vancomycin

Vancomycin is an antibiotic typically used to treat colon inflammation (colitis) and diarrhea that may occur sometimes after antibacterial treatment, and bacterial infections that are resistant to other antibiotics. Vancomycin belongs to a class of antibiotics known as glycopeptides which are considered the last resort treatment for life-threatening infections of certain gram-positive bacteria.

Gram-positive bacteria are structurally different from gram-negative bacteria, and the types are identified by whether the bacteria get dyed or not in the Gram stain lab test. Oral vancomycin is not very well absorbed systemically and is used only to treat intestinal bacterial infection and inflammation. Intravenous vancomycin is administered to treat other bacterial infections such as endocarditis, skin, bone and blood infections.

Vancomycin kills bacteria by inhibiting the synthesis of the bacterial cell wall, and in addition, prevents bacterial multiplication by altering the cell wall permeability and RNA synthesis. Vancomycin prevents bacterial cell wall growth by binding to d-alanyl-d-alanine (d-Ala-d-Ala) terminus part of peptidoglycan, a molecule of sugar and amino acids and the most essential component of the cell wall.

Vancomycin is effective only for gram-positive bacteria because they lack the additional membrane outside the cell wall that gram-negative bacteria have, which vancomycin cannot penetrate. Gram-positive bacteria can develop resistance to vancomycin by replacing the d-Ala-d-Ala terminus with d-alanyl-d-lactate (d-Ala-d-Lac) or d-alanyl-d-serine (d-Ala-d-Ser).

Vancomycin is active against the following gram-positive bacteria:

• Staphylococcus aureus (including methicillin-resistant and methicillin-susceptible [MRSA and MSSA] isolates)
• Clostridium difficile
• Coagulase negative staphylococci (including S. epidermidis and methicillin-resistant isolates)
• Corynebacterium spp.
• Enterococcus spp. (including Enterococcus faecalis)
• Streptococcus gallolyticus (previously known as Streptococcus bovis)
• Viridans group streptococci

Vancomycin is used in the treatment of the following types of bacterial infections in both adult and pediatric patients:

• Staphylococcal enterocolitis
• Clostridium difficile-associated diarrhea
• Infective endocarditis
• Septicemia
• Bone infections
• Skin and skin structure infections
• Lower respiratory tract infections

Off-label uses include:

• Pre-operative antimicrobial prophylaxis
• Surgical prophylaxis
• Bacterial meningitis
• Other serious infections by susceptible bacteria 

• Do not administer vancomycin to patients with known hypersensitivity to vancomycin
• Use vancomycin only for a proven or strongly suspected bacterial infection to prevent the development of drug resistant bacteria
• Oral vancomycin is not effective for systemic infections; use only to treat pseudomembranous colitis due to C. difficile and enterocolitis due to S. aureus
• Systemic infections are treated with intravenous vancomycin
• Prolonged vancomycin use may result in bacterial or fungal superinfection
• Rapid intravenous (IV) infusion can cause “red man syndrome” with symptoms such as red rashes, hives, itching, angioedema and low blood pressure leading to shock and cardiac arrest; reactions are stronger in children and patients who are also concurrently treated with muscle relaxant anesthetics
• Avoid leakage of vancomycin from the vein (extravasation); can damage tissue
• Use as prophylaxis for endocarditis only for high-risk patients as per American Heart Association (AHA) guidelines
• Can be toxic to the ears (ototoxicity) depending on the dosage and duration of treatment; discontinue use if ear symptoms such as tinnitus or vertigo occur
• Systemic vancomycin can cause acute kidney injury and inflammation, especially when used simultaneously with other drugs that are toxic to the kidneys or in patients with impaired kidney function; use with caution
• Vancomycin should not be injected into the eye chambers to prevent infection during or before cataract surgery; retinal vascular inflammation and bleeding, with vision loss have been reported
• Severe, life-threatening skin reactions can occur with vancomycin use; discontinue promptly at the first sign of such reactions
• Single-dose flexible bags are not recommended for use during pregnancy because it contains polyethylene glycol (PEG) 400 and N-acetyl-D-alanine (NADA), which caused fetal malformations in animal reproduction studies; if vancomycin is needed during pregnancy, use other available formulations of vancomycin

Common side effects of vancomycin include:

Oral

• Nausea
• Abdominal pain
• Vomiting
• Diarrhea
• Flatulence
• Low potassium levels in blood (hypokalemia)
• Fever (pyrexia)
• Chills
• Rashes
• Urinary tract infection
• Headache
• Swelling of extremities (peripheral edema)
• Back pain
• Fatigue
• Toxicity to the kidney (nephrotoxicity)
• Low blood count of neutrophil, a type of immune cell (neutropenia)
• Low platelet count (thrombocytopenia)
• High level of eosinophils, a type of immune cell (eosinophilia)
• Severe allergic reaction (anaphylaxis)

