysis session (if applicable) to obtain an estimated steady state level a) High flux filters in HD will remove ~ 20-40% of the vancomycin dose … Take it away, Steph! 5.0 Avoid using except in cases of strongly suspected or documented infection to reduce the development of resistant organisms dose adjustment and AUC ... patients with normal or mild liver disease due to the v ancomycin prolonged half-lives [43, 44]. Vancomycin: Dose adjustment for renal impairment. Prescribing to patients with kidney disease requires knowledge about the drug, the extent of the patient’s altered physiology, and pharmacokinetic principles that influence the design of dosing regimens. By the end of it, you'll be an expert on vancomycin. 3)Azithromycin: Avoid Azithromycin in patients with Liver disease. Vancomycin therapy in patients with impaired renal function: a nomogram for dosage. Ann Intern Med 1981; 94:343. Lake KD, Peterson CD. A simplified dosing method for initiating vancomycin therapy. Pharmacotherapy 1985; 5:340. Patients with decompensated liver cirrhosis have various serious complications which require multiple drugs for therapeutic or prophylactic use. Tetracycline HCL: Avoid. The ideal dosing regimen for vancomycin maximizes the amount of drug received. In obese patients a dose based on adjusted body weigh may be considered. But if a better guide for vancomycin dosing exists, then I am unaware of it. Vancomycin: Dose Adjustment Pearls. Drug dosing requirements for hypoglycemic agents in patients with chronic kidney disease are listed in Table 5.4, 18, 19 Because metformin … In the elderly, greater dosage reductions ... patients or those with liver disease, edema, or … DESCRIPTION. 1. In selected patients, a loading dose (25-30 mg/kg of total body weight; maximum 3000 mg) may be considered in order to achieve rapid attainment of serum concentrations. Precise vancomycin dosing is important to maximize treatment success in patients with CKD. Vancomycin is a glycopeptide antibiotic administered intravenously for treatment of patients with suspected or proven invasive gram-positive infections, including methicillin-resistant Staphylococcus aureus (MRSA).. Vancomycin Hydrochloride for Injection, USP is a lyophilized powder, for preparing intravenous (IV) infusions, in vials each containing the equivalent of 500 mg or 1 g vancomycin base. We report the derivation, validation, and postimplementation evaluation of a vancomycin dosing application (VancApp) for optimizing dosing decisions in patients with CKD. Severe disease or recurrent infection (≥1 severity marker) or first recurrence •PO Vancomycin 125mg 6hrly •Add IV Metronidazole if colitis suspected Severe disease not responding to treatment •PO Vancomycin 500mg 6hrly •Add IV Metronidazole if colitis suspected Duration: 10-14 days Decompensated chronic liver disease … An adult infectious disease pharmacist adjusts a vancomycin dose for a MRSA patient, aiming for a trough concentration of 10-15mcg/mL, although the only assay available was taken three hours earlier than intended, he uses DoseMeRx to calculate the trough level reached and a safe therapeutic dose … regimen for vancomycin using dosing nomograms and an appropriate PK model Given a patient history, therapeutic goal and serum concentration data, calculate k and V D and use to adjust the patient’s maintenance dose regimen ... Liver disease 19 For clearance of 10-50 mL/min/1.73 m 2, the dose of 15 mg/kg is recommended every 24-96 hours and, for clearances of less than 10 mL/min/1.73 m 2, the dose of 7.5 mg/kg every 48-72 hours. The next dose … creatinine or treatment failure.1 Patients who fail to respond to metronidazole after 2 to 3 days of treatment (i.e. We present the case of a 56-year-old woman who developed acute renal failure requiring hemodialysis as a result of unmonitored vancomycin infusions for … 36 Those findings suggest that dose adjustment of linezolid in patients with mild-to-moderate liver disease … tion should be paid to the possibility of ARC and the need for individualized dose adjustment based on the results of therapeutic drug monitoring. 5. Patients getting hemodialysis may be dosed according to their actual body weight, but the weight-based dose will depend on dialyzer permeability and timing of vancomycin dosing. The manufacturers recommend a dosage of 50 mg every 12 hours in patients with creatinine clearance between 15 to 30 mL/min and not using the drug in patients with creatinine clearance below 15 mL/min. However, the limitations of the Child-Pugh score are acknowledged, and further research is needed to develop more sensitive liver function tests to guide drug dosage adjustment in patients with hepatic dysfunction. Trough (pre) levels (taken 30 minutes or less prior to next dose) are recommended in: o Patients with deteriorating/unstable renal function (increase in baseline serum creatinine of 40 µmol/L or greater, or increase of 50% or more from baseline). Vancomycin hydrochloride for injection, USP is a lyophilized powder, for preparing intravenous (IV) infusions, in ADD-Vantage ® vials each containing the equivalent of 500 mg, 750 mg or 1 g vancomycin … mellitus, liver dysfunction, and active malignancy). inflammatory bowel disease. 