Vancomycin

Pharmacologic Category

Glycopeptide

Dosing: Adult

Usual dosage range: Note: Initial IV dosing in nonobese patients should be based on actual body weight; subsequent dosing should generally be adjusted based on serum vancomycin concentrations and renal function. Patient-specific pharmacokinetic calculations may be needed to determine appropriate dose and interval in patients expected to have altered pharmacokinetics (eg, morbid obesity, burns, critical illness, unstable renal function, pregnancy, cystic fibrosis). For patients with uncomplicated skin and soft tissue infections who are not obese and have normal renal function, serum trough monitoring is generally not needed (IDSA [Liu 2011]). In adult patients with normal renal function, doses ≥4 g per day are associated with increased toxicity (ASHP/IDSA/SIDP [Rybak 2009]; Lodise 2008).

Oral: Note: Ineffective for treating systemic infections: 125 to 500 mg 4 times daily

IV: Note: Ineffective for treating C. difficile infections: 15 to 20 mg/kg/dose (rounded to the nearest 250 mg; usual maximum: 2 g/dose initially) every 8 to 12 hours (ASHP/IDSA/SIDP [Rybak 2009]). Note: 15 mg/kg/dose (usual maximum: 2 g/dose initially) every 12 hours is a usual starting dose in most nonobese patients with normal renal function; refer to infection-specific dosing (Drew 2019; IDSA [Liu 2011]; Murray 2015).

Loading dose: Complicated infections in seriously ill patients: A loading dose of 25 to 30 mg/kg (based on actual body weight) may be used to rapidly achieve target concentrations (ASHP/IDSA/SIDP [Rybak 2009]; Reardon 2015).

Indication-specific dosing:

Bloodstream infection:

Empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours; adjust dose to obtain a trough concentration of 15 to 20 mcg/mL or an AUC/minimum inhibitory concentration (MIC) of 400 to 600 (ASHP/IDSA/SIDP [Rybak 2009]; Heil 2018; Men 2016; Neely 2018). A loading dose may be considered in seriously ill patients (ASHP/IDSA/SIDP [Rybak 2009]; IDSA [Liu 2011]). Treat uncomplicated S. aureus infection for ≥14 days from first negative blood culture, with longer courses warranted for endocarditis or metastatic sites of infection (IDSA [Liu 2011]; IDSA [Mermel 2009]).

Empiric therapy or pathogen-specific therapy for methicillin-resistant coagulase-negative staphylococci: IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours (most patients with normal renal function can be started with 15 mg/kg/dose every 12 hours); adjust dose to obtain a trough concentration of 15 to 20 mcg/mL (Drew 2019). Treat uncomplicated bacteremia for 5 to 7 days from day of first negative blood culture, with longer courses warranted for endocarditis or metastatic sites of infection (IDSA [Mermel 2009]; Tufariello 2019). For catheter-related bloodstream infections, consider antibiotic lock therapy for catheter salvage, in addition to systemic therapy (IDSA [Mermel 2009]).

Antibiotic lock technique (catheter-salvage strategy) (off-label use): Note: For infections caused by susceptible organisms when the catheter cannot be removed; use in addition to systemic antibiotics. Catheter salvage is not recommended for S. aureus (Girand 2019; IDSA [Mermel 2009]).

Intracatheter: Prepare lock solution to final concentration of vancomycin 5 mg/mL; may be combined with heparin. Instill into each lumen of the catheter access port using a volume sufficient to fill the catheter (2 to 5 mL) with a dwell time of up to 72 hours, depending on frequency of catheter use. Withdraw lock solution prior to catheter use; replace with fresh vancomycin lock solution after catheter use. Antibiotic lock therapy is given for the same duration as systemic antibiotics (IDSA [Mermel 2009]; LaPlante 2007).

Cerebrospinal fluid shunt infection (off-label use): As a component of empiric therapy or pathogen-specific therapy (eg, methicillin-resistant S. aureus or coagulase-negative staphylococci):

IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours; adjust dose to obtain a trough concentration of 15 to 20 mcg/mL (IDSA [Tunkel 2017]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/SIDP [Rybak 2009]).

Intraventricular (adjunct to systemic therapy; use a preservative-free preparation): 5 to 20 mg/day; some experts recommend adjusting dosage and administration interval based on cerebrospinal fluid (CSF) vancomycin concentrations (goal: 10 to 20 times MIC of causative organism), ventricular size, and daily output from ventricular drain (IDSA [Tunkel 2017]); data for monitoring are limited (Smetana 2018). When intraventricular vancomycin is administered via a ventricular drain, clamp drain for 15 to 60 minutes after administration (allows solution to equilibrate in CSF) (IDSA [Tunkel 2004]; IDSA [Tunkel 2017]). Note: Intraventricular administration is generally reserved for use in patients who fail parenteral therapy despite removal of CSF shunt or when CSF shunt cannot be removed (Baddour 2019).

Clostridioides (formerly Clostridium) difficile infection: Note: Criteria for disease severity is based on expert opinion and should not replace clinical judgment (IDSA/SHEA [McDonald 2018]).

Oral:

Nonsevere C. difficile infection (supportive clinical data: WBC ≤15,000 cells/mm3 and serum creatinine <1.5 mg/dL):

Initial episode: 125 mg 4 times daily for 10 days (IDSA/SHEA [McDonald 2018])

First recurrence:

If vancomycin was used for initial episode: Pulsed-tapered regimen: 125 mg 4 times daily for 10 to 14 days, then 125 mg twice daily for 7 days, then 125 mg once daily for 7 days, then 125 mg every 2 or 3 days for 2 to 8 weeks (IDSA/SHEA [McDonald 2018])

If metronidazole or fidaxomicin was used for initial episode: 125 mg 4 times daily for 10 days (IDSA/SHEA [McDonald 2018])

Second or subsequent recurrence: Pulsed-tapered regimen as above or 125 mg 4 times daily for 10 days followed by rifaximin (SHEA/IDSA [McDonald 2018])

Severe C. difficile infection (supportive clinical data: WBC >15,000 cells/mm3 and/or serum creatinine ≥1.5 mg/dL): 125 mg 4 times daily (IDSA/SHEA [McDonald 2018])

Fulminant C. difficile infection (supportive clinical data: ileus, megacolon, and/or hypotension/shock): Oral or via nasogastric tube: 500 mg 4 times daily with IV metronidazole; if ileus present, may consider vancomycin retention enema (IDSA/SHEA [McDonald 2018]).

Rectal:

Fulminant C. difficile infection with ileus: Retention enema (off-label route): 500 mg in 100 mL NS; retained for as long as possible and administered every 6 hours. Use in combination with oral vancomycin (if the ileus is partial) or in place of oral vancomycin (if the ileus is complete) plus IV metronidazole. Note: Optimal regimen not established (IDSA/SHEA [McDonald 2018]). Use of rectal vancomycin should be reserved for patients who have not responded to standard therapy and performed by individuals with expertise in administration, as there is risk of colonic perforation (Kelly 2019).

Cystic fibrosis, acute pulmonary exacerbation (off-label use): Empiric or pathogen-directed therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose every 8 hours; adjust dose to obtain trough concentration of 15 to 20 mcg/mL (Pettit 2017; Simon 2019). Duration is usually 10 days to 3 weeks or longer based on clinical response (Flume 2009; Simon 2019).

Diabetic foot infection, moderate to severe (off-label use): Empiric or pathogen-directed therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours; adjust dose to obtain trough concentration of 15 to 20 mcg/mL. For empiric therapy, use as part of an appropriate combination regimen. Duration (which may include appropriate oral step-down therapy) is usually 2 to 4 weeks in the absence of osteomyelitis (IDSA [Lipsky 2012]; Weintrob 2019).

Endocarditis, treatment:

Enterococcus (native or prosthetic valve) (penicillin-resistant strains or patients unable to tolerate beta-lactams): IV: 15 mg/kg/dose (usual maximum: 2 g/dose initially) every 12 hours in combination with gentamicin for 6 weeks; adjust dose to obtain a trough concentration of 10 to 20 mcg/mL (AHA [Baddour 2015]); some experts favor a trough of 15 to 20 mcg/mL (BSAC [Gould 2012]; ESC [Habib 2015]).

S. aureus, methicillin-resistant or methicillin-susceptible (severe-beta lactam hypersensitivity) (alternative agent): IV:

Native valve: 15 mg/kg/dose (usual maximum: 2 g/dose initially) every 12 hours for 6 weeks; adjust dose to obtain a serum trough concentration of 10 to 20 mcg/mL (AHA [Baddour 2015]) or 15 to 20 mg/kg/dose (usual maximum dose: 2 g/dose initially) every 8 to 12 hours for 6 weeks; adjust dose to obtain a trough concentration of 15 to 20 mcg/mL (IDSA [Liu 2011]).

Prosthetic valve: 15 mg/kg/dose (usual maximum: 2 g/dose initially) every 12 hours; adjust dose to obtain a trough concentration of 10 to 20 mcg/mL (AHA [Baddour 2015]) or 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours; adjust dose to obtain a trough concentration of 15 to 20 mcg/mL (IDSA [Liu 2011]). Duration of therapy: At least 6 weeks (combine with rifampin for the entire duration of therapy and gentamicin for the first 2 weeks) (AHA [Baddour 2015]; IDSA [Liu 2011]).

Viridans group streptococci and S. bovis (native or prosthetic valve) (penicillin or ceftriaxone intolerance): IV: 15 mg/kg/dose (usual maximum dose: 2 g/dose initially) every 12 hours for 4 weeks (native valve) or 6 weeks (prosthetic valve); adjust dose to obtain a trough concentration of 10 to 15 mcg/mL (AHA [Baddour 2015]).

Endophthalmitis, treatment (off-label use): Intravitreal: Usual dose: 1 mg per 0.1 mL NS or sterile water injected into vitreum, usually in combination with ceftazidime (Durand 2019; Endophthalmitis Vitrectomy Study Group 1995). A repeat dose(s) may be considered at 24 to 48 hours based on culture result, severity of the infection, and response to treatment (Durand 2019).

Intra-abdominal infection (off-label use): As a component of empiric therapy or pathogen-specific therapy (eg, methicillin-resistant S. aureus): IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours; adjust dose to obtain a trough concentration of 15 to 20 mcg/mL (ASHP/IDSA/SIDP [Rybak 2009]; IDSA [Solomkin 2010]).

Intracranial abscess (brain abscess, intracranial epidural abscess) or spinal epidural abscess (off-label use): As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours; adjust dose to obtain a trough concentration of 15 to 20 mcg/mL. A loading dose may be considered in seriously ill patients (ASHP/IDSA/SIDP [Rybak 2009]; IDSA [Liu 2011]). Duration generally ranges from 4 to 8 weeks for brain abscess and spinal epidural abscess and 6 to 8 weeks for intracranial epidural abscess (Bodilsen 2018; Sexton 2019a; Sexton 2019b; Southwick 2020).

Meningitis, bacterial (off-label use): As a component of empiric therapy or pathogen-specific therapy (eg, methicillin-resistant S. aureus or penicillin- and cephalosporin-resistant S. pneumoniae): IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours; adjust dose to obtain a trough concentration of 15 to 20 mcg/mL (IDSA [Tunkel 2004]; IDSA [Tunkel 2017]) A loading dose may be considered in seriously ill patients (ASHP/IDSA/SIDP [Rybak 2009]; IDSA [Liu 2011]).

Osteomyelitis: As a component of empiric therapy or pathogen-specific therapy (eg, methicillin-resistant S. aureus): IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours (IDSA [Liu 2011]) or 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 12 hours (IDSA [Berbari 2015]); adjust dose to obtain a trough concentration of 15 to 20 mcg/mL. A loading dose may be considered in seriously ill patients (ASHP/IDSA/SIDP [Rybak 2009]). Duration is generally ≥6 weeks; shorter courses are appropriate if the affected bone is completely resected (IDSA [Berbari 2015]; Osmon 2019).

Peritonitis, treatment (peritoneal dialysis patients) (off-label use): Note: Intraperitoneal administration is preferred to IV administration. Adjust dose to obtain a trough concentration between 15 and 20 mcg/mL (ISPD [Li 2016]). Consider a 25% dose increase in patients with significant residual renal function (urine output >100 mL/day) (ISPD [Li 2010]; ISPD [Li 2016]; Mancini 2018; Szeto 2018).

Intermittent (preferred): Intraperitoneal: 15 to 30 mg/kg added to one exchange of dialysate every 5 to 7 days (allow to dwell for ≥6 hours); supplemental doses and more frequent monitoring of serum levels may be needed for patients receiving automated peritoneal dialysis (ISPD [Li 2016]).

Continuous (with every exchange): Intraperitoneal: Loading dose: 30 mg/kg added to first exchange of dialysate; maintenance dose: 1.5 mg/kg/bag for each subsequent exchange of dialysate (Bunke 1983; ISPD [Li 2016]).

