Vancomycin: Difference between revisions
(Replace manual dosing with dynamic SMW tables (Adult + Pediatric))
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==Adult Dosing==
==Adult Dosing==
 
===Indications by Disease===
===Loading Doses===
{{#ask: [[Has DrugName::Vancomycin]] [[Has Population::Adult]]
*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>
|?Treats disease=Disease
*Sample Loading Dose Table (individual ED guidelines may differ)
|?Has Dose=Dose
**'''<40kg:'''  750mg IV
|?Has Context=Context
**'''40-59kg:'''  1000mg IV
|format=table
**'''60-90kg:'''  1500mg IV
|limit=50
**'''>90kg:'''  2000mg IV
|mainlabel=-
*Alternative loading dose for serious infections: 20-25mg/kg IV
|headers=show
*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>
|sort=Treats disease
*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==
==Pediatric Dosing==
'''All: Adjust repeat doses based on serum levels'''
===Indications by Disease===
 
{{#ask: [[Has DrugName::Vancomycin]] [[Has Population::Pediatric]]
===General (<7 Days Old)===
|?Treats disease=Disease
*'''<1.2kg'''
|?Has Dose=Dose
**15mg/kg IV q24h
|?Has Context=Context
**First Dose: 15mg/kg IV x 1
|format=table
*'''1.2-2kg'''
|limit=50
**10-15mg/kg IV q12-18h
|mainlabel=-
**First Dose: 10-15mg/kg IV x 1
|headers=show
*'''>2.1kg'''
|sort=Treats disease
**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==

Revision as of 01:51, 20 March 2026

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

Indications by Disease

DiseaseDoseContext
Ascending cholangitis15-20mg/kgMRSA coverage for severe sepsis
Brain abscess15mg/kg IV q12hrTrauma/Post-surgical
Cellulitis20mg/kg IV q12hrsInpatient
Clostridium difficile125 mg PO four times daily for 10 daysSevere
Clostridium difficile125 mg PO four times daily for 10 daysNon-Severe
Diabetic foot infection15-20mg/kg IV q12hrsInpatient DFI
Discitis15-20 mg/kg IV BIDInpatient Therapy
Endocarditis30mg/kg/day IV in 2 dosesMRSA Native Valve Endocarditis
Endocarditis30mg/kg/day IV in 2 dosesProsthetic Valve Endocarditis (Early)
Endocarditis15-20 mg/kg IV BID dailyIVDA Endocarditis
Epidural abscess (spinal)15-20mg/kg BIDEmpiric
Infectious tenosynovitis25-30 mg/kg IV loading dose then 15-20mg/kg IV q12hrsEmpiric
Ludwig's angina15-20 mg/kg IV q8 hrs (max 2 g per dose)Immunocompromised, MRSA
Mastoiditis15-20mg/kg IV q12 hoursEmpiric
Open fracture1 g IV (immediately and q12 hours x 2 total doses)Grade III Fractures
Orbital cellulitis15-20mg/kg IV BIDInpatient
Osteomyelitis1g IV q12hPostoperative
Osteomyelitis1g IV q12hIVDU
Osteomyelitis1g IV q12hDM/Vascular insufficiency
Osteomyelitis1g IV q12hElderly/Hematogenous
Peritoneal dialysis-associated peritonitis30mg/kg loading followed by 0.6 mg/kg IP dailyEmpiric IP
Pneumonia (main)15–20 mg/kg IV q8-12h (target AUC/MIC 400-600)ICU, Risk of MRSA
Pneumonia (main)15-20 mg/kg IV q8-12hVAP, High Risk
Pneumonia (main)15-20 mg/kg IV q8-12hHAP, High Risk
Septic bursitis25-30 mg/kg IV loading then 15-20 mg/kg IVInpatient
Staphylococcal enterocolitis125-500mg PO q6hStaphylococcal enterocolitis
Suppurative parotitis15-20mg/kg IV BID dailyInpatient

Pediatric Dosing

Indications by Disease

DiseaseDoseContext
Brain abscess15mg/kg IV q6hrsPediatric Trauma/Post-surgical
Cellulitis15mg/kg IV q6hrsPediatric Inpatient
Clostridium difficile10mg/kg PO QID x 10 days (max 125mg/dose)Pediatric Non-Severe
Endocarditis15mg/kg IV q6hrs (max 2g/dose)Pediatric Empiric
Epidural abscess (spinal)15mg/kg IV q6hrsPediatric Empiric
Ludwig's angina15mg/kg IV q6hrsPediatric MRSA
Mastoiditis15mg/kg IV q6hrsPediatric MRSA
Neutropenic fever15mg/kg IV q6hrsPediatric, MRSA/catheter
Open fracture15mg/kg IV (max 1g) then q12hrs x 2 dosesPediatric Grade III
Orbital cellulitis15mg/kg IV q6hrsPediatric Inpatient
Osteomyelitis15mg/kg IV four times dailySickle Cell Disease
Osteomyelitis10mg/kg q6 hChildren
Osteomyelitis15mg/kg load, then reduce doseNewborn
Pediatric fever of uncertain source15mg/kg90 days to 36 months consider adding
Pneumonia (peds)15mg/kg/dose q6hrs IVHospitalized PICU severely ill
Staphylococcal enterocolitis40mg/kg/day PO divided q6h (max 2g/day)Staphylococcal enterocolitis
Suppurative parotitis15mg/kg IV q6hrsPediatric Inpatient
Ventriculoperitoneal shunt infectionage-based dosingEmpiric with Cefotaxime or Ceftriaxone

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[3]

Antibiotic Sensitivities[4]

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. ↑ Lyon GD and Bruce DL. Diphenhydramine reversal of vancomycin-induced hypotension. Anesth Analg. 1988 Nov;67(11):1109-10.
  2. ↑ 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
  3. ↑ Bactericidal agents in the treatment of MRSA infections—the potential role of daptomycin. J. Antimicrob. Chemother. (2006) 58 (6): 1107-1117.
  4. ↑ Sanford Guide to Antimicrobial Therapy 2014
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