Vancomycin: Difference between revisions

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==General==
==General==
*Type: 125mg, 250mg
*Type: [[Is DrugClass::Glycopeptide]]
*Dosage Forms:  
*Dosage Forms:  
**IV
**IV
**May mix IV with 30mL water and give PO
**PO: Mix IV form with 30mL water  
**May mix with 100mL NS and give PR
**PR: Mix IV form with 100mL NS
*Common Trade Names: Vancocin
*Common Trade Names: Vancocin


==Adult Dosing==
==Adult Dosing==
===General===
 
===Loading Doses===
*15-20mg/kg IV loading dose<ref>Ryback M, 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. </ref>
*Sample Loading Dose Table (individual ED guidelines may differ)
**'''<40kg:'''  750mg IV
**'''40-59kg:'''  1000mg IV
**'''60-90kg:'''  1500mg IV
**'''>90kg:'''  2000mg IV
*Alternative loading dose for serious infections: 20-25mg/kg IV
*Loading doses of 30mg/kg has shown improved target trough levels at 12 hrs with no difference in nephrotoxicity<ref>Rosini JM, et al. A randomized trial of loading vancomycin in the emergency department. Ann Pharmacother. 2015; 49(1):6-13.</ref><ref>Rosini JM, et al. High single-dose vancomycin loading is not associated with increased nephrotoxicity in emergency department sepsis patients. Acad Emerg Med. 2016 Feb 6.</ref>
*Adjust maintenance dose based on serum levels
 
===Maintenance===
'''All: Adjust repeat doses based on serum levels'''
*'''<50kg:'''  500mg IV q12h
*'''<50kg:'''  500mg IV q12h
*'''50-69kg:'''  750mg IV q12h
*'''50-69kg:'''  750mg IV q12h
*'''>70kg:'''  1000mg IV q12h
*'''>70kg:'''  1000mg IV q12h
*Alternative (All Weights): 10-15 mg/kg IV q12
*Alternative (All Weights): 10-15mg/kg IV q12
*Adjust dose based on serum levels
*Adjust dose based on serum levels


===[[C. Difficile]] Infection===
===[[Clostridium Difficile]]===
*1st occurrence
*1st occurrence
**Uncomplicated: 125mg PO q6h x 10-14 days
**Uncomplicated: 125mg PO q6h x 10-14 days
**Complicated:  500mg PO/NG q6h
**Complicated:  500mg PO/NG q6h
***May use in combo with metronidazole IV
***May use in combo with [[metronidazole]] IV
***Consider adding vancomycin 500mg PR q6 if complete ileus
***Consider adding vancomycin 500mg PR q6 if complete ileus
*2nd occurrence
*2nd occurrence
**Uncomplicated: 125mg PO q6h x 10-14 days
**Uncomplicated: 125mg PO q6h x 10-14 days
**Complicated:  500mg PO/NG q6h
**Complicated:  500mg PO/NG q6h
***May use in combo with metronidazole IV
***May use in combo with [[metronidazole]] IV
***Consider adding vancomycin 500mg PR q6 if complete ileus
***Consider adding vancomycin 500mg PR q6 if complete ileus
*3rd+ occurrence
*3rd+ occurrence
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===Staphylococcal Enterocolitis===
===Staphylococcal Enterocolitis===
*500-2000 mg/day PO divided q6-8h x 7-10 days
*500-2000mg/day PO divided q6-8h x 7-10 days
*First Dose: 500mg PO x 1
*First Dose: 500mg PO x 1


