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Pronunciation
(van koe MYE sin)
Generic Available (U.S.)
Yes: Excludes capsule
Index Terms
Brand Names: U.S.
Brand Names: Canada
Pharmacologic Category
Use: Labeled Indications
Treatment of patients with infections caused by staphylococcal species and streptococcal species; used orally for staphylococcal enterocolitis or for antibiotic-associated pseudomembranous colitis produced by C. difficile
Use: Unlabeled
Bacterial endophthalmitis; treatment of infections caused by gram-positive organisms in patients who have serious allergies to beta-lactam agents; treatment of beta-lactam resistant gram-positive infections
Pregnancy Risk Factor
B (oral); C (injection)
Pregnancy Considerations
Adverse effects have not been observed in animal studies and there are no controlled studies in pregnant women; however, oral vancomycin is not systemically absorbed. Therefore, I.V. vancomycin has been classified pregnancy category C and oral vancomycin has been classified pregnancy category B. Vancomycin crosses the placenta. In vivo studies and human case reports have documented placental transfer of vancomycin in the second and third trimesters of pregnancy resulting in therapeutic fetal concentrations. Vancomycin has not caused adverse fetal effects, including hearing loss or nephrotoxicity, when administered during pregnancy. A case report has been published of a vancomycin dose rapidly administered over 3 minutes leading to maternal hypotension and fetal bradycardia.The pharmacokinetics of vancomycin may be altered during pregnancy and pregnant patients may need a higher dose of vancomycin. Maternal half-life is unchanged, but the volume of distribution and the total plasma clearance are increased. Individualization of therapy through serum concentration monitoring may be warranted. Vancomycin is recommended for use in pregnant women for prevention of early-onset group B streptococcal (GBS) disease in newborns.
Lactation
Enters breast milk/not recommended
Breast-Feeding Considerations
Small amounts of vancomycin are excreted in human milk and use during breast-feeding is not recommended by the manufacturer. If given orally to the mother, the minimal systemic absorption of the dose would limit the amount available to pass into the milk. If given intravenously, the small amount that distributes to the milk would not be expected to cause systemic toxicity due to the lack of GI absorption. Nondose-related effects could include modification of bowel flora.
Contraindications
Hypersensitivity to vancomycin or any component of the formulation; avoid in patients with previous severe hearing loss
Warnings/Precautions
Concerns related to adverse effects:
• Nephrotoxicity: May cause nephrotoxicity although limited data suggest direct causal relationship; usual risk factors include pre-existing renal impairment, concomitant nephrotoxic medications, advanced age, and dehydration. If multiple sequential (≥2) serum creatinine concentrations demonstrate an increase of 0.5 mg/dL or ≥50% increase from baseline (whichever is greater) in the absence of an alternative explanation, the patient should be identified as having vancomycin-induced nephrotoxicity (Rybak, 2009). Discontinue treatment if signs of nephrotoxicity occur; renal damage is usually reversible.
• Neurotoxicity: May cause neurotoxicity; usual risk factors include pre-existing renal impairment, concomitant neuro-/nephrotoxic medications, advanced age, and dehydration. Ototoxicity, although rarely associated with monotherapy, is proportional to the amount of drug given and the duration of treatment. Tinnitus or vertigo may be indications of vestibular injury and impending bilateral irreversible damage. Discontinue treatment if signs of ototoxicity occur.
• Neutropenia: Prolonged therapy (>1 week) or total doses exceeding 25 g may increase the risk of neutropenia; prompt reversal of neutropenia is expected after discontinuation of therapy.
• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.
Disease-related concerns:
• Renal impairment: Use with caution in patients with renal impairment or those receiving other nephrotoxic or ototoxic drugs; dosage modification required (especially elderly).
