Dosing and uses of Vancocin (vancomycin)
Adult dosage forms and strengths
capsule
- 125mg
- 250mg
injectable solution
- 5mg/mL
powder for injection
- 500mg
- 750mg
- 1g
- 5g
- 10g
Pseudomembranous Colitis/Staphylococcal Enterocolitis
C. difficile: 125 mg PO q6hr for 10 days
S. enterocolitis: 0.5-2 g/day PO divided q6-8hr for 7-10 days
Because of cost of capsules, IV solution is sometimes compounded for PO use
Endocarditis
Treatment: 500 mg IV q6hr or 1 g IV q12hr
Used for staphylococcal, streptococcal, and diphtheroid endocarditis; current American Heart Association (AHA) guidelines recommend using only for high-risk patients
Preoperative Antimicrobial Prophylaxis (Off-label)
Gastrointestinal [GI] and genitourinary [GU] procedures: 1 g IV by slow infusion over 1 hour, beginning 1-2 hours before procedure (with or without gentamicin 1.5 mg/kg; not to exceed 120 mg IV or IM <30 minutes before procedure)
Surgical Prophylaxis (Off-label)
Prophylaxis of infection in cardiac, thoracic, and arterial procedures; craniotomy; joint replacement; amputation
15 mg/kg IV over 1-2 hr; begin administration within 2 hr before incision; duration of prophylaxis for most procedures should be <24 hr
Dosing Modifications
Renal impairment: 15 mg/kg initially; further doses are based on renal function, serum drug level, and institutional protocol; dosing intervals range from q24hr to q96hr, depending on severity of impairment
Dosing Considerations
General dosing recommendation: 2 g/day IV divided q6-12hr; may be increased on basis of body weight or to achieve higher trough values; increased toxicity at dosage >4 g/day
Peak values 18-26 mg/L; trough values 5-10 mg/L; however, Infectious Diseases Society of America and other guidelines urge troughs 15-20 mg/L
Pediatric dosage forms and strengths
capsule
- 125mg
- 250mg
injectable solution
- 5mg/mL
powder for injection
- 750mg
- 500mg
- 1g
- 5g
- 10g
Endocarditis
<1 month: 15 mg/kg followed by 10 mg/kg IV q12hr for neonates in first week of life and q8hr thereafter up to 1 month of age; longer dosing intervals recommended in premature infants
>1 month: 10 mg/kg/day IV divided q6hr; individual dose not to exceed 1 g
Current AHA guidelines recommend using only for high-risk patients
Preoperative Antimicrobial Prophylaxis
GI and GU procedures: 20 mg/kg IV by slow infusion over 1 hour, beginning 1 hour before procedure (with or without gentamicin 1.5 mg/kg; not to exceed 120 mg IV or IM <30 minutes before procedure)
Bacterial Meningitis
15-20 mg/kg IV q6hr
Pseudomembranous Colitis
40 mg/kg/day PO divided q6-8hr for 7-10 days; not to exceed 2 g/day
Other Infections
40 mg/kg/day IV divided q6hr
Dosing Considerations
Neonatal dosing
- <7 days and <1.2 kg: 15 mg/kg IV once daily; monitor serum levels and adjust dose
- <7 days and 1.2-2 kg: 10-15 mg/kg IV q12-18hr; monitor serum levels and adjust dose
- <7 days and >2.1 kg:: 10-15 mg/kg IV q8-12hr; monitor serum levels and adjust dose
- >7 days and <1.2 kg: 15 mg/kg IV q24hr; monitor serum levels and adjust dose
- >7 days and 1.2-2 kg: 10-15 mg/kg IV q8-12hr; monitor serum levels and adjust dose
- >7 days and >2.1 kg: 15-20 mg/kg IV q8hr; monitor serum levels and adjust dose
Vancocin (vancomycin) adverse (side) effects
>10%
Bitter taste (PO)
Erythematous rash on face and upper body (IV; red neck or red man syndrome; related to infusion rate)
Hypotension accompanied by flushing (IV)
Nausea and vomiting (PO)
1-10%
Chills (IV)
Drug fever (IV)
Eosinophilia (IV)
Rash (IV)
Fatique (PO)
Peripheral edema (PO)
Urinary tract infection (PO)
Back pain (PO)
Headache (PO)
Reversible neutropenia (IV)
Phlebitis (IV)
<1%
Nephrotoxicity
Ototoxicity (especially with large doses)
Stevens-Johnson syndrome
Thrombocytopenia
Vasculitis
Postmarketing Reports
Ototoxicity: Hearing loss associated IV administration (most cases had coexisting renal impairment or pre-existing hearing loss, or were coadministered an ototoxic drug), vertigo, dizziness, and tinnitus
Hematopoietic: Reversible neutropenia, thrombocytopenia
Miscellaneous: Anaphylaxis, drug fever, chills, nausea, eosinophilia, rashes, Stevens-Johnson syndrome, toxic epidermal necrolysis, and vasculitis
Warnings
Contraindications
Hypersensitivity
Cautions
Rapid IV administration may result in flushing, pruritus, hypotension, erythema, and urticaria
Endocarditis prophylaxis: Use only for high-risk patients, per AHA guidelines
Unclear whether drug is nephrotoxic or neurotoxic in regular doses, but increased nephrotoxicity and ototoxicity are associated with pre-existing renal impairment, advanced age, dehydration; also appears to potentiate nephro-/neurotoxic effects of other drugs
Ototoxicity may occur; toxicity proportional to amount of drug given and duration of treatment; presence of tinnitus or vertigo may indicate vestibular injury; discontiue if signs of ototoxicity occur
Risk of neutropenia increases with doses >25 g (reversible following discontinuation of therapy)
Avoid extravasation; necrosis may occur
Prolonged use may result in fungal or bacterial superinfection
Use caution in patients with renal impairment; monitor trough concentrations if multiple oral doses administered
Oral vancomycin only indicated for treatment of pseudomembranous colitis due to C. difficile and enterocolitis due to S. aureus; not effective for systemic infections
Pregnancy and lactation
Pregnancy category: C (injection); B (oral)
Lactation: Drug enters breast milk; not recommended
Pregnancy categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA: Information not available.
