vancomycin

REMS

IV: Potentially life-threatening infections when less toxic anti-infectives are contraindicated. Particularly useful in staphylococcal infections, including:
- endocarditis,
- meningitis,
- osteomyelitis,
- pneumonia,
- septicemia,
- soft-tissue infections in patients who have allergies to penicillin or its derivatives or when sensitivity testing demonstrates resistance to methicillin.
PO: Staphylococcal enterocolitis or diarrhea due to
Clostridioides difficile
.
IV: Part of endocarditis prophylaxis in high-risk patients who are allergic to penicillin.

Action ⬆ ⬇

Binds to bacterial cell wall, resulting in cell death.

Therapeutic effects:

Bactericidal action against susceptible organisms.

Spectrum:

Active against gram-positive pathogens, including:
- Staphylococci (including methicillin-resistant strains of Staphylococcus aureus),
- Group A beta-hemolytic streptococci,
- Streptococcus pneumoniae,
- Corynebacterium,
- Clostridioides difficile,
- Enterococcus faecalis,
- Enterococcus faecium.

Pharmacokinetics ⬆ ⬇

Absorption: Poorly absorbed from the GI tract.

Distribution: Widely distributed to tissues. Some penetration (20–30%) of CSF.

Metabolism/Excretion: Oral doses excreted primarily in the feces; IV vancomycin eliminated almost entirely by the kidneys.

Half-Life: Neonates: 6–10 hr; Children 3 mo–3 yr: 4 hr; Children >3 yr: 2–2.3 hr; Adults: 5–8 hr (↑ in renal impairment).

Time/Action Profile ⬆ ⬇

(plasma concentrations)

ROUTE	ONSET	PEAK	DURATION
IV	rapid	end of infusion	12–24 hr

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity.

Use Cautiously in:

Renal impairment (dose ↓ required if CCr ≤80 mL/min);
Hearing impairment;
Intestinal obstruction or inflammation (↑ systemic absorption when given orally);
OB: Pharmacokinetics of IV vancomycin may be altered in pregnancy (volume of distribution may be ); systemic absorption of PO vancomycin expected to be minimal;
Lactation: Use while breastfeeding only if potential maternal benefit justifies potential risk to infant.

Adv. Reactions/Side Effects ⬆ ⬇

CV: hypotension

Derm: ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS, DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS, LINEAR IGA BULLOUS DERMATOSIS, rash, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS

EENT: ototoxicity

GI: nausea, vomiting

GU: nephrotoxicity

Hemat: eosinophilia, leukopenia

Local: phlebitis

MS: back and neck pain

Misc: chills, fever, HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS), vancomycin flushing syndrome (with rapid infusion)

Interactions ⬆ ⬇

Drug-drug:

May cause additive ototoxicity and nephrotoxicity with other ototoxic and nephrotoxic drugs, including aspirin, aminoglycosides, cyclosporine, cisplatin, and loop diuretics.
May enhance neuromuscular blockade from nondepolarizing neuromuscular blocking agents.
↑risk of histamine flush when used with general anesthetics in children.

Route/Dosage ⬆ ⬇

Serious Systemic Infections

IV (Adults ): 500 mg every 6 hr or 1 g every 12 hr (up to 4 g/day).
IV (Children >1 mo): 40 mg/kg/day divided every 6–8 hr. Staphylococcal CNS infection: 60 mg/kg/day divided every 6 hr, maximum dose: 1 g/dose.
IV (Neonates 1 wk–1 mo and >2000 g): 15–20 mg/kg every 8 hr.
IV (Neonates 1 wk–1 mo and 1200–2000 g): 10–15 mg/kg every 8–12 hr.
IV (Neonates 1 wk–1 mo and <1200 g): 15 mg/kg every 24 hr.
IV (Neonates <1 wk and >2000 g): 10–15 mg/kg every 8–12 hr.
IV (Neonates <1 wk and 1200–2000 g): 10–15 mg/kg every 12–18 hr.
IV (Neonates <1 wk and <1200 g): 15 mg/kg every 24 hr.
(Adults ): 20 mg/day.
(Children ): 5–20 mg/day.
(Neonates ): 5–10 mg/day.

Renal Impairment

IV (Adults ): An initial loading dose of 750 mg–1 g (not less than 15 mg/kg); serum level monitoring is optimal for choosing maintenance dose in patients with renal impairment; these guidelines may be helpful. CCr 50–80 mL/min: 1 g every 1–3 days; CCr 10–50 mL/min: 1 g every 3–7 days; CCr <10 mL/min: 1 g every 7–14 days.