Pneumonia, as a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours (ASHP/IDSA/SIDP [Rybak 2009]; IDSA [Liu 2011]; ATS/IDSA [Metlay 2019]); most patients with normal renal function can be started with 15 mg/kg/dose (usual maximum: 2 g/dose initially) every 12 hours. Adjust dose to obtain a trough concentration of 15 to 20 mcg/mL (File 2020). A loading dose may be considered in seriously ill patients (ASHP/IDSA/SIDP [Rybak 2009]; IDSA [Liu 2011]). Note: Duration is for ≥7 days and varies based on disease severity and response to therapy (ATS/IDSA [Metlay 2019]; IDSA/ATS [Kalil 2016]; IDSA [Liu 2011]).

Prosthetic joint infection (off-label use): IV:

Pathogen-specific therapy for methicillin-resistant or susceptible S. aureus (alternative agent in beta-lactam intolerance): 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours (Berbari 2019; IDSA [Liu 2011]) or 15 mg/kg/dose (usual maximum: 2 g/dose initially) every 12 hours (IDSA [Osmon 2013]); adjust dose to obtain a trough concentration of 15 to 20 mcg/mL (ASHP/IDSA/SIDP [Rybak 2009]). Duration ranges from 2 to 6 weeks depending on prosthesis management, use of rifampin, and other patient-specific factors (IDSA [Osmon 2013]).

Pathogen-specific therapy for Enterococcus spp (penicillin susceptible [alternative agent] or penicillin resistant): 15 mg/kg/dose (usual maximum: 2 g/dose initially) every 12 hours for 4 to 6 weeks (Berbari 2019; IDSA [Osmon 2013]).

Note: In select cases (eg, debridement and retention of prosthesis or one-stage arthroplasty), give oral suppressive antibiotic therapy with an appropriate regimen following completion of initial treatment (Berbari 2019; IDSA [Osmon 2013]).

Sepsis/septic shock: As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours; adjust dose to obtain a trough concentration of 15 to 20 mcg/mL (ASHP/IDSA/SIDP [Rybak 2009]). Administer within 1 hour of identifying sepsis (Rhodes 2017). A loading dose may be considered in seriously ill patients (ASHP/IDSA/SIDP [Rybak 2009]; Rhodes 2017). A duration of therapy of 7 to 10 days is generally adequate for serious infections (Rhodes 2017).

Septic arthritis, without prosthetic material: As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus or coagulase-negative staphylococci: IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours; adjust dose to obtain a trough concentration of 15 to 20 mcg/mL (ASHP/IDSA/SIDP [Rybak 2009]; IDSA [Liu 2011]). Most patients with normal renal function can be started with 15 mg/kg/dose (usual maximum: 2 g/dose initially) every 12 hours (Goldenberg 2019). Total treatment duration is 3 to 4 weeks (in the absence of osteomyelitis), including appropriate oral step-down therapy (Goldenberg 2019; IDSA [Liu 2011]); some experts recommend 4 weeks of parenteral therapy for patients with concomitant bacteremia (Goldenberg 2019).

Skin and soft tissue infection (hospitalized patient): As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus: IV: 15 mg/kg/dose (usual maximum: 2 g/dose initially) every 12 hours (IDSA [Stevens 2014]); adjust dose to obtain a trough concentration of 10 to 15 mcg/mL (uncomplicated infection) or 15 to 20 mcg/mL (complicated infection or seriously ill) (ASHP/IDSA/SIDP [Rybak 2009]; IDSA [Liu 2011]; IDSA [Stevens 2014]). Note: For empiric therapy of necrotizing infection, must be used in combination with other agents (IDSA [Stevens 2014]).

Streptococcus (group B), maternal prophylaxis for prevention of neonatal disease (alternative agent) (off-label use): Note: Prophylaxis is reserved for pregnant women with a positive group B streptococcus (GBS) vaginal or rectal screening in late gestation or GBS bacteriuria during the current pregnancy, history of birth of an infant with early-onset GBS disease, and unknown GBS culture status with any of the following: birth <37 0/7 weeks' gestation, intrapartum fever, prolonged rupture of membranes, known GBS positive in a previous pregnancy, or intrapartum nucleic acid amplification testing positive for GBS (ACOG 782 2019).

IV: 20 mg/kg at the onset of labor or prelabor rupture of membranes, then every 8 hours until delivery; maximum single dose: 2 g (ACOG 782 2019). Some experts prefer vancomycin 2 g initially and then 1 g every 12 hours thereafter until delivery (Baker 2019). Note: Vancomycin is reserved for use in penicillin-allergic patients at high risk for anaphylaxis, isolates with resistance to clindamycin, or in the absence of susceptibility data (ACOG 782 2019).

Surgical prophylaxis (in combination with other appropriate agents when coverage for methicillin-resistant S. aureus is indicated or for gram-positive coverage in patients unable to tolerate beta-lactams) (off-label use): IV: 15 mg/kg (usual maximum: 2 g/dose initially) started within 60 to 120 minutes prior to initial surgical incision. Vancomycin doses may be repeated intraoperatively in 2 half-lives (approximately 8 to 12 hours in patients with normal renal function) if procedure is lengthy or if there is excessive blood loss (ASHP/IDSA/SIS/SHEA [Bratzler 2013]). In cases where an extension of prophylaxis is warranted postoperatively, total duration should be ≤24 hours (Anderson 2014). Postoperative prophylaxis is not recommended in clean and clean-contaminated surgeries (CDC [Berrios-Torres 2017]).

Surgical site infection: As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S.aureus: IV: 15 mg/kg/dose (usual maximum: 2 g/dose initially) every 12 hours; adjust dose to obtain trough concentrations of 10 to 15 mcg/mL (uncomplicated infection) or 15 to 20 mcg/mL (complicated infections or seriously ill) (ASHP/IDSA/SIDP [Rybak 2009]; IDSA [Stevens 2014]).

Toxic shock syndrome, staphylococcal: As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose (usual maximum: 2 g/dose initially) every 8 to 12 hours; adjust dose to obtain a trough concentration of 15 to 20 mcg/mL (ASHP/IDSA/SIDP [Rybak 2009]; Chu 2019). Duration varies based on underlying etiology; 10 to 14 days of treatment is recommended in the absence of bacteremia or other distinct focus of infection (Chu 2019).

* See Dosage and Administration in AHFS Essentials for additional information.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Renal Impairment: Adult

Oral: There are no dosage adjustments provided in the manufacturer’s labeling. However, dosage adjustment unlikely due to low systemic absorption.

IV: Note: Vancomycin levels should be monitored in patients with any renal impairment. In critically ill patients with renal insufficiency, the initial loading dose (~25 mg/kg) should not be reduced. However, subsequent dosage adjustments should be made based on renal function and trough serum concentrations (Wang 2001).

Dialysis: Poorly dialyzable by intermittent hemodialysis; however, use of high-flux membranes and continuous renal replacement therapy (CRRT) increases vancomycin clearance, and generally requires replacement dosing (Launay-Vacher 2002).

End-stage renal disease (ESRD) on intermittent hemodialysis (IHD) (administer after hemodialysis on dialysis days): Following loading dose of 15 to 25 mg/kg, give either 500 to 1,000 mg or 5 to 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 1,000 mg after HD

10 to 25 mg/L: Administer 500 to 750 mg after HD

>25 mg/L: Hold vancomycin

Redosing based on post-HD concentrations: <10 to 15 mg/L: Administer 500 to 1,000 mg

Peritoneal dialysis (PD): 1 g every 4 to 7 days (Aronoff 2007)

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 to 2 L/hour and minimal residual renal function) and should not supersede clinical judgment:

CVVH: Loading dose of 15 to 25 mg/kg, followed by either 1,000 mg every 48 hours or 10 to 15 mg/kg every 24 to 48 hours

CVVHD: Loading dose of 15 to 25 mg/kg, followed by either 1,000 mg every 24 hours or 10 to 15 mg/kg every 24 hours

CVVHDF: Loading dose of 15 to 25 mg/kg, followed by either 1,000 mg every 24 hours or 7.5 to 10 mg/kg every 12 hours

Note: Consider redosing patients receiving CRRT for vancomycin concentrations <10 to 15 mg/L.

Dosing: Hepatic Impairment: Adult

Oral: There are no dosage adjustments provided in the manufacturer’s labeling. However, dosage adjustment unlikely due to low systemic absorption.

IV: There are no dosage adjustments provided in the manufacturer’s labeling. However, degrees of hepatic dysfunction do not affect the pharmacokinetics of vancomycin (Marti 1996).

Dosing: Pediatric

Initial dosage recommendations presented, serum concentrations should be monitored and adjusted accordingly. Note: Doses require adjustment in renal impairment. Consider single-dose administration with serum concentration monitoring rather than scheduled dosing in patients with urine output <1 mL/kg/hour or if serum creatinine significantly increases from baseline (eg, doubles). Optimal dose and frequency not established in patients receiving ECMO; available data is very limited and primarily from neonatal experience (Amaker 1996; Buck 1998; Hoie 1990; Mulla 2005). Patient-specific considerations (eg, reason for ECMO) and variability with ECMO procedure itself make extrapolation of pharmacokinetic data and dosing to all patients receiving ECMO difficult; closely monitor serum concentrations and determine individual dosing needs in these patients.

General dosing, susceptible infection: Infants, Children, and Adolescents: IV: 45 to 60 mg/kg/day divided every 6 to 8 hours; dose and frequency should be individualized based on serum concentrations (Red Book [AAP 2018]). Note: Every 6 hour dosing recommended as initial dosage regimen if targeting trough serum concentrations >10 mcg/mL (Benner 2009; Frymoyer 2009) in patients with normal renal function. Close monitoring of serum concentrations and assurance of adequate hydration status is recommended; utilize local antibiogram and protocols for further guidance.

Bacteremia [S. aureus (methicillin-resistant)]: Infants, Children, and Adolescents: IV: 15 mg/kg/dose every 6 hours for 2 to 6 weeks depending on severity (IDSA [Liu 2011])

Bone and joint infection:

Osteomyelitis (S. aureus [methicillin-resistant]): Infants, Children, and Adolescents: IV: 15 mg/kg/dose every 6 hours for a minimum of 4 to 6 weeks (IDSA [Liu 2011])

Septic arthritis (S. aureus [methicillin-resistant]): Infants, Children, and Adolescents: IV: 15 mg/kg/dose every 6 hours for minimum of 3 to 4 weeks (IDSA [Liu 2011])

C. difficile infection:

Manufacturer's labeling: Infants, Children, and Adolescents: Oral: 40 mg/kg/day divided every 6 to 8 hours for 7 to 10 days; maximum daily dose: 2,000 mg/day

Guideline recommendations:

Non-severe infection, initial or first recurrence: Children and Adolescents: Oral: 10 mg/kg/dose 4 times daily for 10 days; maximum dose: 125 mg/dose (IDSA/SHEA [McDonald 2018])

Severe/fulminant infection, initial: Children and Adolescents:

Oral: 10 mg/kg/dose 4 times daily for 10 days; maximum dose: 500 mg/dose; may consider adding IV metronidazole in critically ill patients (IDSA/SHEA [McDonald 2018]). If patient is unable to tolerate oral therapy, may use nasogastric administration (ASID [Trubiano 2016]).