Other warnings/precautions:
• Appropriate use: Oral vancomycin is only indicated for the treatment of pseudomembranous colitis due to C. difficile and enterocolitis due to S. aureus and is not effective for systemic infections; parenteral vancomycin is not effective for the treatment of colitis due to C. difficile and enterocolitis due to S. aureus. Note: The Infectious Disease Society of America (IDSA) recommends the use of oral metronidazole for initial treatment of mild-to-moderate C. difficile infection and the use of oral vancomycin for initial treatment of severe C. difficile infection (Cohen, 2010).
• Infusion reactions: Rapid I.V. administration may result in hypotension, flushing, erythema, urticaria, and/or pruritus.
Adverse Reactions
Oral:
>10%: Gastrointestinal: Bitter taste, nausea, vomiting
1% to 10%:
Central nervous system: Chills, drug fever
Hematologic: Eosinophilia
<1%: Interstitial nephritis, ototoxicity, renal failure, thrombocytopenia, vasculitis
Parenteral:
>10%:
Cardiovascular: Hypotension accompanied by flushing
Dermatologic: Erythematous rash on face and upper body (red neck or red man syndrome - infusion rate related)
1% to 10%:
Central nervous system: Chills, drug fever
Dermatologic: Rash
Hematologic: Eosinophilia, reversible neutropenia
Local: Phlebitis
<1%, postmarketing, and/or case reports: Drug rash with eosinophilia and systemic symptoms (DRESS), ototoxicity (rare; use of other ototoxic agents may increase risk), renal failure (limited data suggesting direct relationship), Stevens-Johnson syndrome, thrombocytopenia, vasculitis
Metabolism/Transport Effects
None known.
Drug Interactions
Aminoglycosides: Vancomycin may enhance the nephrotoxic effect of Aminoglycosides. Risk C: Monitor therapy
BCG: Antibiotics may diminish the therapeutic effect of BCG. Risk X: Avoid combination
Bile Acid Sequestrants: May diminish the therapeutic effect of Vancomycin. Management: Avoid concurrent administration of oral vancomycin and bile acid sequestrants when possible. If use of both agents is necessary, consider separating doses by at least 2 hours to minimize the significance of the interaction. Risk D: Consider therapy modification
Colistimethate: Vancomycin may enhance the nephrotoxic effect of Colistimethate. Risk D: Consider therapy modification
Gallium Nitrate: Vancomycin may enhance the nephrotoxic effect of Gallium Nitrate. Risk X: Avoid combination
Neuromuscular-Blocking Agents: Vancomycin may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Nonsteroidal Anti-Inflammatory Agents: May increase the serum concentration of Vancomycin. Risk C: Monitor therapy
Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Vaccination with live attenuated typhoid vaccine (Ty21a) should be avoided in patients being treated with systemic antibacterial agents. Use of this vaccine should be postponed until at least 24 hours after cessation of antibacterial agents. Risk D: Consider therapy modification
Storage
Reconstituted 500 mg and 1 g vials are stable for at either room temperature or under refrigeration for 14 days. Note: Vials contain no bacteriostatic agent. Solutions diluted for administration in either D5W or NS are stable under refrigeration for 14 days or at room temperature for 7 days.
Reconstitution
Reconstitute vials with 20 mL of SWFI for each 1 g of vancomycin (10 mL/500 mg vial; 20 mL/1 g vial; 100 mL/5 g vial; 200 mL/10 g vial). The reconstituted solution must be further diluted with at least 100 mL of a compatible diluent per 500 mg of vancomycin prior to parenteral administration.
Intrathecal (unlabeled route): Vancomycin is available as a powder for injection and may be diluted to 1-5 mg/mL concentration in preservative free 0.9% sodium chloride for administration into the CSF.
Compatibility
Stable in D5NS, D5W, D10W, LR, NS; variable stability (consult detailed reference) in peritoneal dialysis solutions, TPN.