2 g) can be used to facilitate rapid attainment of the target trough serum … Epub 2006 May 23. The usual intravenous dosage of vancomycin is 10 mg/kg per dose given every six hours. ( actual Body weight ) - usually 25 mg/kg adjustment must be made in patients with liver.! Dose … antibiotic dosing during renal failure February 1, 10 g ; Inj mg. Obtained ( range four to 19 ) during the seven- to 28-day courses of vancomycin is often a sub-optimal 4.0. > 125, or receipt of insulin or other hypo-glycemic medications during vancomycin treatment the last hour of subsequent …! Is 125 mg 4 times a day who received vancomycin therapy in patients liver... 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vancomycin dose adjustment in liver failure

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In conclusion, vancomycin dosing schedule does not need to be modified for patients with liver failure, with the exception of patients with ascites. The basic principles of using a CONTINUOUS INFUSION of VANCOMYCIN are simple. The two most common drugs used to treat C. difficile are metronidazole (500 mg PO TID) and vancomycin (125 mg PO QID) for 10–14 days. Discover the world's research 20+ million members Method: We conducted a quasi-experimental study in patients who were prescribed intravenous vancomycin. Dosage adjustment must be made in patients with impaired renal function. While its association with acute kidney injury (AKI) has waxed and waned, recent data … Majority of the drugs are primarily metabolized and excreted by hepatobiliary system; hence, liver cell necrosis contributes to impaired drug handling in liver failure while portosystemic shunt can alter drug action in cirrhosis. The glycopeptide antibiotic vancomycin is a mainstay in the treatment of Gram-positive infection. b)Cirrhosis: Decrease Clindamycin total dose by 50%. lack of improvement, increasing stool frequency after 3 days of treatment or new signs of severe C. difficile-associated diarrhoea), switching to oral vancomycin should be considered.1 The recommended oral dose of vancomycin for C. Question 13 from the first paper of 2010 also mentions it on a tangent. Patients received maintenance doses of 1000 mg during the last hour of subsequent dialysis … Bookmark this page and spend a few days here if you need to. Dosage Pediatric patients. (see box 1) Give the loading dose over the specified time as per eTG (Box 2) The maximal liver function capacity (LiMAx) test has been recently introduced as a non-invasive diagnostic tool for determining acute liver failure … SOS is a rare disease with significant morbidity and mortality. Understand basic principles of vancomycin dosing in adults 3. It's really good. 1 Introduction. Initiate the appropriate vancomycin dosing regimen and adjust the dose … Guidelines issued by the Infectious Diseases Society of America in 2006 recommend increasing the vancomycin dosage … The maximum daily dose … We see the start of the infusion at 1200 (yes, of course we know that, since we … Vancomycin doses were 125 mg (one case), 250 mg (three cases), and 500 mg (two cases) every six hours. liver … Add up total dose of vancomycin and reduce by 10-20% Round to nearest 250 mg This will be the recommended starting dose for CI vancomycin o If patient supra- or sub-therapeutic on intermittent therapy: Estimate intermittent dose needed to make therapeutic and reduce by 10-20% Round to nearest 250 mg If vancomycin must be used, an AUC24 of at least 600 should be ensured to achieve efficacy (unfortunately this dose of vancomycin will increase the risk of nephrotoxicity). Take a level before the 4th new dose. Other patient factors, such as age or obesity, may call for modification of the usual daily dose. Is the clearance of the medication significantly altered? Depending on recent doses and drug levels, an additional pre-operative dose may not be necessary. 1)Pen VK: No dose alteration needed. 3. This test is used to monitor levels of the antimicrobial drug vancomycin in the blood. Vancomycin has been traditionally administered as brief intravenous infusions in a dosage of 1 g/12 hours to achieve trough vancomycin levels of 5 to 10 mg/L. Dosage adjustments are recommended when creatinine clearance is below 40 mL/min, see Section 4.2 Dose and Method of Administration. Recommended dose: 25-30 mg/kgIV based on actual body weight, for 1 dose, followed by maintenance dose separated by recommended dosing interval consider capping the loading dose at a maximum of 3g loading doses DO NOT need to be adjusted in patients with renal dysfunction; only maintenance dosing interval requires adjustment Note that this recommendation is … patient was treated with vancomycin (1 gm every 12 hours, with drug monitoring and adjustment to kidney function) and rifampicin (600 mg/day). Pharmacists should be cognizant of recommended drug-dosing alterations for patients with cirrhosis that are necessitated by decreased hepatic and/or renal function. Oral vancomycin: treatment of primary sclerosing cholangitis in children with. Severe ascites = endstage liver disease d) Renal failure… Vancomycin SINGLE Level-(dosing by levels) Original calc . Therefore, the 24h-AUC/MIC ratio is the parameter that correlates with efficacy. Vancomycin is indicated for initial therapy when methicillin-resistant Staphylococci are suspected, but after susceptibility data are available, therapy should be adjusted accordingly. The dosage of vancomycin hydrochloride for injection per day in mg is about 15 times the glomerular filtration rate in mL/min (see following table). Can also use similarly for staphylococcal enterocolitis. Keywords Augmented renal clearance, neurosurgery, vancomycin, therapeutic drug monitoring, renal func- ... Liver disease 0 0 Kidney disease … Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection and monitor renal function Dosage adjustment … -External drain output 150 to 200 mL/day: Increase the dose by … General rules for Vancomycin Monitoring Aim for pre-dose (trough) level: 10-15 mg/L. I found these 2. studies - Ann. The usual intravenous dosage of vancomycin is 10 mg/kg per dose … Even dosage of a medicine cleared by the kidney should be adjusted based on creatinine clearance, even in patients with liver disease. 12 Patients who should be considered for a loading dose include those who are critically-ill, those receiving renal replacement therapy, or those receiving a continuous infusion of vancomycin. A fixed loading dose (1 g of intravenous vancomycin) given at the end of initial HD, and 0.5–1 g maintenance dose after subsequent dialysis provides adequate pre-HD drug level in 96% of patients (5–20 ug/ml) [Decker et al. The trough level of vancomycin was 10-15 g/mL with a … Both prescription and over-the-counter medications can cause hepatotoxicity through a variety of mechanisms. However, it is increasingly clear that the trough level is an inadequate measurement of vancomycin exposure. MIC 1.5 ug/mL is intermediate. The higher ... response failure due to under-dose vancomycin … Liver cirrhosis is the end result of several mechanisms of liver inflammation caused by chronic liver disease, genetic disease… 2)Amoxicillin: No dose adjustment. For vancomycin and the aminoglycosides, a pharmacokinetic consult will be performed by the pharmacist, and the ordering physician will be contacted for dosage changes unless ordered as “pharmacy to dose.” ... by the liver and adjustments are not required. -External drain output 100 to 150 mL/day: Once a day. Yet CKD alters vancomycin pharmacokinetics, making precise dosing a challenge. The dose is usually given once a day, in the morning, but it can be given twice a day (morning and lunchtime) for additional diuresis. Critical Care Pharmacy Resident Due to a lack of reliable liver function tests, it is difficult to obtain sufficient data guiding clinicians in TGC dose adjustment in critically ill patients with liver dysfunction. 2006 Jun;40(6):1186-9. The frequency of VOD varies greatly, from 1-2% in centers performing pediatric BMT for thalassemia to over 50% in some centers doing BM … possible, specific dosage recommendations for patients with hepatic dysfunction. It is slowly bactericidal with a mechanism of action that consists of binding to peptidoglycan precursors and thus Pediatric Patients: The usual intravenous dosage of vancomycin is 10 mg/kg per dose given every six hours. Note: Criteria for disease severity is based on expert opinion and should not replace clinical judgment. Vancomycin prophylaxis should be considered for patients with known … Use Cases. VANCOMYCIN DOSING. Recently, a novel approach for dosing vancomycin in patients undergoing intermittent hemodialysis was highlighted in a report by Vandecasteele et al.2 A vancomycin dose calculator was developed and assessed for its accuracy in achieving trough concentrations of 15-20 mg/L in 18 patients requiring intermittent hemodialysis. Conclusion: In patients with cirrhosis, there was a high incidence of supratherapeutic vancomycin serum concentrations despite the fact that dosing was significantly less than that suggested by the published Kullar nomogram. Furthermore, the practice of waiting until the fourth dose … Avoid in renal insufficiency if alternatives. Consider omitting dose based on the level: - If vancomycin trough level is 20-25mg/L, give new dosage regime without omitting any doses. Cockcroft-Gault CrCl estimates (using the creatinine clearance calculator) should be used for drug dosing rather than the automated MDRD eGFR produced by the clinical chemistry laboratory available on NOTIS. The recommended vancomycin dose is 125 mg every 6 hours for 10 days for the first episode of non-severe CDI. Check a vancomycin level at 24-48 hours post-dose or with am labs on the day of the next hemodialysis session (if applicable) to obtain an estimated steady state level a) High flux filters in HD will remove ~ 20-40% of the vancomycin dose … Take it away, Steph! 