vancomycin

Therapeutic Classification: anti-infectives

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.

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.

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).

(plasma concentrations)

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

Contraindicated in:

Hypersensitivity.

Use Cautiously in:

Renal impairment (↓ dose 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.

CV: hypotension

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

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)

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.

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.
IT (Adults ): 20 mg/day.
IT (Children ): 5–20 mg/day.
IT (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).

(Generic available)

Capsules: 125 mg; 250 mg
Powder for oral solution grape 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

Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.
Monitor IV site for phlebitis and other administration reactions; rotate infusion sites. If symptoms occur, immediately stop infusion and treat as indicated.
Monitor for signs/symptoms of anaphylaxis and vancomycin flushing syndrome (hypotension; pruritus; flushing of face, neck, or upper body; pain and muscle spasm of chest and back). If symptoms occur, stop infusion immediately and treat as indicated. Keep emergency medication and equipment close by during therapy.
Monitor for severe dermatologic reactions such as TEN, SJS, and DRESS. At 1st sign of rash, mucosal lesions, or blisters, immediately discontinue vancomycin and treat as indicated.
Evaluate 8th cranial nerve function by audiometry and serum vancomycin concentrations 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, output, and daily weight. Cloudy or pink urine may be a sign of nephrotoxicity.
Assess for signs of superinfection (black, furry overgrowth on tongue; vaginal itching or discharge; loose or foul-smelling stools).
Monitor for signs/symptoms of CDAD (diarrhea, abdominal cramping, fever, bloody stools). If CDAD occurs, discontinue vancomycin and treat as indicated. May begin up to several weeks following cessation of therapy.

Lab Test Considerations:

Obtain specimens for culture and sensitivity prior to initiating therapy. 1st dose may be given before receiving results.
- Monitor CBC, renal function, and urinalysis for casts, albumin, or cells in the urine periodically during therapy. If acute kidney injury occurs, discontinue vancomycin or ↓ dose.
- Monitor vancomycin concentrations, periodically during therapy. If acute kidney injury occurs, discontinue vancomycin or ↓ dose.

Toxicity and Overdose:

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

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:

IV vancomycin is a vesicant. Monitor closely if administered through a peripheral IV. Can also be infused through a midline catheter or PICC. If extravasation occurs, immediately stop infusion. Leave needle/cannula in place temporarily but do not flush the line. Gently aspirate extravasated solution; then remove needle/cannula. Elevate patient's extremity and apply dry cold compresses. Initiate hyaluronidase antidote for refractory cases in addition to supportive management. For hyaluronidase, inject a total of 1 mL (15 units/mL) intradermally or SUBQ as five separate 0.2-mL injections (using a tuberculin syringe) around the site of extravasation; if IV catheter remains in place, administer IV through the infiltrated catheter; may repeat in 30–60 min if no resolution.
Intermittent Infusion: Reconstitution: Add 10 mL or 20 mL of sterile water for injection to 500-mg or 1-g vials, respectively. Solution stable for 14 days if refrigerated. Concentration: 50 mg/mL. Diluent: Dilute further with 100 mL of 0.9% NaCl, D5W, D5/0.9% NaCl, or LR for every 500 mg of vancomycin being administered. Infusion is stable for 96 hr if refrigerated.Concentration: 5 mg/mL.
Rate: Infuse over ≥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. May need to slow infusion further to 1.5–2 hr if flushing syndrome occurs.
IT: Diluent: Dilute with preservative-free 0.9% NaCl. Concentration: 1–5 mg/mL.
Rate: Directly instill into ventricular cerebrospinal fluid.
Y-Site Compatibility:
- acetaminophen
- acetylcysteine
- acyclovir
- aldesleukin
- alemtuzumab
- allopurinol
- alprostadil
- alteplase
- amikacin
- aminocaproic acid
- amiodarone
- anidulafungin
- argatroban
- arsenic trioxide
- ascorbic acid
- atracurium
- atropine
- azithromycin
- benztropine
- bleomycin
- bumetanide
- buprenorphine
- butorphanol
- caffeine citrate
- calcium chloride
- calcium gluconate
- cangrelor
- carboplatin
- carmustine
- caspofungin
- ceftazidime
- chlorpromazine
- ciprofloxacin
- cisatracurium
- cisplatin
- clindamycin
- cyanocobalamin
- cyclophosphamide
- cyclosporine
- cytarabine
- dacarbazine
- dactinomycin
- daunorubicin
- dexamethasone
- dexmedetomidine
- dexrazoxane
- digoxin
- diltiazem
- diphenhydramine
- dobutamine
- docetaxel
- dopamine
- doxapram
- doxorubicin hydrochloride
- doxorubicin liposomal
- doxycycline
- enalaprilat
- ephedrine
- epinephrine
- epirubicin
- eptifibatide
- eravacycline
- ertapenem
- erythromycin
- esmolol
- etoposide
- etoposide phosphate
- famotidine
- fentanyl
- filgrastim
- fluconazole
- fludarabine
- folic acid
- fosphenytoin
- gemcitabine
- gentamicin
- glycopyrrolate
- granisetron
- hydromorphone
- ifosfamide
- imipenem/cilastatin/relebactam
- insulin aspart
- insulin, regular
- irinotecan
- isavuconazonium
- isoproterenol
- ketamine
- labetalol
- levetiracetam
- levofloxacin
- lidocaine
- linezolid
- lorazepam
- magnesium sulfate
- mannitol
- melphalan
- meperidine
- meropenem
- meropenem/vaborbactam
- mesna
- methadone
- metoclopramide
- metoprolol
- metronidazole
- midazolam
- milrinone
- minocycline
- mitoxantrone
- morphine
- multivitamins
- mycophenolate
- nalbuphine
- naloxone
- nicardipine
- nitroglycerin
- nitroprusside
- norepinephrine
- octreotide
- ondansetron
- oxaliplatin
- oxytocin
- paclitaxel
- palonosetron
- pamidronate
- pantoprazole
- papaverine
- pemetrexed
- penicillin G
- pentamidine
- pentobarbital
- phenobarbital
- phentolamine
- phenylephrine
- phytonadione
- plazomicin
- posaconazole
- potassium acetate
- potassium chloride
- procainamide
- prochlorperazine
- promethazine
- propranolol
- protamine
- pyridoxine
- remifentanil
- rifampin
- sildenafil
- sodium acetate
- sodium bicarbonate
- succinylcholine
- sufentanil
- sulbactam/durlobactam
- tacrolimus
- tedizolid
- thiamine
- thiotepa
- tigecycline
- tirofiban
- tobramycin
- topotecan
- trastuzumab
- vasopressin
- vecuronium
- verapamil
- vinblastine
- vincristine
- vinorelbine
- voriconazole
- zidovudine
- zoledronic acid
Y-Site Incompatibility:
- albumin, human
- aminophylline
- amphotericin B deoxycholate
- amphotericin lipid complex
- amphotericin B liposomal
- azathioprine
- bivalirudin
- blinatumomab
- cefiderocol
- chloramphenicol
- dantrolene
- daptomycin
- defibrotide
- diazepam
- diazoxide
- dimenhydrinate
- epoetin alfa
- fluorouracil
- furosemide
- ganciclovir
- gemtuzumab ozogamicin
- ibuprofen lysine
- idarubicin
- indomethacin
- ketorolac
- leucovorin
- methylprednisolone
- mitomycin
- moxifloxacin
- phenytoin
- rituximab
- trimethoprim/sulfamethoxazole
- valproate sodium

Explain purpose and side effects of medication. Advise patient to read Patient Information before starting therapy.
Advise patient to take missed oral dose as soon as remembered unless almost time for next dose; do not double dose.
Instruct patient to notify health care provider if signs of hypersensitivity, tinnitus, vertigo, or hearing loss occur.
Advise patient to notify health care provider if no improvement of infection 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 women of reproductive potential to notify health care provider if pregnancy is planned or suspected or if breastfeeding.

Resolution of signs and symptoms of infection. Length of time for complete resolution depends on organism and site of infection.
Endocarditis prophylaxis.

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Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

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Assessment ⬆ ⬇

Implementation ⬆ ⬇

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US Brand Names ⬆