17 September 2025
New dosing regimen for intravenous vancomycin in neonates
The glycopeptide antibacterial vancomycin is commonly used in neonatal intensive care units (NICUs) to treat infections known or suspected to be caused by Gram-positive organisms resistant to beta-lactam antibacterials, such as coagulase-negative staphylococci (CoNS), meticillin-resistant Staphylococcus aureus (MRSA), and Enterococcus spp. Licensed product information recommends administration by intermittent intravenous infusion (IIV) over 60 minutes between one and three times daily in infants, the initial frequency being dependent on corrected gestational age and subsequent dosing adjusted according to serum trough concentrations. Following correspondence about a shift in practice to the administration of vancomycin by continuous intravenous infusion (CIV) in NICUs, we undertook a review of this off-label route of administration.
We conducted an extensive literature search on the use of CIV vancomycin in neonates, including its safety and efficacy, initial dosing regimen, target therapeutic concentrations, monitoring, and dose adjustments. Our review found limited evidence for the clinical and microbiological efficacy of CIV compared with IIV vancomycin in neonates, however, CIV was found to have a higher probability of attainment of target serum concentrations and there is no evidence that it is less safe than IIV. There are also practical advantages of CIV, in terms of ease and frequency of blood sampling, as the blood sample can be taken at any time once steady state has been achieved, rather than timing the samples to coincide with trough concentrations.
Since there is limited evidence for the optimum dosing regimen and target serum concentration, particularly in very low birth-weight infants, we used the primary literature, including pharmacokinetic/pharmacodynamic modelling studies, and also consulted with experts from the UK Paediatric Antimicrobial Stewardship (UK-PAS) network, to guide the development of a dosing regimen for CIV vancomycin in neonates for inclusion in BNF for Children (BNFC). This regimen consists of a loading dose followed by a continuous infusion, the initial rate of which is dependent on the corrected gestational age and renal function of the neonate. Brief advice on target concentration, monitoring, and dosage adjustment is also included in the vancomycin monograph (see the Indications and dose, Monitoring requirements, and Directions for administration sections).
The CIV dosing regimen and associated advice have been ratified by the Paediatric Formulary Committee and subsequently published in BNFC for the September 2025 update provided online via MedicinesComplete and NICE, and BNFC app. It will also be included in the 2026-2027 print edition of BNFC.
