Vancomycin

    • Expected pathogen?

    • What is the patient demographics (nosocomial, immunocompromised)?

    • Patient allergies?

    • Renal and hepatic function?

Vancomycin:

    • Use in severe gram-positive infections or MRSA/ORSA.

      • Kills gram +ve by interfering with peptidoglycan synthesis of bacterial cell wall.

      • Bacteriostatic for enterococci

    • Dose is based on body weight, whereas the dosing interval is based on creatinine clearance.

Gentamicin therapeutic level peak: 5-8 mcg/mL; trough: <2 mcg/mL

    • Drug levels are not recommended for patients receiving a short course of therapy (<5 days).

    • Chose MIC conc. low.

    • High MICs >2, has potential for nephrotoxicity.

    • Periodic trough levels (qweek) recommended in patients receiving longer courses of therapy to ensure concentration are adequate. Trough levels should be obtained approximately 30 min before the next dose, usually before third or fourth dose. Therapeutic trough levels range from 5 - 15 mg/L. Peak levels are generally not of benefit.

    • Goal trough: 15 - 20 mcg/mL. Peak levels: 25-40 mcg/mL. Check peak levels in critically ill: endocarditis, OM, meningitis and deep seated inf.

    • ESRD: given single dose 15 mg/kg, redose when levels drop below 10 - 15 mcg/mL.

    • Meningitis: 15 mg/kg IV q12h to 30 mg/kg IV q12

    • VRSA. VISA, hVISA, and VRE are big problems.

Indications for vanco use:

    • Tx of ORSA

    • Tx of MRE

    • Tx serious inf by gram +ve bacteria in pts who are allergic to other ABX

    • Oral Tx of Cl. difficile colitis that has not responded to two courses of metronidazole or is failing metronidazole with a potentially life-threatening colitis

    • Surgical prophylaxis for placement of prosthetic devices at institutions with known high rates of ORSA or Pts colonzied with ORSA.

    • Empiric use suspected in gram +ve meningitis until an organism has been identified and sensitivities confirmed.

    • Life-threatening sepsis synd in a pt with ORSA until pathogen(s) are identified.

    • Documented coagulase-negative Staph. endocarditis.

    • Empiric use for serious dialysis catheter-related blood stream infections until the result of BC

    • Adverse effects: Vanco is usually administered by slow infusion over 1 hour. Rapid infusion can cause red man syndrome, which is a histamine mediated reaction mainfested as flushing and redness of upper body

**DO NOT USE routinely for:

    • Routine surgical prophylaxis

    • empiric Tx for non-septic neutropenic fever.

    • Single BC coagulase-negative Staph or when BC is incosistent with organism

    • routine Tx of Cl. difficile colitis

    • prophylaxis against cath. inf