Rectal: Note: Consider use when ileus is present. Limited data available: Rectal enema: 500 mg in 100 mL NS; dose volume is determined by age (IDSA/SHEA [McDonald 2018]); the optimal doses have not been established in pediatric patients; suggested volumes for children: 1 to 3 years: 50 mL; 4 to 9 years: 75 mL; >10 years: 100 mL (ASID [Trubiano 2016]); administer 4 times daily with or without IV metronidazole (IDSA/SHEA [McDonald 2018])

Second or subsequent recurrence: Children and Adolescents: Pulsed-tapered regimen: Oral: 10 mg/kg/dose 4 times daily for 10 to 14 days; then 10 mg/kg/dose twice daily for 7 days, then 10 mg/kg/dose once daily for 7 days, then 10 mg/kg/dose every 2 or 3 days for 2 to 8 weeks; maximum dose: 125 mg/dose (IDSA/SHEA [McDonald 2018])

CNS infection:

Brain abscess, subdural empyema, spinal epidural abscess [S. aureus (methicillin-resistant)]: Infants, Children, and Adolescents: IV: 15 mg/kg/dose every 6 hours for 4 to 6 weeks (some experts combine with rifampin) (IDSA [Liu 2011])

Meningitis: Infants, Children, and Adolescents: IV: 15 mg/kg/dose every 6 hours; Note: Maintain trough serum concentrations of 15 to 20 mcg/mL (IDSA [Tunkel 2004]; IDSA [Tunkel 2017])

S. aureus (methicillin-resistant): Infants, Children, and Adolescents: IV: 15 mg/kg/dose every 6 hours for 2 weeks (some experts combine with rifampin) (IDSA [Liu 2011])

VP-shunt infection, ventriculitis: Limited data available: Infants, Children, and Adolescents: Intrathecal/intraventricular (use a preservative-free preparation): 5 to 20 mg/day; usual dose: 10 or 20 mg/day (IDSA [Tunkel 2004]; IDSA [Tunkel 2017]); due to the smaller CSF volume in infants, some guidelines recommend decreasing the infant dose (IDSA [Tunkel 2017])

Endocarditis, treatment:

Empiric therapy/culture negative: Children and Adolescents: IV 60 mg/kg/day divided every 6 hours; maximum daily dose: 2,000 mg/day; use in combination with other antibiotics for at least 4 weeks; longer duration may be required if prosthetic material is present; dosage should be adjusted to target trough serum concentrations of 10 to 15 mcg/mL; higher trough concentrations (15 to 20 mcg/mL) may be needed if there is a lack of response or if a resistant organism (MIC >1 mcg/mL) is identified (AHA [Baltimore 2015])

Streptococcus (including enterococcus): Children and Adolescents: IV: 40 mg/kg/day divided every 8 to 12 hours for at least 4 to 6 weeks; a longer duration and additional antibiotics may be required depending on organism and presence of prosthetic material; dosage should be adjusted to target trough serum concentrations of 10 to 15 mcg/mL; higher trough concentrations (15 to 20 mcg/mL) may be needed for resistant organisms (MIC >1 mcg/mL) or if there is a lack of response (AHA [Baltimore 2015])

S. aureus:

Non-methicillin resistant: Children and Adolescents: IV: 40 mg/kg/day divided every 8 to 12 hours for at least 4 to 6 weeks; a longer duration and additional antibiotics may be required depending on organism and presence of prosthetic material; dosage should be adjusted to target trough serum concentrations of 10 to 15 mcg/mL; higher trough concentrations (15 to 20 mcg/mL) may be needed for resistant organisms (MIC >1 mcg/mL) or if there is a lack of response (AHA [Baltimore 2015])

Methicillin-resistant:

AHA Guidelines: Children and Adolescents: IV: 40 mg/kg/day divided every 8 to 12 hours for at least 6 weeks; maximum daily dose: 2,000 mg/day; a longer duration may be required depending on the presence of prosthetic material; dosage should be adjusted to target trough serum concentrations of 15 to 20 mcg/mL (AHA [Baltimore 2015])

IDSA Guidelines: Infants, Children, and Adolescents: IV: 60 mg/kg/day divided every 6 hours (IDSA [Liu 2011])

Enterocolitis (S. aureus): Infants, Children, and Adolescents: Oral: 40 mg/kg/day divided every 6 to 8 hours for 7 to 10 days; maximum daily dose: 2,000 mg/day

Intra-abdominal infection, complicated (MRSA): Infants, Children, and Adolescents: IV: 40 mg/kg/day divided every 6 to 8 hours (IDSA [Solomkin 2010])

Peritonitis (peritoneal dialysis) (ISPD [Warady 2012]):

Prophylaxis: Infants, Children, and Adolescents:

Touch contamination of PD line (if known MRSA colonization): Intraperitoneal: 25 mg per liter

High-risk gastrointestinal procedures: Note: Use should be reserved for patients at high risk for MRSA: IV: 10 mg/kg administered 60 to 90 minutes before procedure; maximum dose: 1,000 mg

Treatment: Infants, Children, and Adolescents:

Intermittent: Intraperitoneal: Initial dose: 30 mg/kg in the long dwell; subsequent doses: 15 mg/kg/dose every 3 to 5 days during the long dwell; Note: Increased clearance may occur in patients with residual renal function; subsequent doses should be based on serum concentration obtained 2 to 4 days after the previous dose; redosing should occur when serum concentration <15 mcg/mL.

Continuous: Intraperitoneal: Loading dose: 1,000 mg per liter of dialysate; maintenance dose: 25 mg per liter

Pneumonia:

Community-acquired pneumonia (CAP): Infants >3 months, Children, and Adolescents: IV: 40 to 60 mg/kg/day every 6 to 8 hours; dosing to achieve AUC/MIC >400 has been recommended for treating moderate to severe MRSA infections (IDSA/PIDS [Bradley 2011])

Alternate dosing: S. aureus (methicillin-resistant): Infants, Children, and Adolescents: IV: 60 mg/kg/day divided every 6 hours for 7 to 21 days depending on severity (IDSA [Liu 2011])

Health care-associated pneumonia (HAP), S. aureus (methicillin-resistant): Infants, Children, and Adolescents: IV: 60 mg/kg/day divided every 6 hours for 7 to 21 days depending on severity (IDSA [Liu 2011])

Septic thrombosis of cavernous or dural venous sinus [S. aureus (methicillin-resistant)]: Infants, Children, and Adolescents: IV: 15 mg/kg/dose every 6 hours for 4 to 6 weeks (some experts combine with rifampin) (IDSA [Liu 2011])

Skin and skin structure infections, complicated: [MRSA or S. aureus (methicillin sensitive) in penicillin allergic patients]: Infants, Children, and Adolescents (IDSA [Stevens 2014]):

Non-necrotizing infection: IV: 10 mg/kg/dose every 6 hours

Necrotizing infection: IV: 15 mg/kg/dose every 6 hours. Continue until further debridement is not necessary, patient has clinically improved, and patient is afebrile for 48 to 72 hours.

Alternate dosing: S. aureus (methicillin-resistant): Infants, Children, and Adolescents: IV: 60 mg/kg/day divided every 6 hours for 7 to 14 days (IDSA [Liu 2011])

Surgical (perioperative) prophylaxis: Infants, Children, and Adolescents: IV: 15 mg/kg/dose within 120 minutes prior to surgical incision. May be administered in combination with other antibiotics depending upon the surgical procedure (ASHP/IDSA/SIS/SHEA [Bratzler 2013]).

Dosing: Renal Impairment: Pediatric

Oral: There are no dosage adjustments provided in manufacturer's labeling; however, dosage adjustment unlikely due to low systemic absorption.

IV: Note: Vancomycin levels should be monitored in patients with any renal impairment:

Infants, Children, and Adolescents: The following adjustments have been recommended (Aronoff 2007): Note: Renally adjusted dose recommendations are based on doses of 10 mg/kg/dose every 6 hours or 15 mg/kg/dose every 8 hours:

GFR 30 to 50 mL/minute/1.73 m2: 10 mg/kg/dose every 12 hours

GFR 10 to 29 mL/minute/1.73 m2: 10 mg/kg/dose every 18 to 24 hours

GFR <10 mL/minute/1.73 m2: 10 mg/kg/dose; redose based on serum concentrations

Intermittent hemodialysis: 10 mg/kg/dose; redose based on serum concentrations

Peritoneal dialysis (PD): 10 mg/kg/dose; redose based on serum concentrations

Continuous renal replacement therapy (CRRT): 10 mg/kg/dose every 12 to 24 hours; monitor serum concentrations

Dosing: Hepatic Impairment: Pediatric

Oral: There are no dosage adjustments provided in the manufacturer's labeling; however, dosage adjustment unlikely due to low systemic absorption.

IV: There are no dosage adjustments provided in the manufacturer's labeling; however, degrees of hepatic dysfunction do not affect the pharmacokinetics of vancomycin (Marti 1996).

Calculations

• Clostridium Difficile Disease Severity Score (Hines VA)
• Clostridium Difficile Disease Severity Score (UPMC 2008)
• Creatinine Clearance by Cockcroft-Gault
• Creatinine Clearance by Cockcroft-Gault (SI units)
• Creatinine Clearance by Cockcroft-Gault with IBW
• Creatinine Clearance by Cockcroft-Gault with IBW (SI units)
• Creatinine Clearance by Jelliffe
• Creatinine Clearance by Sanaka
• Glomerular Filtration Rate by Abbreviated MDRD
• Glomerular Filtration Rate by Abbreviated MDRD (SI units)
• Glomerular Filtration Rate by MDRD
• Glomerular Filtration Rate by MDRD (IDMS-Traceable SCr)
• Glomerular Filtration Rate by MDRD (SI units)
• Glomerular Filtration Rate by Schwartz
• Glomerular Filtration Rate Estimate in African Americans by AASK Equation
• Vancomycin: Dosing by Serum Levels

Use: Labeled Indications

Clostridioides (formerly Clostridium) difficile infection (oral): Treatment of C. difficile infection (CDI)

Endocarditis (injection):

Corynebacteria (diphtheroids): Treatment of diphtheroid endocarditis in combination with either rifampin, an aminoglycoside, or both in early-onset prosthetic valve endocarditis caused by diphtheroids

Enterococcal: Treatment of endocarditis caused by enterococci (eg, Enterococcus faecalis), in combination with an aminoglycoside

Staphylococcal: Treatment of staphylococcal endocarditis

Streptococcal: Treatment of endocarditis due to Streptococcus viridans or Streptococcus bovis, as monotherapy or in combination with an aminoglycoside

Enterocolitis (oral): Treatment of enterocolitis caused by Staphylococcus aureus (including methicillin-resistant strains). Note: Staphylococcal enterocolitis is uncommon; the disease and treatment are not well described in the literature (Iwata 2014; Lin 2010).

Staphylococcal infections (injection): Treatment of serious or severe infections (eg, bloodstream infections, bone infections, lower respiratory tract infections, skin and skin structure infections) caused by susceptible strains of methicillin-resistant (beta-lactam-resistant) staphylococci; empiric therapy of infections when methicillin-resistant staphylococci are suspected

* See Uses in AHFS Essentials for additional information.

Use: Off-Label: Adult

Catheter-related bloodstream infection, antibiotic lock technique (catheter-salvage therapy)Level of Evidence [G]

Based on the Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection, vancomycin antibiotic lock therapy is recommended for patients for whom catheter salvage is the goal, in combination with systemic antimicrobial therapy, especially when peripheral cultures are positive.

Cerebrospinal fluid shunt infectionLevel of Evidence [G]

Based on the IDSA guidelines for health care-associated ventriculitis and meningitis, vancomycin is an effective and recommended systemic therapy (as part of an empiric combination regimen) for treatment of health care-associated ventriculitis and meningitis. Intraventricular administration of vancomycin, as an adjunct to systemic therapy, may be considered in patients with poor response to systemic antimicrobial therapy alone.

Clostridioides (formerly Clostridium) difficile infection (rectal administration)Level of Evidence [C, G]

Rectal administration of vancomycin is recommended in national practice guidelines for the management of fulminant C. difficile infection despite evidence based on case reports/series. Access Full Off-Label Monograph

Cystic fibrosis, acute pulmonary exacerbationLevel of Evidence [C]

Clinical experience suggests the utility of vancomycin in the treatment of acute pulmonary exacerbations of cystic fibrosis Ref.

Diabetic foot infection, moderate to severeLevel of Evidence [G]

Based on the IDSA clinical practice guidelines for the diagnosis and treatment of diabetic foot infections, vancomycin is an effective and recommended treatment in the management of moderate to severe diabetic foot infection.

Endophthalmitis, treatmentLevel of Evidence [C]

Data from a limited number of patients studied suggest that intravitreal vancomycin may be beneficial for the treatment of postoperative endophthalmitis Ref. Clinical experience based on data from peer-reviewed scientific literature also suggests the utility of vancomycin in the management of bacterial endophthalmitis Ref.

Intra-abdominal infectionLevel of Evidence [G]

Based on the Surgical Infection Society and IDSA guidelines for diagnosis and management of complicated intra-abdominal infection in adults and children, vancomycin is effective and recommend in patients with intra-abdominal infection due to methicillin-resistant S. aureus (MRSA) or ampicillin-resistant enterococci.

Intracranial abscess (brain abscess, intracranial epidural abscess) or spinal epidural abscessLevel of Evidence [C, G]

Based on the IDSA guidelines for the treatment of MRSA infections in adults and children, vancomycin is an effective and recommended agent in the treatment of MRSA infections of the CNS, including brain abscess and spinal epidural abscess. Clinical experience suggests the utility of vancomycin for the treatment of intracranial epidural abscess (Sexton 2019a).

Meningitis, bacterialLevel of Evidence [G]

Based on the IDSA guidelines for the management of bacterial meningitis and for health care-associated ventriculitis and meningitis, vancomycin is an effective and recommended systemic therapy as part of an empiric regimen for treatment of bacterial meningitis when Streptococcus pneumoniae or MRSA is a presumptive pathogen.

Peritonitis, treatment (peritoneal dialysis patients)Level of Evidence [G]

Based on the International Society for Peritoneal Dialysis (ISPD) peritonitis recommendations, intraperitoneal vancomycin in continuous ambulatory peritoneal dialysis (CAPD) is effective and recommended for empiric treatment of peritonitis caused by gram-positive organisms in CAPD patients.

Prosthetic joint infectionLevel of Evidence [G]

Based on the IDSA guidelines for the management of prosthetic joint infection, vancomycin is effective and recommended for treatment of prosthetic joints infected with staphylococci or Enterococcus spp.

Streptococcus (group B), maternal prophylaxis for prevention of neonatal diseaseLevel of Evidence [G]

Based on the American College of Obstetricians and Gynecologists (ACOG) prevention of group B streptococcal (GBS) early-onset disease in newborns guideline, maternal administration of IV vancomycin is recommended for intrapartum prophylaxis to prevent early-onset GBS disease in the newborn in mothers at high risk for anaphylaxis to penicillin and who have clindamycin-resistant GBS.