==Pediatric Dosing==
==Pediatric Dosing==
'''All: Adjust repeat doses based on serum levels'''
===General (<7 Days Old)===
*'''<1.2kg'''
**15mg/kg IV q24h
**First Dose: 15mg/kg IV x 1
*'''1.2-2kg'''
**10-15mg/kg IV q12-18h
**First Dose: 10-15mg/kg IV x 1
*'''>2.1kg'''
**10-15mg/kg IV q8-12h
**First Dose: 10-15mg/kg IV x 1
===General (7 Days - 1 Month Old)===
*'''<1.2kg'''
**15mg/kg IV q24h
**First Dose: 15mg/kg IV x 1
*'''1.2-2kg'''
**10-15mg/kg IV q8-12h
**First Dose: 10-15mg/kg IV x 1
*'''>2.1kg'''
**15-20mg/kg IV q8
**First Dose: 15-20mg/kg IV x 1
===General (1 Month - 11 Years)===
*10-15mg/kg IV q6-8h
*First Dose: 10-15mg/kg IV x 1
*Max: 1 gram per dose
===General (12 - 16 Years)===
*1000mg IV q12h
*First Dose: 1000mg IV x 1
*Alt: 10-15mg/kg IV q12
*Info: Repeat dosing may require up to 1200-1500mg IV q12h or 10mg/kg IV q8
===[[Clostridium Difficile]]===
*40mg/kg/day PO divided q6-8h x 7-10 days
*First Dose: 10-13mg/kg x 1
*Max 500mg/dose, 2000mg/day
*For severe infection or recurrence
*May use in combination with [[metronidazole]] PO
===Staphylococcal Enterocolitis===
*40mg/kg/day PO divided q6-8h x 7-10 days
*First Dose: 10-13mg/kg x 1
*Max 500mg/dose, 2000mg/day
===Community-Acquired [[Pneumonia (main)|Pneumonia]]===
*40mg/kg/day PO divided q6-8h x 10-14 days
*First Dose: 10-13mg/kg x 1
*Info: Switch to appropriate oral regiment when possible


==Special Populations==
==Special Populations==
*Pregnancy:
*[[Pregnancy|Drug ratings in pregnancy]]: C
*Lactation:
*Lactation: Probably safe
*Renal Dosing
*Renal Dosing
**Adult
**Adult
***CrCl 50-90: 15mg/kg x1, then usual dose q12-24h
***CrCl 10-50: 15mg/kg x1, then usual dose q24h-96h
***CrCl <10: 15mg/kg x1, then usual dose q4-7 days
***Hemodialysis: Give supplement only if high-flux dialyzer used
***Peritoneal dialysis: No supplement
**Pediatric
**Pediatric
*Hepatic Dosing
***CrCl 10-50: give q18-48h
**Adult
***CrCl <10: give q48-96h
**Pediatric
***Hemodialysis: Give supplement only if high-flux dialyzer used
***Peritoneal dialysis: No supplement
*Hepatic Dosing (Adult & Pediatric)
**Not defined


==Contraindications==
==Contraindications==
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==Adverse Reactions==
==Adverse Reactions==
===Serious===
===Serious===
*[[Anaphylaxis]]
*Severe [[hypotension]] (rapid IV use) - not much evidence but consider anti-histamine<ref>Lyon GD and Bruce DL. Diphenhydramine reversal of vancomycin-induced hypotension. Anesth Analg. 1988 Nov;67(11):1109-10.</ref>:
**1.25-1.67mg/kg/dose [[diphenhydramine]] IV to pediatric patients
**25 - 50mg [[diphenhydramine]] IV to adults
*Thrombophlebitis
*Tissue necrosis (if extravasation)
*vasculitis
*Exfoliative dermatitis
*[[Stevens-Johnson Syndrome]]
*[[Toxic Epidermal Necrolysis]]
*Drug rash with eosinophilia and systemic symptoms
*Interstitial nephritis
*Nephrotoxicity
*Ototoxicity
*Neutropenia
*[[Thrombocytopenia]]
*Superinfection
*[[Clostridium difficile]]


===Common===
===Common===
*[[Vancomycin infusion reaction]] (rapid IV use) - formerly "red man syndrome"<ref>Alvarez-Arango, S, Ogunwole, SM, Sequist, TD, Burk, CM, Blumenthal, KG. Vancomycin infusion reaction—moving beyond “red man syndrome.” N Engl J Med. 2021;384:1283-1286. doi:10.1056/NEJMp2031891</ref>
*[[Hypotension]](rapid IV use)
*[[Fever]]
*[[Nausea]]
*Rigors
*[[Eosinophilia]]
*[[Rash]]
*[[Urticaria]]
*Phlebitis
*Tinnitus
*[[Dizziness]]/[[Vertigo]]
*Elevated BUN/Creatinine
*[[Vomiting]] (PO use)
*Flatulence (PO use)