Endocarditis Prophylaxis in Penicillin-Allergic Patients

IV (Adults and Adolescents): 1 g single dose 1 hr preprocedure.
IV (Children ): 20 mg/kg single dose 1 hr preprocedure.

Diarrhea Due to C. difficile

PO (Adults ): 125 mg every 6 hr for 10 days.
PO (Children ): 40 mg/kg/day divided into 3 or 4 doses for 7–10 days (not to exceed 2 g/day).

Staphylococcal Enterocolitis

PO (Adults ): 500–2000 mg/day in 3–4 divided doses for 7–10 days.
PO (Children ): 40 mg/kg/day in 3–4 divided doses for 7–10 days (not to exceed 2 g/day).

Availability ⬆ ⬇

(Generic available)

Capsules: 125 mg; 250 mg
Powder for oral solutiongrape flavor: 3.75 g/bottle; 7.5 g/bottle; 15 g/bottle
Premixed infusion: 500 mg/100 mL D5W; 750 mg/150 mL D5W; 1000 mg/200 mL D5W or 0.9% NaCl; 1250 mg/200 mL D5W; 1500 mg/300 mL D5W; 1750 mg/350 mL D5W; 2000 mg/400 mL D5W
Solution for injection: 250 mg/vial; 500 mg/vial; 750 mg/vial; 1 g/vial; 1.5 g/vial; 5 g/vial; 10 g/vial; 100 g/vial

Assessment ⬆ ⬇

Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.
Obtain specimens for culture and sensitivity prior to initiating therapy. First dose may be given before receiving results.
Monitor IV site closely. Vancomycin is irritating to tissues and causes necrosis and severe pain with extravasation. Rotate infusion site.
Monitor BP during IV infusion.
Evaluate eighth cranial nerve function by audiometry and serum vancomycin levels prior to and throughout therapy in patients with borderline renal function or those >60 yr of age. Prompt recognition and intervention are essential in preventing permanent damage.
Monitor intake and output ratios and daily weight. Cloudy or pink urine may be a sign of nephrotoxicity.
Assess patient for signs of superinfection (black, furry overgrowth on tongue; vaginal itching or discharge; loose or foul-smelling stools). Report occurrence.
Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction.
C. difficile-Associated Diarrhea: Assess bowel status (bowel sounds, frequency and consistency of stools, presence of blood in stools) throughout therapy.

Lab Test Considerations:

Monitor for casts, albumin, or cells in the urine or decreased specific gravity, CBC, and renal function periodically during therapy.
- May cause ↑ BUN levels.

Toxicity and Overdose:

Trough concentrations should not exceed 10 mcg/mL (mild to moderate infections) or 15–20 mcg/mL (for severe infections).

Implementation ⬆ ⬇

Vancomycin must be given orally for treatment of staphylococcal enterocolitis and
C. difficile
-associated diarrhea. Orally administered vancomycin is not effective for other types of infections.
PO: Use calibrated measuring device for liquid preparations. Shake well before use. Oral solution is stable for 14 days if refrigerated.

IV Administration:

Intermittent Infusion: Diluent: To reconstitute, add 10 mL of sterile water for injection to 500-mg vial or 20 mL of sterile water for injection to 1-g vial for a concentration of 50 mg/mL. Dilute further with at least 100 mL of 0.9% NaCl, D5W, D5/0.9% NaCl, or LR for every 500 mg of vancomycin being administered. Reconstituted vials stable for 14 days if refrigerated. Infusion is stable for 96 hr if refrigerated.Concentration: 5 mg/mL.
Rate: Infuse over at least 60 min (90 min for doses >1 g). Do not administer rapidly or as a bolus, to minimize risk of thrombophlebitis, hypotension, and vancomycin flushing syndrome (sudden, severe hypotension; flushing and/or maculopapular rash of face, neck, chest, and upper extremities). May need to slow infusion further to 1.5–2 hr if vancomycin flushing syndrome occurs.
Diluent: Dilute with preservative-free NS.Concentration: 1–5 mg/mL.

Patient/Family Teaching ⬆ ⬇

Advise patients on oral vancomycin to take as directed. Take missed doses as soon as remembered unless almost time for next dose; do not double dose.
Instruct patient to report signs of hypersensitivity, tinnitus, vertigo, or hearing loss.
Advise patient to notify health care professional if no improvement is seen in a few days.
Patients with a history of rheumatic heart disease or valve replacement need to be taught importance of using antimicrobial prophylaxis prior to invasive dental or medical procedures.
Rep: Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