Surgical prophylaxisLevel of Evidence [G]

Based on the American Society of Health-System Pharmacists (ASHP) clinical practice guidelines for antimicrobial prophylaxis in surgery, vancomycin given as an alternative antibiotic in patients with beta-lactam allergy requiring surgical prophylaxis is effective and recommended for a number of surgical procedures.

Level of Evidence Definitions

Level of Evidence Scale

Clinical Practice Guidelines

Clostridioides (Formerly Clostridium) difficile Infection:

American College of Gastroenterology (ACG), “Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections,” April 2013

European Society of Clinical Microbiology and Infectious Diseases (ESCMID), “Update of the Treatment Guidance Document for Clostridium difficile infection,” March 2014

IDSA/SHEA, "Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children," February 2018

Coronary Artery Bypass Graft Surgery:

“2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery,” November 2011

Diabetic Foot Infection:

IDSA, “The Diagnosis and Treatment of Diabetic Foot Infections,” 2012

Infective Endocarditis:

AHA, "2007 Guidelines for the Prevention of Infective Endocarditis,” April 2007

AHA, “Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications,” October 2015

British Society for Antimicrobial Chemotherapy (BSAC), "Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults," 2012

Meningitis, Bacterial:

IDSA, "Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis” February 2017

IDSA, “Management of Bacterial Meningitis,” October 2004

Methicillin-Resistant Staphylococcus aureus (MRSA) Infections:

IDSA, “Practice Guidelines for the Treatment of Methicillin-Resistant Staphylococcus Aureus,” February 2011

Neutropenic Fever:

ASCO/IDSA, "Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy," February 2018

Opportunistic Infections:

HHS, "Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents," September 2015

Osteomyelitis, Native Vertebral:

IDSA, "Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults," 2015

Perinatal Group B Streptococcal Disease:

ACOG, “Prevention of Group B Streptococcal Early-Onset Disease in Newborns,” 2019

Pneumonia, Community-Acquired:

ATS/IDSA, "Diagnosis and Treatment of Adults With Community-Acquired Pneumonia," October 2019

Pneumonia, Hospital-Acquired and Ventilator-Associated:

IDSA/ATS, "Management of Adults with Hospital-Acquired and Ventilator-Associated Pneumonia," July 2016.

Prosthetic Joint Infection:

IDSA, “Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guideline,” January 2013

Sepsis:

“Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016,” March 2017

Skin and Soft-tissue Infection:

IDSA, “Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections,” June 2014.

Surgical Prophylaxis:

ASHP, “Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery,” February 2013

“The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis in Cardiac Surgery, Part I: Duration,” January 2006

“The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis in Cardiac Surgery, Part II: Antibiotic Choice,” April 2007

Administration: IV

Administer vancomycin with a final concentration not to exceed 5 mg/mL by IV intermittent infusion over at least 60 minutes (recommended infusion period of ≥30 minutes for every 500 mg administered [ASHP/IDSA/SIDP (Rybak 2009)]); in adult patients in need of fluid restriction, a concentration up to 10 mg/mL may be used, but risk of infusion-related reactions is increased. Not for IM administration.

If a maculopapular rash appears on the face, neck, trunk, and/or upper extremities (red man syndrome), slow the infusion rate to over 11/2 to 2 hours and increase the dilution volume (Healy 1990; Rybak 1986; Szymusiak-Mutnick 1996). Hypotension, shock, and cardiac arrest (rare) have also been reported with too rapid of infusion. Administration of antihistamines prior to infusion may prevent or minimize this reaction (Rybak 1986; Wilhem 1999).

Irritant; ensure proper needle or catheter placement prior to and during infusion. Avoid extravasation.

Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity. Information conflicts regarding the use of dry cold or dry warm compresses (Hurst 2004; Reynolds 2014); however, dry warm compresses may be of benefit in increasing local blood flow to enhance drug removal from the extravasation site. Intradermal hyaluronidase may be considered for refractory cases (Reynolds 2014).

Hyaluronidase: Intradermal: Inject a total of 1 mL (15 units/mL) as 5 separate 0.2 mL injections (using a tuberculin syringe) along injection site and edematous area (Reynolds 2014).

Administration: Injectable Detail

pH: 3.9 (in distilled water or sodium chloride 0.9%); 2.5 to 4.5 (5% solution in water)

Administration: Oral

Solution (Firvanq): Shake reconstituted oral solution well before each use.

Injection: Reconstituted powder for injection (not premixed solution) may be diluted and used for oral administration; common flavoring syrups may be added to improve taste. The unflavored, diluted solution may also be administered via nasogastric tube.

Administration: Other

Antibiotic lock technique (off-label use): Instill prepared vancomycin lock solution into each lumen of the catheter access port using a volume sufficient to fill the catheter (2 to 5 mL) with a dwell time of 48 to 72 hours (dependent on frequency of catheter use). Withdraw lock solution prior to catheter use; replace with fresh vancomycin lock solution after catheter use (IDSA [Mermel 2009]; LaPlante 2007).

Administration: Intrathecal

Intraventricular (off-label route): Use preservative-free preparations only. May be administered intraventricularly with a final concentration of 2.5 to 10 mg/mL for the treatment of CSF shunt infections. When administered through a ventricular drain, clamp drain for 15 to 60 minutes before opening the drain to allow vancomycin solution to equilibrate in the CSF (IDSA [Tunkel 2004 2017]; Ng 2014).

Administration: Intravitreal

Off-label route: May administer vancomycin intravitreally with a final concentration of 1 mg/0.1 mL NS or sterile water (Durand 2019; Kelsey 1995).

Administration: Rectal

Off-label route: May be administered as a retention enema per rectum (IDSA/SHEA [McDonald 2018]); 500 mg in 100 to 500 mL of NS, volume depending on length of segment being treated. If sodium chloride causes hyperchloremia could use solution with lower chloride concentration (eg, LR) (ACG [Surawicz 2013]).

Administration: Pediatric

Oral:

Oral solution (Firvanq): Shake reconstituted oral solution well before each use.

Powder for injection: Reconstituted powder for injection (not premixed solution) may be diluted and used for oral administration; common flavoring syrups may be added to improve taste. The unflavored, diluted solution may also be administered via nasogastric tube.

Parenteral: Administer intermittent IV infusion over 60 minutes. 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 administer dose over 90 to 120 minutes (Healy 1990; Szymusiak-Mutnick 1996) and increase the dilution volume; the reaction usually dissipates in 30 to 60 minutes; administration of antihistamines just before the infusion may also prevent or minimize this reaction.

Irritant; ensure proper needle or catheter placement prior to and during infusion. Avoid extravasation. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity. Information varies regarding the use of dry cold or dry warm compresses (Hurst 2004; Reynolds 2014); however, dry warm compresses may be of benefit in increasing local blood flow to enhance drug removal from the extravasation site. Intradermal hyaluronidase may be considered for refractory cases (Reynolds 2014).

Intrathecal/Intraventricular: Administer as diluted solution (1 to 10 mg/mL) (Al-Jeraisy 2004; Cook 2009; Pfausler 1997)

Rectal: Instill vancomycin enema solution via rectal foley; retain for 1 hour. In pediatric patients the optimal doses have not been established; suggested volumes for pediatric patients: 1 to 3 years of age: 50 mL; 4 to 9 years of age: 75 mL; >10 years of age: 100 mL (ASID [Trubiano 2016]).

Vesicant/Extravasation Risk

Irritant

Dietary Considerations

May be taken with food.

Storage/Stability

Capsules: Store at 15°C to 30°C (59°F to 86°F).

Flexible bags: Store below 25°C (77°F) in the original package. Use within 28 days of removal from aluminum overpouch. Stable at room temperature for 28 days.

Galaxy containers: Store Galaxy containers at or below -20°C (-4°F). Handle frozen product containers with care; may be fragile in the frozen state. Thaw frozen containers at 25°C (77°F) or 5°C (41°F). Do not immerse in water bath or microwave. Thawed solution in remains chemically stable for 72 hours at 25°C (77°F) or for 30 days when stored at 5°C (41°F). Do not refreeze thawed antibiotics.

Oral solution (Firvanq): Store at 2°C to 8°C (36°F to 46°F) prior to and following reconstitution; discard reconstituted solution after 14 days or if appears hazy or contains particulates. Protect from light.

Vials: Store intact vials at 20°C to 25°C (68°F to 77°F). Reconstitute vial using an appropriate diluent; recommendations may vary by product; refer to manufacturer's labeling for choice of diluent and for appropriate storage conditions and timeframes. Prior to administration, further dilution in a compatible solution is required; recommendations may vary by product; refer to manufacturer's labeling for list of compatible solutions and appropriate storage conditions and timeframes.

Pharmacy bulk packages: Store at 20°C to 25°C (68°F to 77°F). Discard pharmacy bulk packages no later than 4 hours after initial closure puncture.

Preparation for Administration: Adult

IV: Reconstitute 500 mg, 750 mg, and 1 g vials and 5 g bulk vials with a compatible diluent to a final concentration of 50 mg/mL (10 g bulk vials may be reconstituted to a final concentration of 100 mg/mL). 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, intraventricular (off-label route): Vancomycin powder for injection may be diluted to a 2.5, 5, or 10 mg/mL concentration in preservative free 0.9% sodium chloride for administration into the CSF (Ng 2014).

Oral:

Oral solution (Firvanq): Refer to manufacturer's product labeling for reconstitution instructions.

Powder for injection: Reconstitute powder for injection; flavoring syrups may be added to improve taste. See Extemporaneous Preparations section for details. Note: Multiple concentrations described (25 mg/mL, 50 mg/mL); use caution when determining dose volume.

Preparation for Administration: Pediatric

Oral:

Oral solution (Firvanq): Tap bottom of bottle containing powder for oral solution to loosen powder; shake provided grape flavored diluent. Add about half of the provided diluent to the bottle containing the powder for oral solution, recap and shake for ~45 seconds. Add rest of diluent and shake for ~30 seconds. Consult product labeling for additional information.

Powder for injection: Reconstitute powder for injection; flavoring syrups may be added to improve taste. See Extemporaneous Preparations section for details. Note: Multiple concentrations described (25 mg/mL, 50 mg/mL); use caution when determining dose volume.

Parenteral: Reconstitute vials with SWFI to a final concentration of 50 mg/mL (see manufacturer's labeling for specific details). Further dilute the reconstituted solution in a compatible diluent (eg, D5W, NS) to a final concentration ≤5 mg/mL. In fluid restricted patients, a concentration of 10 mg/mL may be used, but the risk of infusion reactions increases.

Intrathecal/intraventricular: Dilute to 1 to 5 mg/mL concentration in preservative free NS for administration into the CSF (Al-Jeraisy 2004; Pfausler 1997); concentrations as high as 10 mg/mL have been reported in adults (Cook 2009)

Rectal enema: Reconstitute powder for injection; further dilution of dose in NS to prepare either a 1 mg/mL or 5 mg/mL enema solution have been used in adults (eg, 500 mg in 100 mL or 500 mL NS) (IDSA/SHEA [McDonald 2018]); the more dilute solutions (1 mg/mL) have been suggested to ensure delivery to the ascending and transverse colon (ACG [Surawicz 2013]). If sodium chloride causes hyperchloremia, a solution with lower chloride concentration (eg, LR) could be considered (ACG [Surawicz 2013]).

Compatibility

See Trissel’s IV Compatibility Database

Open Trissel's IV Compatibility

Extemporaneously Prepared

Note: A vancomycin oral solution (25 mg/mL or 50 mg/mL) is commercially available (Firvanq).

Oral Solution

Using a vial of vancomycin powder for injection (reconstituted to 50 mg/mL), add the appropriate volume for the dose to 30 mL of water and administer orally or via NG tube. For oral administration, common flavoring syrups may be added to improve taste.

Vancomycin hydrochloride injection [prescribing information]. Lake Zurich, IL: Fresenius Kabi; February 2018.

25 mg/mL Oral Solution

A vancomycin 25 mg/mL solution in Ora-Sweet and water (1:1) may be prepared by reconstituting vancomycin for injection with sterile water, then dilute with a 1:1 mixture of Ora-Sweet and distilled water to a final concentration of 25 mg/mL; transfer to amber prescription bottle. Stable for 75 days refrigerated or for 26 days at room temperature.

Ensom MH, Decarie D, and Lakhani A, “Stability of Vancomycin 25 mg/mL in Ora-Sweet and Water in Unit-Dose Cups and Plastic Bottles at 4°C and 25°C,” Can J Hosp Pharm 2010, 63(5):366-72.[PubMed 22479004]

Medication Patient Education with HCAHPS Considerations

What is this drug used for?

Injection:

• It is used to treat or prevent bacterial infections.

All Oral Products:

• It is used to treat diarrhea caused by a bacterial infection called C diff.

• It is used to treat a type of bowel infection.

