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Gram-positive bacteremia is a common infection in pediatric oncology and stem cell transplant (SCT) patients requiring therapy with vancomycin. Optimal dosing of vancomycin in this patient population has not been well established.All pediatric oncology and SCT patients receiving vancomycin between October 2006 and March 2007 were included in this study. Therapeutic levels were defined as levels between 10 and 15 mg/dL and low therapeutic levels were between 5 and 9 mg/dL. Information regarding any recent or concurrent nephrotoxic medications was collected.Fifty-six patients received 82 courses of vancomycin during the study period. More patients (53.7%) received vancomycin for empiric therapy and 78% had recent or concurrent use of nephrotoxic medications. Using standardized vancomycin dosing guided by a computerized provider order entry system, there were significantly more patients who were in the subtherapeutic range than the supratherapeutic range (P=0.0023). There were also significantly more patients in the low therapeutic than the therapeutic range (P<0.0001). A small number of courses (3.5%) were associated with supratherapeutic levels. There was no association between the concurrent or recent use of nephrotoxic medications and vancomycin levels.Pediatric oncology and SCT patients with normal renal function require higher daily vancomycin doses than other pediatric patients.