Y-site administration: Compatible: Acyclovir, aldesleukin, allopurinol, alprostadil, amifostine, amiodarone, amsacrine, anidulafungin, atracurium, caspofungin, caffeine citrate, cisatracurium, cyclophosphamide, cyclosporine, dexmedetomidine, diltiazem, docetaxel, doripenem, doxapram, doxorubicin liposome, enalaprilat, esmolol, etoposide phosphate, fenoldopam, fentanyl, filgrastim, fluconazole, fludarabine, gallium nitrate, gemcitabine, granisetron, hetastarch in lactate electrolyte injection (Hextend®), hydromorphone, insulin (regular), labetalol, levofloxacin, linezolid, lorazepam, magnesium sulfate, melphalan, meperidine, meropenem, midazolam, milrinone, morphine, mycophenolate, nicardipine, ondansetron, oxytocin, paclitaxel, palonosetron, pancuronium, pemetrexed, remifentanil, sodium bicarbonate, tacrolimus, teniposide, theophylline, thiotepa, tigecycline, tolazoline, vecuronium, vinorelbine, zidovudine. Incompatible: Albumin, amphotericin B cholesteryl sulfate complex, bivalirudin, ciprofloxacin, drotrecogin alfa, idarubicin. Variable (consult detailed reference): Ampicillin, ampicillin/sulbactam, aztreonam, cefazolin, cefepime, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, foscarnet, heparin, methotrexate, nafcillin, pantoprazole, piperacillin, piperacillin/tazobactam, propofol, sargramostim, ticarcillin/clavulanate, TPN, warfarin.
Compatibility in syringe: Compatible: Caffeine citrate, pantoprazole. Incompatible: Ceftriaxone, dimenhydrinate, heparin.
Mechanism of Action
Inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding tightly to D-alanyl-D-alanine portion of cell wall precursor
Pharmacodynamics/Kinetics
Absorption: Oral: Poor; I.M.: Erratic; Intraperitoneal: ~38%
Distribution: Vd: 0.4-1 L/kg; Distributes widely in body tissue and fluids, except for CSF
Relative diffusion from blood into CSF: Good only with inflammation (exceeds usual MICs)
Uninflamed meninges: 0-4 mcg/mL; serum concentration dependent
Inflamed meninges: 6-11 mcg/mL; serum concentration dependent
CSF:blood level ratio: Normal meninges: Nil; Inflamed meninges: 20% to 30%
Protein binding: ~50%
Half-life elimination: Biphasic: Terminal:
Newborns: 6-10 hours
Infants and Children 3 months to 4 years: 4 hours
Children >3 years: 2.2-3 hours
Adults: 5-11 hours; significantly prolonged with renal impairment
End-stage renal disease: 200-250 hours
Time to peak, serum: I.V.: Immediately after completion of infusion
Excretion: I.V.: Urine (80% to 90% as unchanged drug); Oral: Primarily feces
Dosage
Usual dosage range:
Infants >1 month and Children: I.V.: 10-15 mg/kg every 6 hours
Adults: Initial intravenous dosing should be based on actual body weight; subsequent dosing adjusted based on serum trough vancomycin concentrations.
I.V.: 2-3 g/day (or 30-60 mg/kg/day) in divided doses every 8-12 hours (Rybak, 2009); Note: Dose requires adjustment in renal impairment
Oral: 500-2000 mg/day in divided doses every 6 hours
Indication-specific dosing:
Catheter-related infections: Adults: Antibiotic lock technique (Mermel, 2009): 2 mg/mL ± 10 units heparin/mL or 2.5 mg/mL ± 2500 or 5000 units heparin/mL or 5 mg/mL ± 5000 units heparin/mL (preferred regimen); instill into catheter port with a volume sufficient to fill the catheter (2-5 mL). Note: May use SWFI/NS or D5W as diluents. Do not mix with any other solutions. Dwell times generally should not exceed 48 hours before renewal of lock solution. Remove lock solution prior to catheter use, then replace.