Pharmacology of Vancocin (vancomycin)
Mechanism of action
Inhibits cell-wall biosynthesis; blocks glycopeptide polymerization by binding tightly to D-alanyl-D-alanine portion of cell wall precursor
Absorption
PO, poor; IM, erratic; intraperitoneal, ~38%
Peak serum time (IV): Immediately after completion of infusion
Distribution
Distributed widely in body tissues and fluid, except for cerebrospinal fluid (CSF)
Relative diffusion from blood into CSF: Good only with inflammation (exceeds usual minimal inhibitory concentrations); CSF level nil with normal meninges, 20-30% of blood level with inflamed meninges
Protein bound: ~50%
Elimination
Half-life; 5-11 hr (adults); 6-10 hr (newborns); 2-2.3 hr (children); 4 hr (infants and children 3 months to 4 years); 200-250 hr (renal impairment or end-stage renal disease)
Excretion: Urine (IV; 80-90% as unchanged drug); primarily feces (PO)
Administration
IV Compatibilities
Solution: D5/NS, D5W, D10W, LR, sodium bicarbonate 3.75%, NS, sodium lactate 1/6m
Additive: Amikacin, atracurium, calcium gluconate, cefepime, cimetidine, corticotropin, dimenhydrinate, erythromycin, famotidine, hydrocortisone, meropenem, ofloxacin, potassium chloride, ranitidine, verapamil, vitamins B and C
Syringe: Caffeine
Y-site (partial list): Acyclovir, alatrofloxacin, aldesleukin, allopurinol, amifostine, amiodarone, ampicillin, ampicillin-sulbactam, cefpirome, ceftizoxime, clarithromycin, diltiazem, esmolol, fluconazole, insulin, labetalol, lorazepam, linezolid, magnesium sulfate, midazolam, morphine, nicardipine, ondansetron, paclitaxel, pancuronium, perphenazine, remifentanil, sargramostim, sodium bicarbonate, tacrolimus, teniposide
IV Incompatibilities
Additive: Aminophylline(?), amobarbital, aztreonam (may be compatible at low concentrations of vancomycin and aztreonam), chlorothiazide, chloramphenicol, dexamethasone, dexamethasone sodium phosphate, heparin(?), pentobarbital, phenobarbital, sodium bicarbonate(?)
Syringe: Heparin
Y-site: Heparin, albumin, amphotericin B cholesteryl sulfate, aztreonam(?), bivalirudin, cefazolin(?), cefotaxime(?), cefotetan(?), cefoxitin(?), ceftazidime(?), ceftriaxone(?), cefuroxime(?), foscarnet, gatifloxacin, idarubicin, methotrexate(?), nafcillin, omeprazole, piperacillin(?), piperacillin-tazobactam (?), propofol(?), sargramostim, ticarcillin (may be compatible at low concentrations of vancomycin), ticarcillin-clavulanate (may be compatible at low concentrations of vancomycin), warfarin (may be compatible at low concentrations of warfarin)
IV Preparation
Add 10 mL of SWI to 500-mg vial and 20 mL of SWI to 1-g vial to yield 50 mg/mL solution; further dilution is required, depending on method of administration
Intermittent infusion: Dilute 500 mg with ≥100 mL of diluent and 1 g with ≥200 mL of diluent (NS or D5W)
Continuous infusion: Dilute in sufficient amount to permit infusion over 24 hours
IV Administration
Intermittent (preferred): Administer over 60 minutes; not to exceed 10 mg/min
Continuous: Administer over 24 hours
Stability
Reconstituted solutions stable at 2-8°C for at least 4 days