Intravenous

• Injection site pain and irritation
• Vein inflammation (phlebitis)
• Drug fever
• Chills
• General discomfort
• Hypersensitivity reactions including:
  • Severe allergic reaction (anaphylaxis)
  • Red man syndrome typically related to rapid infusion, with symptoms including:
    • Red rash and flushing on the face, neck and upper torso
    • Hives (urticaria)
    • Itching (pruritus)
    • Low blood pressure (hypotension)
    • Swelling in the tissue under the skin and mucous membranes (angioedema)
• Severe skin reactions including:
  • Toxic epidermal necrolysis (TEN)
  • Stevens-Johnson syndrome (SJS)
  • Drug reaction with eosinophilia and systemic symptoms (DRESS)
  • Acute generalized exanthematous pustulosis (AGEP)
  • Linear lgA bullous dermatosis (LABD)
• Acute kidney injury
• Inflammation in the kidney (interstitial nephritis)
• Increase in blood urea nitrogen (BUN) levels
• Increase in serum creatinine levels
• Colon inflammation (pseudomembranous colitis) due to Clostridium difficile overgrowth
• Muscle pain
• Dizziness
• Ringing in the ears (tinnitus)
• Hearing loss
• Vertigo
• Wheezing
• Shortness of breath (dyspnea)
• Blood vessel inflammation (vasculitis)
• Hypotension
• Shock
• Chest pain
• Cardiac arrest
• Blood disorders including:
  • Low blood count of neutrophil, a type of immune cell (neutropenia)
  • Low count of granulocytes, immune cells with granules (agranulocytosis)
  • Low count of leukocyte immune cells (leukopenia)
  • Low platelet count (thrombocytopenia)
  • Low count of all types of blood cells (pancytopenia)
  • High level of eosinophils, a type of immune cell (eosinophilia)

This is not a complete list of all side effects or adverse reactions that may occur from the use of this drug.

Call your doctor for medical advice about serious side effects or adverse reactions. You may also report side effects or health problems to the FDA at 1-800-FDA-1088.

Capsule (Vancocin)

• 125mg
• 250mg

Injection, lyophilized powder for reconstitution (generic)

• 500mg
• 750mg
• 1g
• 5g
• 10g

Kit, powder for oral solution (Firvanq)

• 3.75g
• 7.5g
• 10.5g
• 15g

Injection, single-dose flexible bag (generic)

• 500mg/100mL
• 750mg/150mL
• 1g/200mL
• 1.25g/250mL
• 1.5g/300mL
• 1.75g/350mL
• 2g/400mL

Adult:

Staphylococcal Enterocolitis

• 0.5-2 g/day orally divided every 6-8 hours for 7-10 days

Clostridium difficile-associated Diarrhea

• 125 mg orally divided every 6 hours for 10 days

Infective Endocarditis

• For enterococcal endocarditis, use in combination with an aminoglycoside
• Indicated for treatment of early-onset prosthetic valve endocarditis caused by Staphylococcus epidermidis in combination with rifampin and an aminoglycoside
• Usual dosage: 2 g divided either as 500 mg every 6 hours or 1 gram every 12 hours
• Initial daily dose should be no less than 15 mg/kg

Septicemia

• Usual dosage: 2 g divided either as 500 mg every 6 hours or 1 gram every 12 hours
• Initial daily dose should be no less than 15 mg/kg

Skin and Skin Structure Infections

• Usual dosage: 2 g divided either as 500 mg every 6 hours or 1 g every 12 hours
• Initial daily dose should be no less than 15 mg/kg

Bone Infections

• Usual dosage: 2 g divided either as 500 mg every 6 hours or 1 gram every 12 hours
• Initial daily dose should be no less than 15 mg/kg

Lower Respiratory Tract Infections

• Usual dosage: 2 g divided either as 500 mg q6hr or 1 gram q12hr
• Initial daily dose should be no less than 15 mg/kg

Preoperative Antimicrobial Prophylaxis (Off-label)

• Gastrointestinal (GI) and genitourinary (GU) procedures: 1 g intravenously by slow infusion over 1 hour, beginning 1-2 hours before procedure (with or without gentamicin 1.5 mg/kg; not to exceed 120 mg intravenous (IV) or intramuscular (IM) within 30 minutes before procedure)

Surgical Prophylaxis (Off-label)

• Prophylaxis of infection in cardiac, thoracic, and arterial procedures; craniotomy; joint replacement; amputation
• 15 mg/kg IV over 1-2 hours; begin administration within 2 hours before incision; duration of prophylaxis for most procedures should be less than 24 hours

Dosing Modifications

Renal impairment

• Mild-to-severe: Initial dose should be no less than 15 mg/kg
• Functionally anephric patients: Initial dose of 15 mg/kg of body weight to achieve prompt therapeutic serum concentration; start at 1.9 mg/kg/24 hours after the initial dose of 15 mg/kg

Dosing Considerations

• Peak values 18-26 mg/L; trough values 5-10 mg/L; however, Infectious Diseases Society of America and other guidelines urge troughs 15-20 mg/L
• Only treat or prevent infections proven or strongly suspected to be caused by susceptible bacteria to reduce development of drug-resistant bacteria