C. difficile
-associated diarrhea (CDAD):
Infants >1 month and Children: Oral: 40 mg/kg/day in 3-4 divided doses added to fluids for 7-10 days (maximum: 2000 mg/day)
Adults:
Oral:
Manufacturer recommendations: 500-2000 mg/day in 3-4 divided doses for 7-10 days (usual dose: 125-500 mg every 6 hours)
IDSA guideline recommendations: Severe infection: 125 mg every 6 hours for 10-14 days; Severe, complicated infection: 500 mg every 6 hours with or without concurrent I.V. metronidazole. May consider vancomycin retention enema (in patients with complete ileus) (Cohen, 2010).
Rectal (unlabeled route): Retention enema (in patients with complete ileus): SHEA/IDSA guideline recommendations: Severe, complicated infection in patients with ileus: 500 mg every 6 hours (in 100 mL 0.9% sodium chloride) with oral vancomycin with or without concurrent I.V. metronidazole (Cohen, 2010)
Complicated infections in seriously-ill patients: Adults: I.V.: Loading dose: 25-30 mg/kg (based on actual body weight) may be used to rapidly achieve target concentration; then 15-20 mg/kg/dose every 8-12 hours (Rybak, 2009)
Enterocolitis
(S. aureus):
Infants >1 months and Children: Oral: 40 mg/kg/day in 3-4 divided doses added to fluids for 7-10 days (maximum: 2000 mg/day)
Adults: Oral: 500-2000 mg/day in 3-4 divided doses for 7-10 days (usual dose: 125-500 mg every 6 hours)
Meningitis:
Infants >1 month and Children:
I.V.: 15 mg/kg every 6 hours (Tunkel, 2004)
Intrathecal, intraventricular (unlabeled route): 5-20 mg/day (Tunkel, 2004)
Children: Alternate regimen: S. aureus (methicillin-resistant) (unlabeled use; Liu, 2011): I.V.: 15 mg/kg/dose every 6 hours for 2 weeks (some experts combine with rifampin)
Adults:
I.V.: 30-60 mg/kg/day in divided doses every 8-12 hours (Rybak, 2009) or 500-750 mg every 6 hours. Note: For PCN-resistant Streptococcus pneumoniae (MIC ≥2 mcg/mL), combine with a third-generation cephalosporin.
Alternate regimen: S. aureus (methicillin-resistant) (unlabeled use; Liu, 2011): 15-20 mg/kg/dose every 8-12 hours for 2 weeks (some experts combine with rifampin
Intrathecal, intraventricular (unlabeled route): 5-20 mg/day
Pneumonia:
Community-acquired pneumonia (CAP):
Infants >3 months and Children (IDSA/PIDS, 2011): I.V.: Note: In children ≥5 years, a macrolide antibiotic should be added if atypical pneumonia cannot be ruled out.
Group A Streptococcus (alternative to ampicillin or penicillin in beta-lactam allergic patients): 40-60 mg/kg/day divided every 6-8 hours
Presumed bacterial (in addition to recommended antibiotic therapy), S. pneumoniae, moderate-to-severe infection (MICs to penicillin ≤2.0 mcg/mL) (alternative to ampicillin or penicillin): 40-60 mg/kg/day divided every 6-8 hours
S. aureus (methicillin-susceptible) (alternative to cefazolin/oxacillin): 40-60 mg/kg/day divided every 6-8 hours
S. aureus, moderate-to-severe infection (methicillin-resistant +/- clindamycin susceptible) (preferred): 40-60 mg/kg/day divided every 6-8 hours or dosing to achieve AUC/MIC >400
Alternate regimen: 60 mg/kg/day divided every 6 hours for 7-21 days, depending on severity (Liu, 2011)
S. pneumoniae, moderate-to-severe infection (MICs to penicillin ≥4.0 mcg/mL) (alternative to ceftriaxone in beta-lactam allergic patients): 40-60 mg/kg/day divided every 6-8 hours
Adults: S. aureus (methicillin-resistant): I.V.: 45-60 mg/kg/day divided every 8-12 hours (maximum dose: 2 g) for 7-21 days depending on severity (Liu, 2011)
Healthcare-associated pneumonia (HAP): S. aureus (methicillin-resistant): I.V.:
Infants and Children: 60 mg/kg/day divided every 6 hours for 7-21 days depending on severity (Liu, 2011)
Adults: 45-60 mg/kg/day divided every 8-12 hours (maximum dose: 2 g) for 7-21 days depending on severity (American Thoracic Society [ATS], 2005; Liu, 2011; Rybak 2009)
Prophylaxis against infective endocarditis: I.V.:
Children:
Dental, oral, or upper respiratory tract surgery: 20 mg/kg/dose administered 1 hour prior to the procedure. Note: American Heart Association (AHA) guidelines recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur.
