Vancomycin
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
| Disease | Dose | Context |
|---|---|---|
| Ascending cholangitis | 15-20mg/kg | MRSA coverage for severe sepsis |
| Brain abscess | 15mg/kg IV q12hr | Trauma/Post-surgical |
| Cellulitis | 20mg/kg IV q12hrs | Inpatient |
| Clostridium difficile | 125 mg PO four times daily for 10 days | Severe |
| Clostridium difficile | 125 mg PO four times daily for 10 days | Non-Severe |
| Diabetic foot infection | 15-20mg/kg IV q12hrs | Inpatient DFI |
| Discitis | 15-20 mg/kg IV BID | Inpatient Therapy |
| Endocarditis | 30mg/kg/day IV in 2 doses | MRSA Native Valve Endocarditis |
| Endocarditis | 30mg/kg/day IV in 2 doses | Prosthetic Valve Endocarditis (Early) |
| Endocarditis | 15-20 mg/kg IV BID daily | IVDA Endocarditis |
| Epidural abscess (spinal) | 15-20mg/kg BID | Empiric |
| Infectious tenosynovitis | 25-30 mg/kg IV loading dose then 15-20mg/kg IV q12hrs | Empiric |
| Ludwig's angina | 15-20 mg/kg IV q8 hrs (max 2 g per dose) | Immunocompromised, MRSA |
| Mastoiditis | 15-20mg/kg IV q12 hours | Empiric |
| Open fracture | 1 g IV (immediately and q12 hours x 2 total doses) | Grade III Fractures |
| Orbital cellulitis | 15-20mg/kg IV BID | Inpatient |
| Osteomyelitis | 1g IV q12h | Postoperative |
| Osteomyelitis | 1g IV q12h | IVDU |
| Osteomyelitis | 1g IV q12h | DM/Vascular insufficiency |
| Osteomyelitis | 1g IV q12h | Elderly/Hematogenous |
| Peritoneal dialysis-associated peritonitis | 30mg/kg loading followed by 0.6 mg/kg IP daily | Empiric 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 q8-12h | VAP, High Risk |
| Pneumonia (main) | 15-20 mg/kg IV q8-12h | HAP, High Risk |
| Septic bursitis | 25-30 mg/kg IV loading then 15-20 mg/kg IV | Inpatient |
| Staphylococcal enterocolitis | 125-500mg PO q6h | Staphylococcal enterocolitis |
| Suppurative parotitis | 15-20mg/kg IV BID daily | Inpatient |
Pediatric Dosing
Indications by Disease
| Disease | Dose | Context |
|---|---|---|
| Brain abscess | 15mg/kg IV q6hrs | Pediatric Trauma/Post-surgical |
| Cellulitis | 15mg/kg IV q6hrs | Pediatric Inpatient |
| Clostridium difficile | 10mg/kg PO QID x 10 days (max 125mg/dose) | Pediatric Non-Severe |
| Endocarditis | 15mg/kg IV q6hrs (max 2g/dose) | Pediatric Empiric |
| Epidural abscess (spinal) | 15mg/kg IV q6hrs | Pediatric Empiric |
| Ludwig's angina | 15mg/kg IV q6hrs | Pediatric MRSA |
| Mastoiditis | 15mg/kg IV q6hrs | Pediatric MRSA |
| Neutropenic fever | 15mg/kg IV q6hrs | Pediatric, MRSA/catheter |
| Open fracture | 15mg/kg IV (max 1g) then q12hrs x 2 doses | Pediatric Grade III |
| Orbital cellulitis | 15mg/kg IV q6hrs | Pediatric Inpatient |
| Osteomyelitis | 15mg/kg IV four times daily | Sickle Cell Disease |
| Osteomyelitis | 10mg/kg q6 h | Children |
| Osteomyelitis | 15mg/kg load, then reduce dose | Newborn |
| Pediatric fever of uncertain source | 15mg/kg | 90 days to 36 months consider adding |
| Pneumonia (peds) | 15mg/kg/dose q6hrs IV | Hospitalized PICU severely ill |
| Staphylococcal enterocolitis | 40mg/kg/day PO divided q6h (max 2g/day) | Staphylococcal enterocolitis |
| Suppurative parotitis | 15mg/kg IV q6hrs | Pediatric Inpatient |
| Ventriculoperitoneal shunt infection | age-based dosing | Empiric 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
- Adult
- Hepatic Dosing (Adult & Pediatric)
- Not defined
Contraindications
- Allergy to class/drug
Adverse Reactions
Serious
- Anaphylaxis
- Severe hypotension (rapid IV use) - not much evidence but consider anti-histamine[1]:
- 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
- Vancomycin infusion reaction (rapid IV use) - formerly "red man syndrome"[2]
- Hypotension(rapid IV use)
- Fever
- Nausea
- Rigors
- Eosinophilia
- Rash
- Urticaria
- Phlebitis
- Tinnitus
- Dizziness/Vertigo
- Elevated BUN/Creatinine
- Vomiting (PO use)
- Flatulence (PO use)
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]
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
- ↑ Lyon GD and Bruce DL. Diphenhydramine reversal of vancomycin-induced hypotension. Anesth Analg. 1988 Nov;67(11):1109-10.
- ↑ 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
- ↑ Bactericidal agents in the treatment of MRSA infections—the potential role of daptomycin. J. Antimicrob. Chemother. (2006) 58 (6): 1107-1117.
- ↑ Sanford Guide to Antimicrobial Therapy 2014