Frequently reported side effects of this drug

• Abdominal pain

• Diarrhea

• Passing gas

• Loss of strength and energy

• Back pain

• Headache

• Vomiting

• Nausea

Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:

• Kidney problems like unable to pass urine, blood in the urine, change in amount of urine passed, or weight gain

• Low potassium like muscle pain or weakness, muscle cramps, or an abnormal heartbeat

• Flushing

• Painful urination

• Trouble hearing

• Hearing loss

• Shortness of breath

• Wheezing

• Itching

• Muscle pain

• Chest pain

• Dizziness

• Passing out

• Chills

• Sore throat

• Change in balance

• Swelling of arms or legs

• Rash during infusion

• Clostridioides (formerly Clostridium) difficile-associated diarrhea like abdominal pain or cramps, severe diarrhea or watery stools, or bloody stools

• Severe injection site redness, edema, pain, or irritation

• Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.

Medication Safety Issues

Sound-alike/look-alike issues:

High alert medication:

Contraindications

Hypersensitivity to vancomycin or any component of the formulation

Warnings/Precautions

Concerns related to adverse effects:

• Extravasation and thrombophlebitis: IV vancomycin is an irritant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation. Pain, tenderness, and necrosis may occur with extravasation. If thrombophlebitis occurs, slow infusion rates, dilute solution (eg, 2.5 to 5 g/L) and rotate infusion sites.

• Nephrotoxicity: May cause nephrotoxicity although limited data suggest direct causal relationship; usual risk factors include preexisting renal impairment, concomitant nephrotoxic medications, advanced age, dehydration, critically-ill patients, patients with rapidly changing renal function, higher vancomycin serum levels, prolonged exposure, and concomitant piperacillin/tazobactam administration. 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 (ASHP/IDSA/SIDP [Rybak 2009]). Discontinue treatment if signs of nephrotoxicity occur; renal damage is usually reversible. Nephrotoxicity has been reported following treatment with oral vancomycin (typically in patients >65 years of age).

• Neutropenia: Prolonged therapy and use of concomitant drugs that cause neutropenia may increase the risk; monitor leukocyte counts periodically in these patients. Prompt reversal of neutropenia is expected after discontinuation of therapy.

• Ototoxicity: Ototoxicity is rarely associated with monotherapy. Ototoxicity manifests as tinnitus, hearing loss, dizziness, or vertigo. It has been most frequently reported in older patients, patients receiving excessive doses, those who have underlying hearing loss, or those receiving concomitant ototoxic drugs (eg, aminoglycosides). Serial auditory function testing may be helpful to minimize risk. Ototoxicity may be transient or permanent; discontinue treatment if signs of ototoxicity occur.

• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile infection (CDI); CDI has been observed >2 months postantibiotic treatment.

Disease-related concerns:

• Inflammatory bowel disease: Clinically significant serum concentrations have been reported in patients with inflammatory disorders of the intestinal mucosa who have taken oral vancomycin (multiple doses) for the treatment of C. difficile-associated diarrhea. Although use may be warranted, the risk for adverse reactions may be higher in this situation; consider monitoring serum trough concentrations, especially with renal insufficiency, severe colitis, and concurrent enteral vancomycin administration (IDSA/SHEA [McDonald 2018]; Pettit 2015).

• Pregnancy: [US Boxed Warning]: The formulation of vancomycin injection containing the excipients, polyethylene glycol (PEG 400) and N-acetyl D-alanine (NADA), is not recommended for use during pregnancy. PEG 400 and NADA have caused fetal malformations in animal reproduction studies. If use of vancomycin is needed during pregnancy, use other available formulations of vancomycin.

• Renal impairment: Use with caution in patients with renal impairment or those receiving other nephrotoxic or ototoxic drugs; dosage modification required (especially in elderly patients). Accumulation may occur after multiple oral doses of vancomycin in patients with renal impairment; consider monitoring trough concentrations in this circumstance.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Other warnings/precautions:

• Appropriate use: Oral vancomycin is only indicated for the treatment of CDI or enterocolitis due to S. aureus and is not effective for systemic infections; parenteral vancomycin is not effective for the treatment of enterocolitis. Prescribing vancomycin in the absence of a proven or strongly suspected bacterial infection or prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.

• Infusion reactions: Rapid IV administration (eg, over <60 minutes) may result in hypotension, flushing, erythema, urticaria, pruritus, wheezing, dyspnea, and, rarely, cardiac arrest. Reactions usually cease promptly after infusion is stopped. Frequency of infusion reactions may increase with concomitant administration of anesthetics. If used in conjunction with anesthesia, complete the vancomycin infusion prior to anesthesia induction.

• Intraocular administration (off-label route): Hemorrhagic occlusive retinal vasculitis (HORV), including permanent visual loss, has been reported in patients receiving intracameral or intravitreal administration of vancomycin during or after cataract surgery. Safety and efficacy of intraocularly administered vancomycin has not been established; vancomycin is not indicated for prophylaxis of endophthalmitis.

• Intraperitoneal administration (off-label route): Use caution when administering intraperitoneally (IP); in some continuous ambulatory peritoneal dialysis (CAPD) patients, chemical peritonitis (cloudy dialysate, fever, severe abdominal pain) has occurred. Symptoms are self-limited and usually clear after vancomycin discontinuation.

* See Cautions in AHFS Essentials for additional information.

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 with IV administration. Careful monitoring and dosing adjustment is necessary.

Reproductive Considerations

Pregnancy status should be evaluated in females of reproductive potential prior to using the IV formulation containing the excipients polyethylene glycol (PEG 400) and N-acetyl D-alanine (NADA).

Pregnancy Considerations

Vancomycin crosses the placenta and can be detected in fetal serum, amniotic fluid, and cord blood (Bourget 1991; Reyes 1989). Adverse fetal effects, including sensorineural hearing loss or nephrotoxicity, have not been reported following maternal use during the second or third trimesters of pregnancy.

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 may be increased (Bourget 1991). Individualization of therapy through serum concentration monitoring may be warranted.

Vancomycin is recommended for the treatment of Clostridioides (formerly Clostridium) difficile infections in pregnant women (ACG [Surawicz 2013]). Vancomycin is recommended as an alternative agent to prevent the transmission of group B streptococcal (GBS) disease from mothers to newborns (ACOG 782 2019). In patients colonized with MRSA, vancomycin is recommended as part of the antibiotic regimen for prophylactic use prior to cesarean delivery (ACOG 199 2018).

[US Boxed Warning]: The formulation of vancomycin injection containing the excipients polyethylene glycol (PEG 400) and N-acetyl D-alanine (NADA) is not recommended for use during pregnancy. PEG 400 and NADA have caused fetal malformations in animal reproduction studies. If use of vancomycin is needed during pregnancy, use other available formulations of vancomycin.

Breast-Feeding Considerations

Vancomycin is present in breast milk following IV administration.

The relative infant dose (RID) of vancomycin is 4.8% when calculated using the highest breast milk concentration located and compared to an infant therapeutic oral dose of 40 mg/kg/day.

In general, breastfeeding is considered acceptable when the RID is <10% (Anderson 2016; Ito 2000).

Using the highest milk concentration (12.7 mcg/mL), the estimated daily infant dose via breast milk is 1.9 mg/kg/day. This milk concentration was obtained 4 hours after maternal administration of IV vancomycin 1 g every 12 hours; therapy had been initiated at least 1 week prior to milk sampling (Reyes 1989).

Vancomycin exhibits minimal oral absorption; therefore, the amount available to pass into the milk would be limited following oral administration.

In general, antibiotics that are present in breast milk may cause non-dose-related modification of bowel flora. Monitor infants for GI disturbances, such as thrush or diarrhea (WHO 2002).

Vancomycin is recommended for the treatment of Clostridioides (formerly Clostridium) difficile infections in breastfeeding women (ACG [Surawicz 2013]). According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother.

Lexicomp Pregnancy & Lactation, In-Depth

• Vancomycin

Briggs' Drugs in Pregnancy & Lactation

• Vancomycin

Adverse Reactions

Injection:

>10%: Cardiovascular: Hypotension (accompanied by flushing)

1% to 10%:

Cardiovascular: Local phlebitis

Central nervous system: Chills, drug fever

Dermatologic: Skin rash

Hematologic & oncologic: Eosinophilia, neutropenia (reversible)

Frequency not defined: Cardiovascular: Flushing of face and neck (Red man syndrome; may be infusion related)

<1%, postmarketing, and/or case reports: DRESS syndrome (drug rash with eosinophilia and systemic symptoms), ototoxicity (rare; use of other ototoxic agents may increase risk), renal failure (limited data suggesting direct relationship), Stevens-Johnson syndrome, thrombocytopenia, vasculitis

Oral:

>10%: Gastrointestinal: Abdominal pain, dysgeusia (with oral solution), nausea

1% to 10%:

Cardiovascular: Peripheral edema

Central nervous system: Fatigue, headache

Gastrointestinal: Diarrhea, flatulence, vomiting

Genitourinary: Urinary tract infection

Neuromuscular & skeletal: Back pain

Miscellaneous: Fever

<1%, postmarketing, and/or case reports: Increased serum creatinine, interstitial nephritis, ototoxicity, renal failure, renal insufficiency, thrombocytopenia, vasculitis

* See Cautions in AHFS Essentials for additional information.

Allergy and Idiosyncratic Reactions

• Glycopeptide Antibiotic Allergy

Metabolism/Transport Effects

None known.

Drug Interactions Open Interactions

Aminoglycosides: Vancomycin may enhance the nephrotoxic effect of Aminoglycosides. Risk C: Monitor therapy

BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination

BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Risk C: Monitor therapy

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

Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Risk X: Avoid combination

Colistimethate: Vancomycin may enhance the nephrotoxic effect of Colistimethate. Management: Avoid coadministration of colistimethate and vancomycin whenever possible due to the potential for additive or synergistic nephrotoxicity. If coadministration cannot be avoided, closely monitor renal function. Risk D: Consider therapy modification

Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Risk C: Monitor therapy

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

Piperacillin: May enhance the nephrotoxic effect of Vancomycin. Risk C: Monitor therapy

Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Risk D: Consider therapy modification

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 3 days after cessation of antibacterial agents. Risk D: Consider therapy modification

Monitoring Parameters

Intravenous: Periodic renal function tests, CBC, pregnancy test prior to use for formulation containing PEG 400 and NADA excipients, serum trough vancomycin concentrations in select patients (eg, aggressive dosing, life-threatening infection, seriously ill, unstable renal function, concurrent nephrotoxins, prolonged courses)

Suggested frequency of trough vancomycin concentration monitoring for intermittent infusion (ASHP/IDSA/SIDP [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 to 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. For patients with uncomplicated skin and soft tissue infections who are not obese and have normal renal function, serum trough monitoring is generally not needed (IDSA [Liu 2011]).

Oral/rectal therapy: Serum sample monitoring is not typically required; systemic absorption of enteral vancomycin may occur in patients with mucosal disruption due to colitis, especially in patients with renal failure. Monitoring serum vancomycin levels may be considered for patients with renal failure who have severe colitis and require a prolonged course of enteral vancomycin (IDSA/SHEA [McDonald 2018]; Pettit 2015).

Reference Range

IV:

Timing of serum samples: Draw trough concentration just before the administration of a dose at steady-state conditions. Steady state conditions generally occur approximately after the third dose; therefore, may begin monitoring vancomycin trough concentrations before the fourth dose (usually within 1 hour of administration). More specific recommendations for timing of serum samples may be found in Monitoring Parameters. Drawing peak concentrations is no longer recommended (Alvarez 2016; ASHP/IDSA/SIDP [Rybak 2009]).

Therapeutic levels: Trough: ≥10 mcg/mL. For pathogens with a minimum inhibitory concentration (MIC) ≤1 mcg/mL, the minimum trough concentration should be 15 mcg/mL to meet target AUC/MIC of ≥400. For complicated infections (eg, bacteremia, endocarditis, osteomyelitis, meningitis, and hospital-acquired pneumonia caused by S. aureus) or infections associated with severe sepsis or septic shock, trough concentrations of 15 to 20 mcg/mL are recommended to improve penetration and improve clinical outcomes (ASHP/IDSA/SIDP [Rybak 2009]; Liu 2011; Rhodes 2017). The American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines for hospital-acquired pneumonia and the IDSA meningitis guidelines also recommend trough concentrations of 15 to 20 mcg/mL (Kalil 2016; Tunkel 2004; Tunkel 2017).

Toxic: >80 mcg/mL (SI: >54 micromole/L)

Intraventricular (off-label route): Limited data available (IDSA [Tunkel 2004; Tunkel 2017]; Smetana 2018): Prior to administration of the next intraventricular dose, withdraw a sample of CSF. This trough CSF concentration divided by the vancomycin MIC for the isolated bacterial pathogen (inhibitory quotient) should exceed 10 to 20.

