Neonatal Drug Therapy Manual


Disclaimer: Official controlled document is the CHEO and Ottawa Hospital online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Alternate Name(s): 
Original Date: 
March 1993
Revised Date: 
December 2020
  • Staphylococcal infections resistant to cloxacillin
  • May be used as initial therapy in severely ill patients
  • IV intermittent infusion: over 1 hour

0 - 14 days:

  • < 28 weeks GA: 20 - 22 mg/kg/dose Q24h
  • 29-34 weeks GA: 20 - 22 mg/kg/dose Q18h
  • > 35 weeks GA: 20 - 22 mg/kg/dose Q12h

> 14 days:

  • < 28 weeks corrected GA: 20 - 22 mg/kg/dose Q18h
  • 29 - 34 weeks corrected GA: 20 - 22 mg/kg/dose Q12h
  • > 35 weeks corrected GA: 20 - 22 mg/kg/dose Q8-12h

Infant (corrected GA > 42 weeks and PNA > 4 weeks):

  • 15 mg/kg/dose Q6h

Dosage adjustment required in renal impairment.  Refer to available references or clinical pharmacist for dosage adjustment

Side Effects: 
  • Dermatologic: red man syndrome (associated with rapid infusion rate)
  • Hematologic: eosinophilia, neutropenia
  • Local: phlebitis
  • Otic: ototoxicity associated with high drug levels
  • Renal: nephrotoxicity (enhanced by aminoglycoside therapy)
Parameters to Monitor: 
  • Baseline serum creatinine and Pre level. Repeat both once weekly.  Pre (Trough) levels > 15 mg/L should be monitored a minimum of twice weekly
  • WBC
  • Infusion site


  • Therapeutic drug levels:
    • Serum Levels: Pre level only, 0 - 30 minutes before dose
    • Initial level:
      • Prior to 2nd or 3rd dose if:
        • dosing intervals of Q12H or less frequent
        • renal impairment
      • Prior to 5th dose

 ** When checking trough level, administer next dose as scheduled. Do not wait for level to be reported unless otherwise advised

  • Pre (Trough) levels:
    • 6 - 10 mg/L
      • Infections (e.g. bacteremia) with coagulase negative staphylococci (i.e. S. epidermidis) including line infections
    • 10 - 15 mg/L
      • CNS infections, shunt infections or other deep-seated infections.  Skin and soft tissue infections caused by methicillin resistant Staphylococcus aureus (MRSA)
    • 15 - 20 mg/L
      • These levels can be considered in individual patients with invasive or persistent methicillin resistant Staphylococcus aureus (MRSA) infections such as infective endocarditis, osteomyelitis, meningitis, pneumonia or severe soft tissue infections.
  • Post (Peak) levels: Not routine
Reconstitution and Stability: 

IV intermittent infusion:

  • Vancomycin 1000 mg vial
    • Add 20 mL SWFI.  Take 5 mL (250 mg) and add to 45 mL D5W
    • Final concentration: 5 mg/mL
  • Vancomycin 500 mg vial
    • Add 10 mL SWFI. Take 5 mL (250 mg) and add to 45 mL D5W
    • Final concentration: 5 mg/mL

- Solutions Compatible: dextrose, saline, dextrose-saline combinations

- Y-site Compatible: calcium, fentanyl, heparin (in low concentrations of 0.5 to 1 unit/mL used to maintain IV line potency), midazolam, morphine, pancuronium, SMOF, TPN

Incompatible: dexamethasone, heparin (concentrations greater than 1 unit/mL), phenobarbital


- Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Chambers HF.  Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children: Executive Summary. Clin Infect Dis. Feb 1 2011: 52 (3): 285-292

- Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook 22nd Edition. Hudson: Lexi-Comp Inc.; 2015.

- Trissel LA. Handbook on Injectable Drugs 19th Edition. Bethesda, Maryland; American Society of Health-System Pharmacists. 2017

- Rajon K, Vaillancourt R, Varughese N, Villarreal G.  Vancomycin use, dosing and serum  trough concentrations in the pediatric population: a retrospective institutional review. Pharmacy Practice 2017 Apr-Jun;15(2):887

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