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DRUG INFORMATION RESPONSE FORM

DATE QUESTION RECEIVED: AUGUST 15, 2014 DATE RESPONSE SUBMITTED: AUGUST 28, 2014

DRUG INFORMATION QUESTION: WHAT IS THE DOSING FOR VANCOMYCIN FOR A PATIENT THAT HAS PERITONEAL DIALYSIS
ASSOCIATED PERITONITIS?

RESPONSE
Patients who present with peritoneal dialysis-associated peritonitis should be treated empirically with
broad-spectrum antibiotics to ensure gram-positive and gram-negative coverage. Dual antibiotic therapy can
be achieved with a first generation cephalosporin or vancomycin for gram-positive organisms with the addition
of a third-generation cephalosporin or aminoglycoside for gram-negative organisms. However, with the
increase presence of methicillin-resistant organisms, using vancomycin for empiric gram-positive coverage is a
better option. The intraperitoneal (IP) route is the preferred route of administration for vancomycin when it is
used to treat peritoneal dialysis associated peritonitis. The IP route allows for high levels of antibiotics at the
site of infection, and the infection further enhances the absorption vancomycin. Vancomycin is typically about
50% absorbed, but in the presence of peritonitis it is about 90% absorbed. The IP route also allows self-
administration after proper training.
Vancomycin dosing is dependent on the type of peritoneal dialysis that the patient receives, as well as
the frequency of dosing chosen. For patients who receive continuous ambulatory peritoneal dialysis (CAPD), IP
vancomycin can be given with each exchange (continuous), or once daily (intermittent). For patients receiving
continuous dosing, the recommended loading dose is 1,000 mg IP, followed by a maintenance dose of 25 mg
per exchange. If the patient receives intermittent dosing, the vancomycin is added to the dialysis solution and
it must dwell for at least 6 hours for adequate absorption into systemic circulation. The recommended dosing
for intermittent dosing is 15 to 30 mg/kg every 5 to 7 days.
Patients who are on automated peritoneal dialysis (APD) are dosed differently than patients who are on
CAPD. In APD, intermittent dosing of vancomycin is preferred. A loading dose of 30 mg/kg IP in a long dwell
should be administered followed by 15 mg/kg IP in a long dwell every 3 to 5 days. The goal of IP vancomycin
dosing is to keep serum troughs above 15 g/mL, which is usually achieved with a dosing interval of every 4 to
5 days. There will be variability in serum troughs due to higher peritoneal clearance in APD so obtaining levels
is best to determine efficacy. IP levels of vancomycin will be lower than serum levels, so dosing should be
based on serum vancomycin levels. Re-dosing is appropriate once the serum levels go below 15 g/mL.
Duration of therapy is dependent on the isolated pathogen. If clinical improvement is seen after 3 to 5
days of therapy for streptococcus or enterococcus that requires continued therapy with vancomycin, continue
treatment for 14 days for streptococcus infection and 21 days for enterococcus infection. If there is clinical
improvement of peritonitis with exit-site or tunnel infection, consider catheter removal and treat for 21
days. For other gram-positive organisms, including coagulase-negative staphylococcus, treat for 14 days. In
the presence of an exit-site or tunnel infection, consider catheter removal and treat for 14 to 21 days.
Staphylococcus aureus is known to cause severe peritonitis that is often due to catheter infection or touch
contamination. In concurrent exit-site or tunnel infection, strong consideration of catheter removal is
necessary for an adequate response to antibiotic therapy. There should be a minimum rest period of 2 weeks
before re-initiation of PD. The duration of therapy for S. aureus is 21 days. Addition of rifampin (1 week) can
be considered as adjunct for the prevention of relapse of S. aureus peritonitis.
REFERENCES:




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1. Li PK-T, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. Peritoneal Dialysis-Related
Infections Recommendations: 2010 Update. Periton Dialysis Int. 2010;30:393-423.
2. Blunden M, Zeitlin D, Ashman N, Fan SLS. Single UK centre experience on the treatment of PD
peritonitisantibiotic levels and outcomes. Nephrol Dial Transplant. 2007;22:17141719.