GI/GU procedure: 20 mg/kg (plus gentamicin 1.5 mg/kg) administered 1 hour prior to surgery. Note: Routine prophylaxis no longer recommended by the AHA.
Adults:
Dental, oral, or upper respiratory tract surgery: 1 g 1 hour before surgery. Note: AHA guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur
GI/GU procedure: 1 g plus 1.5 mg/kg gentamicin 1 hour prior to surgery. Note: As of April 2007, routine prophylaxis no longer recommended by the AHA.
Susceptible gram-positive infections (MIC ≤1 mcg/mL; Rybak, 2009): I.V.:
Infants >1 month and Children: 10 mg/kg/dose every 6 hours (manufacturer recommendations) or 15 mg/kg/dose (maximum dose: 2 g) every 6 hours (Liu, 2011)
Adults: 15-20 mg/kg/dose (usual: 750-1500 mg) every 8-12 hours
Note: If MIC ≥2 mcg/mL, alternative therapies are recommended.
Bacteremia (S. aureus [methicillin-resistant]) (unlabeled use; Liu, 2011): I.V.:
Children: 15 mg/kg/dose every 6 hours for 2-6 weeks depending on severity
Adults: 15-20 mg/kg/dose every 8-12 hours for 2-6 weeks depending on severity
Brain abscess, subdural empyema, spinal epidural abscess (S. aureus [methicillin-resistant]) (unlabeled use; Liu, 2011): I.V.:
Children.: 15 mg/kg/dose every 6 hours for 4-6 weeks (some experts combine with rifampin)
Adults: 15-20 mg/kg/dose every 8-12 hours for 4-6 weeks (some experts combine with rifampin)
Endocarditis, native valve (S. aureus [methicillin-resistant]) (unlabeled use; Liu, 2011): I.V.:
Children: 15 mg/kg/dose every 6 hours for 6 weeks
Adults: 15-20 mg/kg/dose every 8-12 hours for 6 weeks
Endocarditis, prosthetic valve (S. aureus [methicillin-resistant]) (unlabeled use; Liu, 2011): I.V.:
Children: 15 mg/kg/dose every 6 hours for at least 6 weeks
Adults: 15-20 mg/kg/dose every 8-12 hours for at least 6 weeks (combine with rifampin for the entire duration of therapy and gentamicin for the first 2 weeks)
Endophthalmitis (unlabeled use): Adults: Intravitreal: Usual dose: 1 mg/0.1 mL NS instilled into vitreum; may repeat administration if necessary in 3-4 days, usually in combination with ceftazidime or an aminoglycoside. Note: Some clinicians have recommended using a lower dose of 0.2 mg/0.1 mL, based on concerns for retinotoxicity.