==Pharmacology==
==Pharmacology==
*Half-life:  
*Half-life: 4-6h (7.5 days ESRD)
*Metabolism:  
*Metabolism: CYP450
*Excretion:  
*Excretion:  
*Mechanism of Action:
**IV route: Urine
**PO Route: Minimal systemic absorption unless intestinal inflammation or renal impairment
*Mechanism of Action
**Bactericidal against S. aureus and pneumococci
**Bacteriostatic against enterococci<ref>Bactericidal agents in the treatment of MRSA infections—the potential role of daptomycin. J. Antimicrob. Chemother. (2006) 58 (6): 1107-1117.</ref>
 
==[[Antibiotic Sensitivities]]<ref>Sanford Guide to Antimicrobial Therapy 2014</ref>==
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Group'''
| align="center" style="background:#f0f0f0;"|'''Organism'''
| align="center" style="background:#f0f0f0;"|'''Sensitivity'''
|-
| Gram Positive||[[Strep. Group A, B, C, G]]||'''S'''
|-
| ||[[Strep. Pneumoniae]]||'''S'''
|-
| ||[[Viridans strep]]||X1
|-
| ||Strep. anginosus gp||X1
|-
| ||[[Enterococcus faecalis]]||'''S'''
|-
| ||[[Enterococcus faecium]]||I
|-
| ||[[MSSA]]||'''S'''
|-
| ||[[MRSA]]||'''[[Has MRSA::S]]'''
|-
| ||[[CA-MRSA]]||'''S'''
|-
| ||[[Staph. Epidermidis]]||'''S'''
|-
| ||[[C. jeikeium]]||'''S'''
|-
| ||[[L. monocytogenes]]||'''S'''
|-
| Gram Negatives||[[N. gonorrhoeae]]||R
|-
| ||[[N. meningitidis]]||R
|-
| ||[[Moraxella catarrhalis]]||X1
|-
| ||[[H. influenzae]]||X1
|-
| ||[[E. coli]]||R
|-
| ||[[Klebsiella]] sp||R
|-
| ||E. coli/Klebsiella ESBL+||R
|-
| ||E coli/Klebsiella KPC+||R
|-
| ||[[Enterobacter]] sp, AmpC neg||R
|-
| ||[[Enterobacter]] sp, AmpC pos||R
|-
| ||[[Serratia]] sp||X1
|-
| ||Serratia marcescens||R
|-
| ||[[Salmonella]] sp||R
|-
| ||[[Shigella]] sp||R
|-
| ||[[Proteus mirabilis]]||X1
|-
| ||[[Proteus vulgaris]]||R
|-
| ||[[Providencia sp.]]||X1
|-
| ||[[Morganella sp.]]||X1
|-
| ||[[Citrobacter freundii]]||X1
|-
| ||[[Citrobacter diversus]]||X1
|-
| ||[[Citrobacter sp.]]||X1
|-
| ||[[Aeromonas sp]]||X1
|-
| ||[[Acinetobacter sp.]]||R
|-
| ||[[Pseudomonas aeruginosa]]||R
|-
| ||[[Burkholderia cepacia]]||R
|-
| ||[[Stenotrophomonas maltophilia]]||R
|-
| ||[[Yersinia enterocolitica]]||X1
|-
| ||[[Francisella tularensis]]||X1
|-
| ||[[Brucella sp.]]||R
|-
| ||[[Legionella sp.]]||X1
|-
| ||[[Pasteurella multocida]]||X1
|-
| ||[[Haemophilus ducreyi]]||R
|-
| ||[[Vibrio vulnificus]]||X1
|-
| Misc||[[Chlamydophila sp]]||X1
|-
| ||[[Mycoplasm pneumoniae]]||X1
|-
| ||[[Rickettsia sp]]||R
|-
| ||[[Mycobacterium avium]]||X1
|-
| Anaerobes||[[Actinomyces]]||'''S'''
|-
| ||[[Bacteroides fragilis]]||R
|-
| ||[[Prevotella melaninogenica]]||R
|-
| ||[[Clostridium difficile]]||'''S'''
|-
| ||[[Clostridium (not difficile)]]||'''S'''
|-
| ||[[Fusobacterium necrophorum]]||X1
|-
| ||[[Peptostreptococcus sp.]]||'''S'''
|}
 
===Key===
{{Template:Antibacterial Spectra Key}}


==See Also==
==See Also==
*[[Antibiotics (Main)]]
*[[Antibiotics (Main)]]
*[[Vancomycin infusion reaction]]


==Source==
==References==
*Epocrates
<references/>


[[Category:Drugs]]
[[Category:Pharmacology]]
[[Category:ID]]