Advanced Practitioners Physical Assessment/Monitoring

Perform culture and sensitivity testing and evaluate for use-related cautions prior to beginning therapy. Obtain renal function tests prior to initial intravenous dosing as well as periodic renal function tests, urinalysis, CBC with differential, and serum trough concentrations in select patient populations; consider dosing adjustments based on results. Assess for signs of superinfection. Appropriate emergency equipment and drug therapy for hypersensitivity reactions should be available. Test for Clostridioides (formerly Clostridium) difficile-associated diarrhea if patient develops diarrhea. Assess for signs of adverse reaction due to drug.

Nursing Physical Assessment/Monitoring

Check ordered labs and report any abnormalities. Monitor for and educate patients to report signs and symptoms of infusion reaction; avoid rapid infusion rate. Monitor patients very closely for hypersensitivity reactions; medications for hypersensitivity should be available. Monitor for severe or bloody diarrhea and send a specimen to the lab to test for Clostridioides (formerly Clostridium) difficile-associated diarrhea. Monitor patients for and educate patient to report signs and symptoms of neurotoxicity (vertigo, ataxia), hearing impairment, or nephrotoxicity (I & O, hematuria, edema).

Dosage Forms Considerations

First-Vancomycin oral solution and Vancomycin+SyrSpend SF oral suspension are compounding kits. Refer to manufacturer’s labeling for compounding instructions.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Capsule, Oral, as hydrochloride:

Vancocin: 250 mg [contains fd&c blue #2 (indigotine)]

Vancocin HCl: 125 mg [contains fd&c blue #2 (indigotine)]

Generic: 125 mg, 250 mg

Kit, Intravenous, as hydrochloride:

Vancosol Pack: 1 g/100 mL in NaCl 0.9% [DSC]

Solution, Intravenous, as hydrochloride:

Generic: 1000 mg/200 mL (200 mL); 1500 mg/300 mL (300 mL)

Solution, Intravenous, as hydrochloride [preservative free]:

Generic: 500 mg/100 mL (100 mL); 2000 mg/400 mL (400 mL); 1 g/200 mL in Dextrose 5% (200 mL); 1 g/200 mL in NaCl 0.9% (200 mL); 500 mg/100 mL in Dextrose 5% (100 mL); 750 mg/150 mL in Dextrose 5% (150 mL)

Solution Reconstituted, Intravenous [preservative free]:

Generic: 1.25 g (1 ea)

Solution Reconstituted, Intravenous, as hydrochloride:

Generic: 10 g (1 ea)

Solution Reconstituted, Intravenous, as hydrochloride [preservative free]:

Generic: 250 mg (1 ea); 500 mg (1 ea); 750 mg (1 ea); 1 g (1 ea); 1.5 g (1 ea); 5 g (1 ea); 10 g (1 ea); 100 g (1 ea)

Solution Reconstituted, Oral, as hydrochloride:

Firvanq: 25 mg/mL (150 mL, 300 mL); 50 mg/mL (150 mL, 300 mL) [contains fd&c red #40, fd&c yellow #10 (quinoline yellow), sodium benzoate; grape flavor]

Firvanq: 50 mg/mL (150 mL) [contains fd&c red #40, fd&c yellow #10 (quinoline yellow), sodium benzoate; white grape flavor]

Generic: 250 mg/5 mL (80 mL, 150 mL, 300 mL)

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Capsule, Oral, as hydrochloride:

Vancocin: 125 mg, 250 mg [contains fd&c blue #2 (indigotine)]

Generic: 125 mg, 250 mg

Solution Reconstituted, Intravenous, as hydrochloride:

Generic: 500 mg (1 ea, 10 mL); 1 g (1 ea, 20 mL, 30 mL); 5 g (1 ea); 10 g (1 ea)

Anatomic Therapeutic Chemical (ATC) Classification

• A07AA09
• J01XA01

Generic Available (US)

Yes

Pricing: US

Capsules (Vancocin HCl Oral)

125 mg (per each): $103.35

Capsules (Vancocin Oral)

250 mg (per each): $190.55

Capsules (Vancomycin HCl Oral)

125 mg (per each): $31.31

250 mg (per each): $57.72

Solution (Vancomycin HCl in Dextrose Intravenous)

1GM/200ML 5% (per mL): $0.16

500 mg/100 mL 5% (per mL): $0.09

750MG/150ML 5% (per mL): $0.10

Solution (Vancomycin HCl in NaCl Intravenous)

1GM/200ML 0.9% (per mL): $0.14

500 mg/100 mL 0.9% (per mL): $0.09

750MG/150ML 0.9% (per mL): $0.10

Solution (Vancomycin HCl Intravenous)

500 mg/100 mL (per mL): $0.18

1000 mg/200 mL (per mL): $0.18

1500MG/300ML (per mL): $0.18

2000MG/400ML (per mL): $0.18

Solution (reconstituted) (Firvanq Oral)

25 mg/mL (per mL): $0.82

50 mg/mL (per mL): $1.09

Solution (reconstituted) (Vancomycin HCl Intravenous)

1 g (per each): $4.14 - $24.78

1.25 g (per each): $24.12

1.5 g (per each): $28.94

5 g (per each): $19.72 - $111.31

10 g (per each): $39.18 - $256.81

100 g (per each): $600.00

250 mg (per each): $4.81

500 mg (per each): $2.96 - $12.83

750 mg (per each): $9.10 - $13.16

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

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

Note: Displays time-dependent antimicrobial killing; slowly bacteriocidal

Absorption: Oral: Poor; Rectal: significant absorption through inflamed colonic mucosa may occur; Intraperitoneal (IP): 60% of an IP dose absorbed in 6 hours

Distribution: Distributes widely in body tissue and fluids, except for CSF

Vd:

Neonate, term: 0.57 to 0.69 L/kg (de Hoog 2004)

Neonates, receiving ECMO (mean age: ~39 weeks): Variable; 1.1 L/kg (range: 0.6 to 2.1 L/kg) (Amaker 1996); others have reported lower values: 0.45 ± 0.18 L/kg (Buck 1998), 0.67 ± 0.15 L/kg (Mulla 2005)

Pediatric patients: Median: 0.57 L/kg (range: 0.26 to 1.05 L/kg) (Marsot 2012)

Adults: 0.4 to 1 L/kg (ASHP/IDSA/SIDP [Rybak 2009])

Relative diffusion from blood into CSF: Good only with inflammation (exceeds usual MICs)

Children:

CSF concentrations: 0.2 to 17.3 mcg/mL (de Hoog 2004)

CSF:blood level ratio: Normal meninges: Nil; Inflamed meninges: 7.1% to 68% (de Hoog 2004)

Adults:

Uninflamed meninges: 0 to 4 mcg/mL; serum concentration dependent (ASHP/IDSA/SIDP [Rybak 2009])

Inflamed meninges: 6 to 11 mcg/mL; serum concentration dependent (ASHP/IDSA/SIDP [Rybak 2009])

CSF:serum level ratio: Normal meninges: Nil; Inflamed meninges: ~80% (Shokouhi 2014)

Protein binding: ~55%

Metabolism: No apparent metabolism

Half-life elimination: Biphasic: Terminal:

Newborns: 6 to 10 hours

Neonates receiving ECMO: 6.53 ± 2.1 hours (Buck 1998); others have reported longer: 10.4 ± 6.7 hours (Mulla 2005)

Infants and Children 3 months to 4 years: 4 hours

Children and Adolescents >3 years: 2.2 to 3 hours

Adults: 4 to 6 hours; significantly prolonged with renal impairment

End-stage renal disease (ESRD): 7.5 days

Time to peak, serum: IV: Immediately after completion of infusion

Excretion: Primarily via glomerular filtration; IV: Urine (75% as unchanged drug in the first 24 hours); Oral: Primarily feces

Clearance: presence of malignancy in children is associated with an increase in vancomycin clearance

Neonates: 0.63 to 1.5 mL/minute/kg; dependent on GA and/or PMA (de Hoog 2004)

Neonates, receiving ECMO: ~0.79 mL/minute/kg (Amaker 1996; Buck 1998); others have reported a slightly slower rate: 0.67 mL/minute/kg (Mulla 2005)

Pediatric patients: Median: 1.1 mL/minute/kg (range: 0.33 to 1.87 mL/minute/kg) (Marsot 2012)

Adults: 0.71 to 1.31 mL/minute/kg (de Hoog 2004)

Pharmacodynamics/Kinetics: Additional Considerations

Geriatric: Total systemic and renal clearance may be reduced.

Local Anesthetic/Vasoconstrictor Precautions

No information available to require special precautions

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.

Effects on Bleeding

Vancomycin has been demonstrated to induce immune thrombocytopenia, causing a significant drop in platelet count following a short (ie, 12-15 hours) period of time after treatment. Both IgG and IgM vancomycin-dependent platelets have been identified post vancomycin administration. Discontinuation has shown to be an effective remedy, as platelet levels return to the pre-exposure counts within 4 days of drug withdrawal.

Dental Usual Dosing

Prophylaxis against infective endocarditis: IV:

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.

Related Information

• Desensitization Protocols
• Dosing Considerations for the Critically Ill Patient With Morbid Obesity
• Management of Drug Extravasations
• Prevention of Infective Endocarditis
• Relative Infant Dose

Pharmacotherapy Pearls

Intermittent infusion: 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 1 g over ≥60 minutes or 2 g over ≥90 minutes (ASHP/IDSA/SIDP [Rybak 2009]).

Continuous infusion (off-label regimen): IDSA MRSA guidelines discourage use of vancomycin continuous infusions due to a lack of clear benefit over intermittent infusion (IDSA [Liu 2011]). However, vancomycin continuous infusions are routinely used in many countries and may be acceptable in certain patient populations (Waineo 2015). Some authors suggest continuous infusion may be useful in outpatient settings, for patients at high risk for nephrotoxicity (eg, concomitant nephrotoxic drugs), or for patients requiring high vancomycin doses (Alvarez 2016; Verrall 2012). Dosing strategies are based upon actual body weight and creatinine clearance and are designed to keep serum concentrations at a target value depending upon susceptibility data (usually ~20 to 25 mg/L) (Alvarez 2016). Continuous infusion methods should only be used in health care environments where the practice is accepted and personnel are trained in dosing and subsequent vancomycin concentration management.

Index Terms

Vancocin; Vancomycin HCl; Vancomycin Hydrochloride

FDA Approval Date

November 06, 1964

References

Al-Jeraisy M, Phelps SJ, Christensen ML, Einhaus S. Intraventricular vancomycin in pediatric patients with cerebrospinal fluid shunt infections. J Pediatr Pharmacol Ther. 2004;9(1):36-42.

Álvarez R, López Cortés LE, Molina J, Cisneros JM, Pachón J. Optimizing the clinical use of vancomycin. Antimicrob Agents Chemother. 2016;60(5):2601-2609. doi: 10.1128/AAC.03147-14.[PubMed 26856841]

Amaker RD, DiPiro JT, Bhatia J. Pharmacokinetics of Vancomycin in Critically Ill Infants Undergoing Extracorporeal Membrane Oxygenation. Antimicrob Agents Chemother. 1996;40(5):1139-1142.[PubMed 8723454]

American Academy of Pediatrics (AAP). In: Kimberlin DW, Brady MT, Jackson MA, Long SA, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018.

American Academy of Pediatrics (AAP). In: Pickering LK, Baker CJ, Kimberlin DW, et al, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

American Academy of Pediatrics Committee on Infectious Diseases. Treatment of bacterial meningitis. Pediatrics. 1988;81(6):904-907.[PubMed 3368290]

American College of Obstetricians and Gynecologists (ACOG). Prevention of group B streptococcal early-onset disease in newborns: ACOG committee opinion, number 782. Obstet Gynecol. 2019;134(1):e19-e40. doi: 10.1097/AOG.0000000000003334.[PubMed 31241599]

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin no. 199: use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2018;132(3):e103-e119.[PubMed 30134425]

American Thoracic Society and Infectious Diseases Society of America, "Guidelines for the Management of Adults With Hospital-Acquired, Ventilator-Associated, and Healthcare-Associated Pneumonia," Am J Respir Crit Care Med, 2005, 171(4):388-416.[PubMed 15699079]

Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(6):605-627. doi: 10.1086/676022.[PubMed 24799638]

Anderson PO, Sauberan JB. Modeling drug passage into human milk. Clin Pharmacol Ther. 2016;100(1):42-52.[PubMed 27060684]

Apisarnthanarak A, Razavi B, Mundy LM. Adjunctive intracolonic vancomycin for severe Clostridium difficile colitis: case series and review of the literature. Clin Infect Dis. 2002;35(6):690-696.[PubMed 12203166]

Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults and Children. 5th ed. Philadelphia, PA: American College of Physicians; 2007.

Baddour LM, Flynn PM, Fekete T. Infections of cerebrospinal fluid shunts and other devices. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 21, 2019.

Baddour LM, Wilson WR, Bayer AS, et al; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association [published correction appears in Circulation. 2015;132(17):e215]. Circulation. 2015;132(15):1435-1486. doi: 10.1161/CIR.0000000000000296.[PubMed 26373316]

Baddour LM, Wilson WR, Bayer AS, et al, “Infective Endocarditis. Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association - Executive Summary: Endorsed by the Infectious Diseases Society of America,” Circulation, 2005, 111(23):3167-184.[PubMed 15956145]

Baker CJ. Neonatal Group B streptococcal disease: prevention. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 21, 2019.