Osteomyelitis (S. aureus [methicillin-resistant]) (unlabeled use; Liu, 2011): I.V.:
Children: 15 mg/kg/dose every 6 hours for 4-6 weeks
Adults: 15-20 mg/kg/dose every 8-12 hours for a minimum of 8 weeks (some experts combine with rifampin)
Septic arthritis (S. aureus [methicillin-resistant]) (unlabeled use; Liu, 2011): I.V.:
Children: 15 mg/kg/dose every 6 hours for minimum of 3-4 weeks
Adults: 15-20 mg/kg/dose every 8-12 hours for 3-4 weeks
Septic thrombosis of cavernous or dural venous sinus (S. aureus [methicillin-resistant]) (unlabeled use; Liu, 2011): I.V.:
Children: 15 mg/kg/dose every 6 hours for 4-6 weeks (some experts combine with rifampin)
Adults: 15-20 mg/kg/dose every 8-12 hours for 4-6 weeks (some experts combine with rifampin)
Skin and skin structure infections, complicated (S. aureus [methicillin-resistant]) (unlabeled use; Liu, 2011): I.V.:
Children: 15 mg/kg/dose every 6 hours for 7-14 days
Adults: 15-20 mg/kg/dose every 8-12 hours for 7-14 days
Dosing interval in renal impairment (vancomycin levels should be monitored in patients with any renal impairment):
Clcr >50 mL/minute: Start with 15-20 mg/kg/dose (usual: 750-1500 mg) every 8-12 hours
Clcr 20-49 mL/minute: Start with 15-20 mg/kg/dose (usual: 750-1500 mg) every 24 hours
Clcr <20 mL/minute: Will need longer intervals; determine by serum concentration monitoring
Note: In the critically-ill patient with renal insufficiency, the initial loading dose (25-30 mg/kg) should not be reduced. However, subsequent dosage adjustments should be made based on renal function and trough serum concentrations.
Poorly dialyzable by intermittent hemodialysis (0% to 5%); however, use of high-flux membranes and continuous renal replacement therapy (CRRT) increases vancomycin clearance, and generally requires replacement dosing.
Intermittent hemodialysis (IHD) (administer after hemodialysis on dialysis days): Following loading dose of 15-25 mg/kg, give either 500 mg to 1 g or 5-10 mg/kg after each dialysis session. (Heintz, 2009). Note: Dosing dependent on the assumption of 3 times/week, complete IHD sessions.
Redosing based on pre-HD concentrations:
<10 mg/L: Administer 1g after HD
10-25 mg/L: Administer 500-750 mg after HD
>25 mg/L: Hold vancomycin
Redosing based on post-HD concentrations: <10-15 mg/L: Administer 0.5-1 g
Peritoneal dialysis (PD):
Administration via PD fluid: 15-30 mg/L (15-30 mcg/mL) of PD fluid
Systemic: Loading dose of 1 g, followed by 500 mg to 1 g every 48-72 hours with close monitoring of levels
Continuous renal replacement therapy (CRRT) (Heintz, 2009; Trotman, 2005): Drug clearance is highly dependent on the method of renal replacement, filter type, and flow rate. Appropriate dosing requires close monitoring of pharmacologic response, signs of adverse reactions due to drug accumulation, as well as drug concentrations in relation to target trough (if appropriate). The following are general recommendations only (based on dialysate flow/ultrafiltration rates of 1-2 L/hour and minimal residual renal function) and should not supersede clinical judgment:
CVVH: Loading dose of 15-25 mg/kg, followed by either 1 g every 48 hours or 10-15 mg/kg every 24-48 hours
CVVHD: Loading dose of 15-25 mg/kg, followed by either 1 g every 24 hours or 10-15 mg/kg every 24 hours
CVVHDF: Loading dose of 15-25 mg/kg, followed by either 1 g every 24 hours or 7.5-10 mg/kg every 12 hours
Note: Consider redosing patients receiving CRRT for vancomycin concentrations <10-15 mg/L.
Dental Usual Dosing
Prophylaxis against infective endocarditis: I.V.:
Infants >1 month and Children:
Dental, oral, or upper respiratory tract surgery: 20 mg/kg 1 hour prior to the procedure. Note: American Heart Association (AHA) guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur.