Latest revision as of 13:18, 30 August 2025

General

  • Type: Glycopeptide
  • Dosage Forms:
    • IV
    • PO: Mix IV form with 30mL water
    • PR: Mix IV form with 100mL NS
  • Common Trade Names: Vancocin

Adult Dosing

Loading Doses

  • 15-20mg/kg IV loading dose[1]
  • Sample Loading Dose Table (individual ED guidelines may differ)
    • <40kg: 750mg IV
    • 40-59kg: 1000mg IV
    • 60-90kg: 1500mg IV
    • >90kg: 2000mg IV
  • Alternative loading dose for serious infections: 20-25mg/kg IV
  • Loading doses of 30mg/kg has shown improved target trough levels at 12 hrs with no difference in nephrotoxicity[2][3]
  • Adjust maintenance dose based on serum levels

Maintenance

All: Adjust repeat doses based on serum levels

  • <50kg: 500mg IV q12h
  • 50-69kg: 750mg IV q12h
  • >70kg: 1000mg IV q12h
  • Alternative (All Weights): 10-15mg/kg IV q12
  • Adjust dose based on serum levels

Clostridium Difficile

  • 1st occurrence
    • Uncomplicated: 125mg PO q6h x 10-14 days
    • Complicated: 500mg PO/NG q6h
      • May use in combo with metronidazole IV
      • Consider adding vancomycin 500mg PR q6 if complete ileus
  • 2nd occurrence
    • Uncomplicated: 125mg PO q6h x 10-14 days
    • Complicated: 500mg PO/NG q6h
      • May use in combo with metronidazole IV
      • Consider adding vancomycin 500mg PR q6 if complete ileus
  • 3rd+ occurrence
    • 125mg PO q6h x 10-14 days, then daily x 7 days, then q2-3 days x 2-8 wk

Staphylococcal Enterocolitis

  • 500-2000mg/day PO divided q6-8h x 7-10 days
  • First Dose: 500mg PO x 1

Pediatric Dosing

All: Adjust repeat doses based on serum levels

General (<7 Days Old)

  • <1.2kg
    • 15mg/kg IV q24h
    • First Dose: 15mg/kg IV x 1
  • 1.2-2kg
    • 10-15mg/kg IV q12-18h
    • First Dose: 10-15mg/kg IV x 1
  • >2.1kg
    • 10-15mg/kg IV q8-12h
    • First Dose: 10-15mg/kg IV x 1

General (7 Days - 1 Month Old)

  • <1.2kg
    • 15mg/kg IV q24h
    • First Dose: 15mg/kg IV x 1
  • 1.2-2kg
    • 10-15mg/kg IV q8-12h
    • First Dose: 10-15mg/kg IV x 1
  • >2.1kg
    • 15-20mg/kg IV q8
    • First Dose: 15-20mg/kg IV x 1

General (1 Month - 11 Years)

  • 10-15mg/kg IV q6-8h
  • First Dose: 10-15mg/kg IV x 1
  • Max: 1 gram per dose

General (12 - 16 Years)

  • 1000mg IV q12h
  • First Dose: 1000mg IV x 1
  • Alt: 10-15mg/kg IV q12
  • Info: Repeat dosing may require up to 1200-1500mg IV q12h or 10mg/kg IV q8

Clostridium Difficile

  • 40mg/kg/day PO divided q6-8h x 7-10 days
  • First Dose: 10-13mg/kg x 1
  • Max 500mg/dose, 2000mg/day
  • For severe infection or recurrence
  • May use in combination with metronidazole PO

Staphylococcal Enterocolitis

  • 40mg/kg/day PO divided q6-8h x 7-10 days
  • First Dose: 10-13mg/kg x 1
  • Max 500mg/dose, 2000mg/day

Community-Acquired Pneumonia

  • 40mg/kg/day PO divided q6-8h x 10-14 days
  • First Dose: 10-13mg/kg x 1
  • Info: Switch to appropriate oral regiment when possible

