Administering vancomycin without dose adjustment in patients with severe kidney failure significantly increases the risk of toxicity due to reduced renal clearance.
Always calculate CrCl and adjust dose; do not administer standard doses without modification.
Therapeutic drug monitoring is essential to avoid supratherapeutic levels.
Monitor for signs of toxicity including tinnitus, vertigo, and rising creatinine.
Consult nephrology for patients on dialysis.
Vancomycin is primarily eliminated unchanged by glomerular filtration in the kidneys. In severe renal impairment (e.g., CrCl <30 mL/min), its clearance is substantially decreased, leading to drug accumulation and elevated serum concentrations.
Risk of nephrotoxicity (worsening kidney function), ototoxicity (hearing loss), and other adverse effects like red man syndrome; prolonged high levels can be life-threatening.
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