GI/GU procedure: 20 mg/kg plus gentamicin 2 mg/kg 1 hour prior to surgery. Note: As of April 2007, routine prophylaxis no longer recommended by the AHA.
Adults:
Dental, oral, or upper respiratory tract surgery: 1 g 1 hour before surgery. Note: AHA guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur
GI/GU procedure: 1 g plus 1.5 mg/kg gentamicin 1 hour prior to surgery. Note: As of April 2007, routine prophylaxis no longer recommended by the AHA.
Administration: Oral
May be administered with food. If patient cannot swallow capsules, the powder for injection (not premixed solution) may be diluted in 30 mL of water for oral administration; flavoring may be added to improve taste. The unflavored, diluted solution may also be administered via nasogastric tube.
Administration: I.M.
Do not administer I.M.
Administration: I.V.
Administer vancomycin with a final concentration not to exceed 5 mg/mL by I.V. intermittent infusion over at least 60 minutes (recommended infusion period of ≥30 minutes for every 500 mg administered).
Red man syndrome may occur if the infusion is too rapid. It is not an allergic reaction, but may be characterized by hypotension and/or a maculopapular rash appearing on the face, neck, trunk, and/or upper extremities. If this should occur, slow the infusion rate to over 11/2 to 2 hours and increase the dilution volume. Reactions are often treated with antihistamines and steroids.
Extravasation treatment: Monitor I.V. site closely; extravasation will cause serious injury with possible necrosis and tissue sloughing. Rotate infusion site frequently.
Administration: Other
Intrathecal (unlabeled route): Vancomycin is available as a powder for injection and may be diluted to 1-5 mg/mL concentration in preservative-free 0.9% sodium chloride for intrathecal administration.
Intravitreal (unlabeled use): May be administered by intravitreal injection.
Rectal (unlabeled route): May be administered as a retention enema per rectum (Cohen, 2010).
Administration: I.V. Detail
pH: 3.9 (in distilled water or sodium chloride 0.9%); 2.5-4.5 (5% solution in water)
Monitoring Parameters
Periodic renal function tests, urinalysis, WBC; serum trough vancomycin concentrations in select patients (eg, aggressive dosing, unstable renal function, concurrent nephrotoxins, prolonged courses)
Suggested frequency of trough vancomycin concentration monitoring (Rybak, 2009):
Hemodynamically stable patients: Draw trough concentrations at least once-weekly.
Hemodynamically unstable patients: Draw trough concentrations more frequently or in some instances daily.
Prolonged courses (>3-5 days): Draw at least one steady-state trough concentration; repeat as clinically appropriate.
Note: Drawing >1 trough concentration prior to the fourth dose for short course (<3 days) or lower intensity dosing (target trough concentrations <15 mcg/mL) is not recommended.
Reference Range
Timing of serum samples: Draw trough just before next dose at steady-state conditions (approximately after the fourth dose). Drawing peak concentrations is no longer recommended.
Therapeutic levels: Trough: ≥10 mcg/mL. For pathogens with an MIC ≤1 mcg/mL, the minimum trough concentration should be 15 mcg/mL to meet target AUC/MIC of ≥400 (see "Note" below). For complicated infections (eg, bacteremia, endocarditis, osteomyelitis, meningitis, and hospital-acquired pneumonia caused by S. aureus), trough concentrations of 15-20 mcg/mL are recommended to improve penetration and improve clinical outcomes (Liu, 2011; Rybak, 2009). The American Thoracic Society (ATS) guidelines for hospital-acquired pneumonia and the Infectious Disease Society of America (IDSA) meningitis guidelines also recommend trough concentrations of 15-20 mcg/mL.
Note: Although AUC/MIC is the preferred pharmacokinetic-pharmacodynamic parameter used to determine clinical effectiveness, trough serum concentrations may be used as a surrogate marker for AUC and are recommended as the most accurate and practical method of vancomycin monitoring (Liu, 2011; Rybak, 2009).
