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.

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.

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

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.
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).

US Brand Names ⬆ ⬇

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.

Classifications ⬆ ⬇

Therapeutic Classification: anti-infectives

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

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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Indications ⬇