5.0 Avoid using except in cases of strongly suspected or documented infection to reduce the development of resistant organisms dose adjustment and AUC ... patients with normal or mild liver disease due to the v ancomycin prolonged half-lives [43, 44]. Vancomycin: Dose adjustment for renal impairment. Prescribing to patients with kidney disease requires knowledge about the drug, the extent of the patient’s altered physiology, and pharmacokinetic principles that influence the design of dosing regimens. By the end of it, you'll be an expert on vancomycin. 3)Azithromycin: Avoid Azithromycin in patients with Liver disease. Vancomycin therapy in patients with impaired renal function: a nomogram for dosage. Ann Intern Med 1981; 94:343. Lake KD, Peterson CD. A simplified dosing method for initiating vancomycin therapy. Pharmacotherapy 1985; 5:340. Patients with decompensated liver cirrhosis have various serious complications which require multiple drugs for therapeutic or prophylactic use. Tetracycline HCL: Avoid. The ideal dosing regimen for vancomycin maximizes the amount of drug received. In obese patients a dose based on adjusted body weigh may be considered. But if a better guide for vancomycin dosing exists, then I am unaware of it. Vancomycin: Dose Adjustment Pearls. Drug dosing requirements for hypoglycemic agents in patients with chronic kidney disease are listed in Table 5.4, 18, 19 Because metformin … In the elderly, greater dosage reductions ... patients or those with liver disease, edema, or … DESCRIPTION. 1. In selected patients, a loading dose (25-30 mg/kg of total body weight; maximum 3000 mg) may be considered in order to achieve rapid attainment of serum concentrations. Precise vancomycin dosing is important to maximize treatment success in patients with CKD. Vancomycin is a glycopeptide antibiotic administered intravenously for treatment of patients with suspected or proven invasive gram-positive infections, including methicillin-resistant Staphylococcus aureus (MRSA).. Vancomycin Hydrochloride for Injection, USP is a lyophilized powder, for preparing intravenous (IV) infusions, in vials each containing the equivalent of 500 mg or 1 g vancomycin base. We report the derivation, validation, and postimplementation evaluation of a vancomycin dosing application (VancApp) for optimizing dosing decisions in patients with CKD. Severe disease or recurrent infection (≥1 severity marker) or first recurrence •PO Vancomycin 125mg 6hrly •Add IV Metronidazole if colitis suspected Severe disease not responding to treatment •PO Vancomycin 500mg 6hrly •Add IV Metronidazole if colitis suspected Duration: 10-14 days Decompensated chronic liver disease … An adult infectious disease pharmacist adjusts a vancomycin dose for a MRSA patient, aiming for a trough concentration of 10-15mcg/mL, although the only assay available was taken three hours earlier than intended, he uses DoseMeRx to calculate the trough level reached and a safe therapeutic dose … regimen for vancomycin using dosing nomograms and an appropriate PK model Given a patient history, therapeutic goal and serum concentration data, calculate k and V D and use to adjust the patient’s maintenance dose regimen ... Liver disease 19 For clearance of 10-50 mL/min/1.73 m 2, the dose of 15 mg/kg is recommended every 24-96 hours and, for clearances of less than 10 mL/min/1.73 m 2, the dose of 7.5 mg/kg every 48-72 hours. The next dose … creatinine or treatment failure.1 Patients who fail to respond to metronidazole after 2 to 3 days of treatment (i.e. We present the case of a 56-year-old woman who developed acute renal failure requiring hemodialysis as a result of unmonitored vancomycin infusions for … 36 Those findings suggest that dose adjustment of linezolid in patients with mild-to-moderate liver disease … tion should be paid to the possibility of ARC and the need for individualized dose adjustment based on the results of therapeutic drug monitoring. 5. Patients getting hemodialysis may be dosed according to their actual body weight, but the weight-based dose will depend on dialyzer permeability and timing of vancomycin dosing. The manufacturers recommend a dosage of 50 mg every 12 hours in patients with creatinine clearance between 15 to 30 mL/min and not using the drug in patients with creatinine clearance below 15 mL/min. However, the limitations of the Child-Pugh score are acknowledged, and further research is needed to develop more sensitive liver function tests to guide drug dosage adjustment in patients with hepatic dysfunction. Trough (pre) levels (taken 30 minutes or less prior to next dose) are recommended in: o Patients with deteriorating/unstable renal function (increase in baseline serum creatinine of 40 µmol/L or greater, or increase of 50% or more from baseline). 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