Toxic: >80 mcg/mL (SI: >54 micromole/L)
Dietary Considerations
May be taken with food.
Patient Education
If administered by infusion, report immediately any chills; pain, swelling, or redness at infusion site; or respiratory difficulty. May cause nausea, vomiting, or GI upset. Report rash or hives, chills or fever, persistent GI disturbances, opportunistic infection (sore throat, chills, fever, burning, itching on urination, vaginal discharge, white plaques in mouth), respiratory difficulty, any change in urine output, chest pain or palpitations, changes in hearing or feeling of fullness in ears, or worsening of condition.
Geriatric Considerations
As a result of age-related changes in renal function and volume of distribution, accumulation and toxicity are a risk in the elderly. Careful monitoring and dosing adjustment is necessary.
Additional Information
Because of its long half-life, vancomycin should be dosed on an every 8- to 12-hour basis. Monitoring of trough serum concentrations is advisable in certain situations. “Red man syndrome”, characterized by skin rash and hypotension, is not an allergic reaction but rather is associated with too rapid infusion of the drug. To alleviate or prevent the reaction, infuse vancomycin at a rate of ≥30 minutes for each 500 mg of drug being administered (eg, 1 g over ≥60 minutes); 1.5 g over ≥90 minutes.
Anesthesia and Critical Care Concerns/Other Considerations
Clinical Pearls/Comments: “Red man syndrome” (characterized by skin rash and hypotension) is not an allergic reaction, but rather is associated with infusion administered too rapidly. To alleviate or prevent the reaction, infuse vancomycin at a rate of ≥30 minutes for each 500 mg of drug being administered (eg, 1 g over ≥60 minutes; 1.5 g over ≥90 minutes). CVVHD clears vancomycin from the circulation while conventional hemodialysis does not.
Limitations which may contribute to clinical failure include poor lung penetration, slow bactericidal activity against S. aureus, limited CNS penetration, high-level resistance to enterococci and S. aureus, and limited activity against bacteria that coat prosthetic devices.
Dental Health: Effects on Dental Treatment
Key adverse event(s) related to dental treatment: Bitter taste. “Red man syndrome”, characterized by skin rash and hypotension, is not an allergic reaction but rather is associated with too rapid infusion of the drug. To alleviate or prevent the reaction, infuse vancomycin at a rate of ≥30 minutes for each 500 mg of drug being administered (eg, 1 g over ≥60 minutes); 1.5 g over ≥90 minutes.
Dental Health: Vasoconstrictor/Local Anesthetic Precautions
No information available to require special precautions
Mental Health: Effects on Mental Status
None reported
Mental Health: Effects on Psychiatric Treatment
May cause neutropenia; use caution with clozapine and carbamazepine
Nursing: Physical Assessment/Monitoring
Assess results of culture and sensitivity tests and patient's allergy history prior to first dose. Use caution with renal impairment or previous hearing loss. Premedication with antihistamines may prevent or minimize "red man" reaction. Infusion site must be monitored closely to prevent extravasation. Monitor for hypotension, rash, neutropenia, nausea, vomiting, and auditory changes on a regular basis during therapy.
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Capsule, oral:
Vancocin®: 125 mg, 250 mg
Infusion, premixed iso-osmotic dextrose solution: 500 mg (100 mL); 750 mg (150 mL); 1 g (200 mL)
Injection, powder for reconstitution: 500 mg, 750 mg, 1 g, 5 g, 10 g
Pricing: U.S. (www.drugstore.com)
Capsules (Vancocin HCl)
125 mg (20): $686.99
250 mg (20): $1194.63
References
Abramowicz M, “Antimicrobial Prophylaxis in Surgery,” Medical Letter on Drugs and Therapeutics, Handbook of Antimicrobial Therapy, 16th ed, New York, NY: Medical Letter, 2002.
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Last full review/revision January 2012
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