Special Populations

  • Drug ratings in pregnancy: C
  • Lactation: Probably safe
  • Renal Dosing
    • Adult
      • CrCl 50-90: 15mg/kg x1, then usual dose q12-24h
      • CrCl 10-50: 15mg/kg x1, then usual dose q24h-96h
      • CrCl <10: 15mg/kg x1, then usual dose q4-7 days
      • Hemodialysis: Give supplement only if high-flux dialyzer used
      • Peritoneal dialysis: No supplement
    • Pediatric
      • CrCl 10-50: give q18-48h
      • CrCl <10: give q48-96h
      • Hemodialysis: Give supplement only if high-flux dialyzer used
      • Peritoneal dialysis: No supplement
  • Hepatic Dosing (Adult & Pediatric)
    • Not defined

Contraindications

  • Allergy to class/drug

Adverse Reactions

Serious

Common

Pharmacology

  • Half-life: 4-6h (7.5 days ESRD)
  • Metabolism: CYP450
  • Excretion:
    • IV route: Urine
    • PO Route: Minimal systemic absorption unless intestinal inflammation or renal impairment
  • Mechanism of Action
    • Bactericidal against S. aureus and pneumococci
    • Bacteriostatic against enterococci[6]

Antibiotic Sensitivities[7]

Group Organism Sensitivity
Gram Positive Strep. Group A, B, C, G S
Strep. Pneumoniae S
Viridans strep X1
Strep. anginosus gp X1
Enterococcus faecalis S
Enterococcus faecium I
MSSA S
MRSA S
CA-MRSA S
Staph. Epidermidis S
C. jeikeium S
L. monocytogenes S
Gram Negatives N. gonorrhoeae R
N. meningitidis R
Moraxella catarrhalis X1
H. influenzae X1
E. coli R
Klebsiella sp R
E. coli/Klebsiella ESBL+ R
E coli/Klebsiella KPC+ R
Enterobacter sp, AmpC neg R
Enterobacter sp, AmpC pos R
Serratia sp X1
Serratia marcescens R
Salmonella sp R
Shigella sp R
Proteus mirabilis X1
Proteus vulgaris R
Providencia sp. X1
Morganella sp. X1
Citrobacter freundii X1
Citrobacter diversus X1
Citrobacter sp. X1
Aeromonas sp X1
Acinetobacter sp. R
Pseudomonas aeruginosa R
Burkholderia cepacia R
Stenotrophomonas maltophilia R
Yersinia enterocolitica X1
Francisella tularensis X1
Brucella sp. R
Legionella sp. X1
Pasteurella multocida X1
Haemophilus ducreyi R
Vibrio vulnificus X1
Misc Chlamydophila sp X1
Mycoplasm pneumoniae X1
Rickettsia sp R
Mycobacterium avium X1
Anaerobes Actinomyces S
Bacteroides fragilis R
Prevotella melaninogenica R
Clostridium difficile S
Clostridium (not difficile) S
Fusobacterium necrophorum X1
Peptostreptococcus sp. S

Key

  • S susceptible/sensitive (usually)
  • I intermediate (variably susceptible/resistant)
  • R resistant (or not effective clinically)
  • S+ synergistic with cell wall antibiotics
  • U sensitive for UTI only (non systemic infection)
  • X1 no data
  • X2 active in vitro, but not used clinically
  • X3 active in vitro, but not clinically effective for Group A strep pharyngitis or infections due to E. faecalis
  • X4 active in vitro, but not clinically effective for strep pneumonia

See Also

References

  1. ↑ Ryback M, 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.
  2. ↑ Rosini JM, et al. A randomized trial of loading vancomycin in the emergency department. Ann Pharmacother. 2015; 49(1):6-13.
  3. ↑ Rosini JM, et al. High single-dose vancomycin loading is not associated with increased nephrotoxicity in emergency department sepsis patients. Acad Emerg Med. 2016 Feb 6.
  4. ↑ Lyon GD and Bruce DL. Diphenhydramine reversal of vancomycin-induced hypotension. Anesth Analg. 1988 Nov;67(11):1109-10.
  5. ↑ Alvarez-Arango, S, Ogunwole, SM, Sequist, TD, Burk, CM, Blumenthal, KG. Vancomycin infusion reaction—moving beyond “red man syndrome.” N Engl J Med. 2021;384:1283-1286. doi:10.1056/NEJMp2031891
  6. ↑ Bactericidal agents in the treatment of MRSA infections—the potential role of daptomycin. J. Antimicrob. Chemother. (2006) 58 (6): 1107-1117.
  7. ↑ Sanford Guide to Antimicrobial Therapy 2014
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