Baltimore RS, Gewitz M, Baddour LM, et al. Infective endocarditis in childhood: 2015 update: a scientific statement from the American Heart Association. Circulation. 2015;132(15):1487-515.[PubMed 26373317]

Baltimore RS, Gewitz M, Baddour LM, et al; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young and the Council on Cardiovascular and Stroke Nursing. Infective endocarditis in childhood: 2015 update: a scientific statement from the American Heart Association. Circulation. 2015;132(15):1487-1515. doi: 10.1161/CIR.0000000000000298.[PubMed 26373317]

Bateman DA, Thomas W, Parravicini E, Polesana E, Locatelli C, Lorenz JM. Serum creatinine concentration in very-low-birth-weight infants from birth to 34-36 wk postmenstrual age. Pediatr Res. 2015;77(5):696-702.[PubMed 25675426 ]

Benner KW, Worthington MA, Kimberlin DW, et al, "Correlation of Vancomycin Dosing to Serum Concentrations in Pediatric Patients: A Retrospective Database Review," J Pediatr Pharmacol Ther, 2009, 14:86-93.

Benner KW, Worthington MA, Kimberlin DW, Hill K, Buckley K, Tofil NM. Correlation of vancomycin dosing to serum concentrations in pediatric patients: a retrospective database review. J Pediatr Pharmacol Ther. 2009;14(2):86-93. doi: 10.5863/1551-6776-14.2.86.[PubMed 23055895]

Berbari E, Baddour LM. Prosthetic joint infection: treatment. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 29, 2019.

Berbari EF, Kanj SS, Kowalski TJ, et al; Infectious Diseases Society of America. 2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clin Infect Dis. 2015;61(6):e26-e46. doi: 10.1093/cid/civ482.[PubMed 26229122]

Berríos-Torres SI, Umscheid CA, Bratzler DW, et al; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784-791. doi: 10.1001/jamasurg.2017.0904.[PubMed 28467526]

Bodilsen J, Brouwer MC, Nielsen H, Van De Beek D. Anti-infective treatment of brain abscess. Expert Rev Anti Infect Ther. 2018;16(7):565-578. doi: 10.1080/14787210.2018.1489722.[PubMed 29909695]

Bourget P, Fernandez H, Delouis C, et al, "Transplacental Passage of Vancomycin During the Second Trimester of Pregnancy," Obstet Gynecol, 1991, 78(5 Pt 2):908-11.[PubMed 1923224]

Bradley JS, Byington CL, Shah SS, et al; Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25-e76.[PubMed 21880587]

Bradley JS, Nelson JD, Barnett ED, Cantey JB, eds. Nelson's Pediatric Antimicrobial Therapy. 24th ed. American Academy of Pediatrics; 2018.

Bratzler DW, Dellinger EP, Olsen KM, et al; American Society of Health-System Pharmacists; Infectious Diseases Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283.[PubMed 23327981]

Buck ML, "Pharmacokinetic Changes During Extracorporeal Membrane Oxygenation: Implications for Drug Therapy of Neonates," Clin Pharmacokinet, 2003, 42(5):403-17.[PubMed 12739981]

Buck ML, "Vancomycin Pharmacokinetics in Neonates Receiving Extracorporeal Membrane Oxygenation," Pharmacotherapy, 1998, 18(5):1082-6.[PubMed 9758319]

Bunke CM, Aronoff GR, Brier ME, Sloan RS, Luft FC. Vancomycin kinetics during continuous ambulatory peritoneal dialysis. Clin Pharmacol Ther. 1983;34(5):631-637.[PubMed 6627823]

Butler M, Olson A, Drekonja D, et al; Agency for Healthcare Research and Quality (US). Early diagnosis, prevention, and treatment of Clostridium difficile: update. Comparative effectiveness review No. 172. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0087162/. Published March 2016.[PubMed 27148613]

Capparelli EV, Lane JR, Romanowski GL, et al, "The Influences of Renal Function and Maturation on Vancomycin Elimination in Newborns and Infants," J Clin Pharmacol, 2001, 41(9):927-34.[PubMed 11549096]

Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease, revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010; 59(RR-10):1-32.[PubMed 21088663]

Chang D, "Influence of Malignancy on the Pharmacokinetics of Vancomycin in Infants and Children," Pediatr Infect Dis J, 1995, 14(8):667-73.[PubMed 8532423 ]

Chang D, Liem L, and Malogolowkin M, "A Prospective Study of Vancomycin Pharmacokinetics and Dosage Requirements in Pediatric Cancer Patients," Pediatr Infect Dis J, 1994, 13(11):969-74.[PubMed 7845750]

Chu VH. Staphylococcal toxic shock syndrome. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 8, 2019.

Cook AM, Mieure KD, Owen RD, Pesaturo AB, Hatton J. Intracerebroventricular administration of drugs. Pharmacotherapy. 2009;29(7):832-845.[PubMed 19558257]

de Hoog M, Mouton JW, van den Anker JN. Vancomycin: pharmacokinetics and administration regimens in neonates. Clin Pharmacokinet. 2004;43(7):417-440.[PubMed 15139793]

Debast SB, Bauer MP, Kuijper EJ; European Society of Clinical Microbiology and Infectious Diseases. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2014;20(suppl 2):1-26. doi: 10.1111/1469-0691.12418.[PubMed 24118601]

Drew RH, Sakoulas G. Vancomycin: Parenteral dosing, monitoring, and adverse effects in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 21, 2019.

Durand M. Bacterial endophthalmitis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 30, 2019.

Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol. 1995;113(12):1479-1496.[PubMed 7487614]

File TM Jr. Treatment of community-acquired pneumonia in adults who require hospitalization. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed February 11, 2020.

Firvanq (vancomycin hydrochloride) [prescribing information]. Wilmington, MA: CutisPharma; October 2019.

Flume PA, Mogayzel PJ Jr, Robinson KA, et al; Clinical Practice Guidelines for Pulmonary Therapies Committee. Cystic fibrosis pulmonary guidelines: treatment of pulmonary exacerbations. Am J Respir Crit Care Med. 2009;180(9):802-808. doi: 10.1164/rccm.200812-1845PP.[PubMed 19729669]

Frymoyer A, Hersh AL, Benet LZ, Guglielmo BJ. Current recommended dosing of vancomycin for children with invasive methicillin-resistant Staphylococcus aureus infections is inadequate. Pediatr Infect Dis J. 2009;28(5):398-402. doi: 10.1097/INF.0b013e3181906e40.[PubMed 19295465]

Frymoyer A, Hersh AL, El-Komy MH, et al. Association between vancomycin trough concentration and area under the concentration-time curve in neonates. Antimicrob Agents Chemother. 2014;58(11):6454-6461.[PubMed 25136027 ]

Gan IM, van Dissel JT, Beekhuis H, Swart W, van Meurs JC. Intravitreal vancomycin and gentamicin concentrations in patients with postoperative endophthalmitis. Br J Ophthalmol. 2001;85(11):1289-1293.[PubMed 11673290]

Girand HL. Antibiotic lock therapy for treatment of catheter-related bloodstream infections. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 9, 2019.

Goldenberg DL, Sexton DJ. Septic arthritis in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 21, 2019.

Golightly LK, Teitelbaum I, Kiser TH, et al, eds. Renal Pharmacotherapy. New York, NY: Springer Science; 2013.

Gottlieb M, Long B, Koyfman A. The evaluation and management of toxic shock syndrome in the emergency department: a review of the literature. J Emerg Med. 2018;54(6):807-814. doi: 10.1016/j.jemermed.2017.12.048.[PubMed 29366615]

Gould FK, Denning DW, Elliott TS, et al; Working Party of the British Society for Antimicrobial Chemotherapy. Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy [published correction appears in J Antimicrob Chemother. 2012;67(5)1304]. J Antimicrob Chemother. 2012;67(2):269-289.[PubMed 22086858]

Habib G, Lancellotti P, Antunes MJ, et al; ESC Scientific Document Group. 2015 ESC guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36(44):3075-3128. doi: 10.1093/eurheartj/ehv319.[PubMed 26320109]

Healy DP, Sahai JV, Fuller SH, Polk RE. Vancomycin-induced histamine release and "red man syndrome": comparison of 1- and 2-hour infusions. Antimicrob Agents Chemother. 1990;34(4):550-554.[PubMed 1693055]

Heil EL, Claeys KC, Mynatt RP, et al. Making the change to area under the curve-based vancomycin dosing. Am J Health Syst Pharm. 2018;75(24):1986-1995. doi: 10.2146/ajhp180034.[PubMed 30333114]

Heintz BH, Matzke GR, Dager WE. Antimicrobial dosing concepts and recommendations for critically ill adult patients receiving continuous renal replacement therapy or intermittent hemodialysis. Pharmacotherapy. 2009;29(5):562-577.[PubMed 19397464]

Hoie EB, Swigart SA, Leuschen MP, et al. Vancomycin pharmacokinetics in infants undergoing extracorporeal membrane oxygenation. Clin Pharm. 1990;9(9):711-715.[PubMed 2225752]

Hurst S, McMillan M. Innovative solutions in critical care units: extravasation guidelines. Dimens Crit Care Nurs. 2004;23(3):125-128.[PubMed 15192356]

Ito S. Drug therapy for breast-feeding women. N Engl J Med. 2000;343(2):118-126.[PubMed 10891521]

Iwata K, Doi A, Fukuchi T, et al. A systematic review for pursuing the presence of antibiotic associated enterocolitis caused by methicillin resistant Staphylococcus aureus. BMC Infect Dis. 2014;14:247-259.[PubMed 24884581]

Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society [published online July 14, 2016]. Clin Infect Dis. doi: 10.1093/cid/ciw353.[PubMed 27418577]

Kelly CP, Lamont JT, Bakken JS. Clostridioides (formerly Clostridium) difficile in adults: treatment and prevention. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 21, 2019.

Kimberlin DW, Brady MT, Jackson MA, Long SS, eds; Committee on Infectious Diseases; American Academy of Pediatrics. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015.

LaPlante KL, Mermel LA. In vitro activity of daptomycin and vancomycin lock solutions on staphylococcal biofilms in a central venous catheter model. Nephrol Dial Transplant. 2007;22(8):2239-2246.[PubMed 17403700]

Launay-Vacher V, Izzedine H, Mercadal L, Deray G. Clinical review: use of vancomycin in haemodialysis patients. Crit Care. 2002;6(4):313-316.[PubMed 12225605]

Le J, Bradley JS, Murray W, et al. Improved vancomycin dosing in children using area under the curve exposure. Pediatr Infect Dis J. 2013;32(4):e155-163.[PubMed 23340565 ]

Leonard MB, Koren G, Stevenson DK, et al, "Vancomycin Pharmacokinetics in Very Low Birth Weight Neonates," Pediatr Infect Dis J, 1989, 8(5):282-6.[PubMed 2657617]

Li PK, Szeto CC, Piraino B, et al. International Society for Peritoneal Dialysis. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int. 2010;30(4):393-423. doi: 10.3747/pdi.2010.00049.[PubMed 20628102]

Li PK, Szeto CC, Piraino B, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int. 2016;36(5):481-508.[PubMed 27282851]

Lin Z, Kotler DP, Schlievert PM, Sordillo EM. Staphylococcal enterocolitis: forgotten but not gone? Dig Dis Sci. 2010;55(5):1200-1207.[PubMed 19609675]

Lipsky BA, Berendt AR, Cornia PB, et al; Infectious Diseases Society of America. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-73. doi: 10.1093/cid/cis346.[PubMed 22619242]

Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis. 2011;52(3):285-292. doi: 10.1093/cid/cir034.[PubMed 21217178]

Lodise TP, Lomaestro B, Graves J, Drusano GL. Larger vancomycin doses (at least four grams per day) are associated with an increased incidence of nephrotoxicity. Antimicrob Agents Chemother. 2008;52(4):1330-1336. doi: 10.1128/AAC.01602-07.[PubMed 18227177]

Mancini A, Todd L. Inconsistencies in ISPD peritonitis recommendations: 2016 update on prevention and treatment and the ISPD catheter-related infection recommendations: 2017 update. Perit Dial Int. 2018;38(4):309-310. doi: 10.3747/pdi.2018.00026.[PubMed 29987068]

Marsot A, Boulamery A, Bruguerolle B, et al. Vancomycin: a review of population pharmacokinetic analyses. Clin Pharmacokinet. 2012;51(1):1-13.[PubMed 22149255]

Martí R, Rosell M, Pou L, Garcia L, Pascual C. Influence of biochemical parameters of liver function on vancomycin pharmacokinetics. Pharmacol Toxicol. 1996;79(2):55-59.[PubMed 8878246]

Matzke GR, Zhanel GG, and Guay DRP, "Clinical Pharmacokinetics of Vancomycin," Clin Pharmacokinet, 1986, 11(4):257-82.[PubMed 3530582]

McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):e1-e48. doi: 10.1093/cid/cix1085.[PubMed 29462280]

Men P, Li HB, Zhai SD, Zhao RS. Association between the AUC0-24/MIC ratio of vancomycin and its clinical effectiveness: a systematic review and meta-analysis. PLoS One. 2016;11(1):e0146224. doi: 10.1371/journal.pone.0146224.[PubMed 26731739]

Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America [published corrections appear in Clin Infect Dis. 2010;50(7):1079; Clin Infect Dis. 2010;50(3):457]. Clin Infect Dis. 2009;49(1):1-45.[PubMed 19489710]

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST.[PubMed 31573350]

Mulla H, Pooboni S. Population pharmacokinetics of vancomycin in patients receiving extracorporeal membrane oxygenation. Br J Clin Pharmacol. 2005;60(3):265-275.[PubMed 16120065]

Murray BE, Arias CA, Nannini EC. Glycopeptides (vancomycin and teicoplanin), streptogramins (quinupristin-dalfopristin), lipopeptides (daptomycin), and lipoglycopeptides (telavancin). In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, PA: Elsevier Saunders;2015:377.