Limitations of use

• Oral vancomycin: Not effective for other types of infections
• IV vancomycin: Not effective for treatment of staphylococcal enterocolitis and C. difficile-associated diarrhea

Pediatric:

Staphylococcal Enterocolitis

• 0.5-2 g/day orally divided every 6-8 hours for 7-10 days

Clostridium difficile-associated Diarrhea

• 125 mg orally divided every 6 hours for 10 days

Preoperative Antimicrobial Prophylaxis

• GI and GU procedures: 20 mg/kg IV by slow infusion over 1 hour, beginning 1 hour before procedure (with or without gentamicin 1.5 mg/kg; not to exceed 120 mg IV or IM within 30 minutes before procedure)

Infective Endocarditis

• For enterococcal endocarditis, use in combination with an aminoglycoside
• Indicated for treatment of early-onset prosthetic valve endocarditis caused by Staphylococcus epidermidis in combination with rifampin and an aminoglycoside
• Younger than 1 month: See dosing considerations
  • One month and older: 10 mg/kg/dose every 6 hours
• Current American Heart Association (AHA) guidelines recommend using only for high-risk patients

Septicemia

• Younger than 1 month: See dosing considerations
• One month and older: 10 mg/kg/dose every 6 hours  

Skin and Skin Structure Infections

• Younger than 1 month: See dosing considerations
• One month and older: 10 mg/kg/dose every 6 hours  

Bone Infections

• Younger than 1 month: See dosing considerations
• One month and older: 10 mg/kg/dose every 6 hours  

Lower Respiratory Tract Infections

• Younger than 1 month: See dosing considerations
• One month and older: 10 mg/kg/dose every 6 hours  

Bacterial Meningitis

• 15-20 mg/kg IV every 6 hours

Other Infections

• 40 mg/kg/day IV divided every 6 hours

Dosing Considerations

Neonatal dosing

• After 20 mg/kg IV loading dose, give maintenance dose according to gestational age (GA) and serum creatinine (Scr)
• GA less than 28 weeks
  • Scr less than 0.5: 15 mg/kg every 12 hours
  • Scr 0.5-0.7: 20 mg/kg every 24 hours
  • Scr 0.8-1: 15 mg/kg every 24 hours
  • Scr 1.1-1.4: 10 mg/kg every 24 hours
  • Scr more than 1.4: 15 mg/kg every 48 hours
• GA >28 wk
  • Scr <0.7: 15 mg/kg every 12 hours
  • Scr 0.7-0.9: 20 mg/kg every 24 hours
  • Scr 1-1.2: 15 mg/kg every 24 hours
  • Scr 1.3-1.6: 10 mg/kg every 24 hours
  • Scr >1.6: 15 mg/kg every 48 hours

Geriatric:

• Vancomycin is excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function
• Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection and monitoring renal function
• Patients older than 65 years: Monitor during and following treatment to detect potential vancomycin induced nephrotoxicity; may take longer to respond to therapy compared to patients 65 years or younger

• Vancomycin overdose is treated with supportive care.
• Vancomycin is not eliminated with dialysis. Filtering the blood externally (hemofiltration and hemoperfusion) with polysulfone resin has been reported to result in increased clearance of vancomycin.

Inform your doctor of all medications you are currently taking, who can advise you on any possible drug interactions. Never begin taking, suddenly discontinue, or change the dosage of any medication without your doctor’s recommendation.

• Vancomycin has no known severe interactions with other drugs.
• Serious interactions of vancomycin include:
  • bacitracin
  • BCG vaccine live
  • cholera vaccine
  • typhoid vaccine live
• Vancomycin has moderate interactions with at least 32 different drugs.
• Vancomycin has minor interactions with at least 52 different drugs.

The drug interactions listed above are not all of the possible interactions or adverse effects. For more information on drug interactions, visit the RxList Drug Interaction Checker.

It is important to always tell your doctor, pharmacist, or health care provider of all prescription and over-the-counter medications you use, as well as the dosage for each, and keep a list of the information.

Check with your doctor or health care provider if you have any questions about the medication.

• Oral vancomycin use may be acceptable during pregnancy; use intravenous vancomycin during pregnancy if benefits outweigh potential risks.
• Some formulations of vancomycin injection which contain polyethylene glycol (PEG 400) and N-acetyl D-alanine (NADA) are not recommended for use during the first or second trimester of pregnancy; PEG 400 and NADA caused fetal malformations in animal reproduction studies.
• Systemic absorption from oral vancomycin is low and it is not known if it is present in breast milk; use with caution.
• Vancomycin is excreted in breast milk with intravenous administration; because of the potential for adverse events, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

• Antibacterial drugs including vancomycin are used only to treat bacterial infections; they are ineffective for viral infections
• Take vancomycin exactly as prescribed; skipping doses or not completing the full treatment course can reduce its efficacy and cause antibiotic-resistant bacteria to develop
• Keep vancomycin out of reach of children