Neely MN, Kato L, Youn G, et al. Prospective trial on the use of trough concentration versus area under the curve to determine therapeutic vancomycin dosing. Antimicrob Agents Chemother. 2018;62(2):e02042-17. doi: 10.1128/AAC.02042-17.[PubMed 29203493]

Ng K, Mabasa VH, Chow I, Ensom MH. Systematic review of efficacy, pharmacokinetics, and administration of intraventricular vancomycin in adults. Neurocrit Care. 2014;20(1):158-171. doi: 10.1007/s12028-012-9784-z.[PubMed 23090839]

Nielsen HE, Sorensen I, and Hansen HE, “Peritoneal Transport of Vancomycin During Peritoneal Dialysis,” Nephron, 1979, 24(6):274-7.[PubMed 514426]

Onwuchuruba CN, Towers CV, Howard BC, Hennessy MD, Wolfe L, Brown MS. Transplacental passage of vancomycin from mother to neonate. Am J Obstet Gynecol. 2014;210(4):352.e1-352.e4. doi: 10.1016/j.ajog.2014.01.019.[PubMed 24679944]

Osmon DR, Berbari EF, Berendt AR, et al; Infectious Diseases Society of America. Diagnosis and management of prosthetic joint infection: clinical practice guideline by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):e1-e25.[PubMed 23223583]

Osmon DR, Tande AJ. Osteomyelitis in adults: Treatment. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed July 8, 2019.

Packer M, Chang DF, Dewey SH, et al; ASCRS Cataract Clinical Committee. Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis. J Cataract Refract Surg. 2011;37(9):1699-1714.[PubMed 21782382]

Pettit NN, DePestel DD, Fohl AL, et al. Risk factors for systemic vancomycin exposure following administration of oral vancomycin for the treatment of Clostridium difficile infection. Pharmacotherapy. 2015;35(2):119-126. doi: 10.1002/phar.1538.[PubMed 25689243]

Pettit RS, Peters SJ, McDade EJ, et al. Vancomycin dosing and monitoring in the treatment of cystic fibrosis: results of a National Practice Survey. J Pediatr Pharmacol Ther. 2017;22(6):406-411. doi: 10.5863/1551-6776-22.6.406.[PubMed 29290740]

Pfausler B, Haring HP, Kampfl A, Wissel J, Schober M, Schmutzhard E. Cerebrospinal fluid (CSF) pharmacokinetics of intraventricular vancomycin in patients with staphylococcal ventriculitis associated with external CSF drainage. Clin Infect Dis. 1997;25(3):733-735.[PubMed 9314470 ]

Reardon J, Lau TT, Ensom MH. Vancomycin loading doses: a systematic review. Ann Pharmacother. 2015;49(5):557-565. doi: 10.1177/1060028015571163.[PubMed 25712445]

Reyes MP and Ostrea EM Jr, "Toxicity of Vancomycin Given During Pregnancy (Reply)," Am J Obstet Gynecol, 1990, 163(4 Pt 1):1376.

Reyes MP, Ostrea EM Jr, Cabinian AE, et al, "Vancomycin During Pregnancy: Does It Cause Hearing Loss or Nephrotoxicity in the Infant?" Am J Obstet Gynecol, 1989, 161(4):977-81.[PubMed 2801848]

Reynolds PM, MacLaren R, Mueller SW, Fish DN, Kiser TH. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34(6):617-632. doi: 10.1002/phar.1396.[PubMed 24420913]

Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43(3):304-377. doi: 10.1007/s00134-017-4683-6.[PubMed 28101605]

Rodvold KA, Everett JA, Pryka RD, and Kraus DM, "Pharmacokinetics and Administration Regimens of Vancomycin in Neonates, Infants and Children," Clin Pharmacokinet, 1997, 33(1):32-51.[PubMed 9250422]

Rokas KE, Johnson JW, Beardsley JR, Ohl CA, Luther VP, Williamson JC. The addition of intravenous metronidazole to oral vancomycin is associated with improved mortality in critically ill patients with Clostridium difficile infection. Clin Infect Dis. 2015;61(6):934-941. doi: 10.1093/cid/civ409.[PubMed 26024909]

Rybak MJ, Boike SC. Monitoring vancomycin therapy. Drug Intell Clin Pharm. 1986;20(10):757-761.[PubMed 3769763]

Rybak MJ, Albrecht LM, Boike SC, et al, "Nephrotoxicity of Vancomycin, Alone and With an Aminoglycoside," J Antimicrob Chemother, 1990, 25(4):679-87.[PubMed 2351627]

Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2009;66(1):82-98.[PubMed 19106348]

Schutze GE, Willoughby RE, Committee on Infectious Diseases, American Academy of Pediatrics. Clostridium difficile infection in infants and children. Pediatrics. 2013;131(1):196-200.[PubMed 23277317 ]

Sexton DJ, Sampson JH. Intracranial epidural abscess. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 30, 2019a.

Sexton DJ, Sampson JH. Spinal epidural abscess. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 30, 2019b.

Shokouhi S, Alavi Darazam I. Determination of vancomycin trough level in serum and cerebrospinal fluid of patients with acute community-acquired meningitis: a prospective study. J Infect. 2014;69(5):424-429. doi: 10.1016/j.jinf.2014.06.010[PubMed 24973553]

Simon RH. Cystic fibrosis: treatment of acute pulmonary exacerbations. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 30, 2019.

Smetana KS, Cook AM. Cerebrospinal fluid vancomycin dosing and monitoring: the quandary posed by guideline recommendations. Clin Infect Dis. 2018;67(6):980-981. doi: 10.1093/cid/ciy189.[PubMed 29518176]

Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infections in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2010;50(12):1695]. Clin Infect Dis. 2010;50(2):133-164.[PubMed 20034345]

Southwick FS. Treatment and prognosis of bacterial brain abscess. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed February 11, 2020.

Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published online ahead of print June 18, 2014]. Clin Infect Dis. 2014;59(2):147-159. doi: 10.1093/cid/ciu296.[PubMed 24947530]

Stockmann C, Hersh AL, Roberts JK, et al. Predictive performance of a vancomycin population pharmacokinetic model in neonates. Infect Dis Ther. 2015;4(2):187-198.[PubMed 25998107 ]

Surawicz CM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478-498.[PubMed 23439232 ]

Szeto CC, Li PK. Concerns regarding inconsistencies within and between ISPD recommendations for peritonitis and catheter-related infections-in reply. Perit Dial Int. 2018;38(4):311-312. doi: 10.3747/pdi.2018.00046.[PubMed 29987069]

Szymusiak-Mutnick BA, Ross MB. Minimizing the occurrence of red-man syndrome. Am J Health Syst Pharm. 1996;53(17):2098.[PubMed 8870903]

Trotman RL, Williamson JC, Shoemaker DM, Salzer WL. Antibiotic dosing in critically ill adult patients receiving continuous renal replacement therapy. Clin Infect Dis. 2005;41(8):1159-1166.[PubMed 16163635]

Trubiano JA, Cheng AC, Korman TM, et al. Australasian Society of Infectious Diseases updated guidelines for the management of Clostridium difficile infection in adults and children in Australia and New Zealand. Intern Med J. 2016;46(4):479-493.[PubMed 27062204]

Tufariello JM, Lowy FD. Infection due to coagulase-negative staphylococci: treatment. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 21, 2019.

Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267-1284.[PubMed 15494903]

Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's clinical practice guidelines for healthcare-associated ventriculitis and meningitis [published online ahead of print February 14, 2017]. Clin Infect Dis. doi: 10.1093/cid/ciw861.[PubMed 28203777]

US Department of Health and Human Services Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed July 11, 2017.

Vancocin (vancomycin hydrochloride) [prescribing information]. Baudette, MN: ANI Pharmaceuticals; February 2018.

Vancomycin Hydrochloride (fliptop vial) [prescribing information]. Lake Forest, IL: Hospira; November 2019.

Vancomycin hydrochloride injection [prescribing information]. Lake Zurich, IL: Fresenius Kabi; February 2018.

Vancomycin hydrochloride injection [prescribing information]. Raleigh, NC: Xellia Pharmaceuticals; February 2019.

Verrall AJ, Llorin R, Tam VH, et al. Efficacy of continuous infusion of vancomycin for the outpatient treatment of methicillin-resistant Staphylococcus aureus infections. J Antimicrob Chemother. 2012;67(12):2970-2973. doi: 10.1093/jac/dks328.[PubMed 22915464]

Waineo MF, Kuhn TC, Brown DL. The pharmacokinetic/pharmacodynamic rationale for administering vancomycin via continuous infusion. J Clin Pharm Ther. 2015;40(3):259-265. doi: 10.1111/jcpt.12270.[PubMed 25865426]

Wang JT, Fang CT, Chen YC, Chang SC. Necessity of a loading dose when using vancomycin in critically ill patients. J Antimicrob Chemother. 2001;47(2):246.[PubMed 11157921]

Warady BA, Bakkaloglu S, Newland J, et al. Consensus Guidelines for the Prevention and Treatment of Catheter-Related Infections and Peritonitis in Pediatric Patients Receiving Peritoneal Dialysis: 2012 Update. Perit Dial Int. 2012;(32)(suppl 2):S32-S86.[PubMed 22851742]

Weintrob AC, Sexton DJ. Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 30, 2019.

Wilhem MP, Estes L. Symposium on antimicrobial agents--Part XII. Vancomycin. Mayo Clin Proc. 1999;74(9):928-935.[PubMed 10488798]

World Health Organization (WHO). Breastfeeding and maternal medication, recommendations for drugs in the Eleventh WHO Model List of Essential Drugs. 2002. Available at http://www.who.int/maternal_child_adolescent/documents/55732/en/[PubMed 23215911]

Brand Names: International

Adimicin (HR); Aekovan (PH); Alvarcin (CR, DO, GT, HN, NI, PA, SV); Celovan (HK); Citerin (MX); Covan (BD); Covancin (IN); Cytovan (IN); Dhacocin (MY, SG); Edicin (BG, CZ, EE, HR, RO, RU, SK, TH, TR, UA); Estavam (MX); Forstaf (IN); Icoplax (AR, PE); Kovan (CL); Levovanox (IT); Mersa (PH); Normedia (SE); Riveran (AR, PE); Vacsol (MX); Vagran (VE); Vamysin (BE); Vanauras (MX); Vanaurus (CR, DO, EC, GT, HN, NI, PA, SV); Vancard (BD); Vancep (ID); Vancin (BD); Vancin-S (TH); Vanco-SAAR (DE); Vanco-Teva (IL); Vancoavenir (IL); Vancobac (BD); Vancobact (EG); Vancocid (TH); Vancocin (AE, AT, AU, BB, BG, HU, IE, JO, LB, LK, MT, NL, RU, SA, SI, VN, ZA); Vancocin CP (AU, CN, IN, MX, PK, TW); Vancocin HCl (BF, BJ, CH, CI, DK, ET, GB, GH, GM, GN, HK, KE, LR, MA, ML, MR, MU, MW, NE, NG, PH, SC, SD, SE, SL, SN, TN, TW, TZ, UG, ZM, ZW); Vancocina (IT); Vancocine (FR); Vancodex (ID); Vancoled (AE, KR, KW, VN); Vancolon (AE, BH, EG, ET, KW, LB, PH, QA, SA); Vancomax (PE, PY); Vancomet (PH); Vanconix (BD); Vancorin (TR); Vancorus (RU); Vancosam (LK); Vancosan (BR, FI, IS, LT, LV); Vancotech (LK); Vancotek (AR); Vancotex (MY); Vancotrat (BR); Vancox (MX); Vancozin (EG, KR); Vanlyo (TW); Vanmicira (CZ); Vantocil (ID); Varedet (AR, PE, PY, UY); Vivocin (MY); Voncon (GR); Vondem (GR); Voxin (GR)

Last Updated 5/6/20