Skip to Content

Vancomycin

Medically reviewed by Drugs.com. Last updated on Jul 26, 2020.

Pronunciation

(van koe MYE sin)

Index Terms

  • Vancocin
  • Vancomycin HCl
  • Vancomycin Hydrochloride

Dosage Forms

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: 750 mg/150 mL (150 mL); 1000 mg/200 mL (200 mL); 1250 mg/250 mL (250 mL); 1500 mg/300 mL (300 mL); 1750 mg/350 mL (350 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: 500 mg (1 ea); 1 g (1 ea); 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, 300 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)

Brand Names: U.S.

  • Firvanq
  • Vancocin
  • Vancocin HCl
  • Vancosol Pack [DSC]

Pharmacologic Category

  • Glycopeptide

Pharmacology

Inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding tightly to D-alanyl-D-alanine portion of cell wall precursor

Absorption

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

Distribution

Distributes widely in body tissue and fluids, except for CSF.

Vd:

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

Infants: 0.56 L/kg (Rainkie 2015).

Children ≤6 years: 0.61 L/kg (Rainkie 2015).

Children >6 years: 0.47 L/kg (Rainkie 2015).

Adolescents: 0.49 L/kg (Rainkie 2015).

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 mg/L (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 mg/L; serum concentration dependent (ASHP/IDSA/SIDP [Rybak 2009]).

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

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

Metabolism

No apparent metabolism

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).

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).

Time to Peak

Serum: IV: Immediately after completion of infusion

Half-Life Elimination

Biphasic: Terminal:

Preterm neonates (GA: 32 to 34 weeks); PNA ~3 to 5 days: 5.9 to 9.8 hours (Schaad 1980).

Term neonates; PNA ~2 to 3 days: 6.7 hours (Schaad 1980).

Infants: 2.8 hours (Rainkie 2015).

Children <6 years: 2.4 hours (Rainkie 2015).

Children ≥6 years: 2.9 hours (Rainkie 2015).

Adolescents: 3.2 hours (Rainkie 2015).

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

End-stage renal disease (ESRD): 7.5 days.

Protein Binding

~55%

Special Populations: Elderly

Total systemic and renal clearance may be reduced.

Special Populations: Children

Extracorporeal membrane oxygenation (ECMO): Reported pharmacokinetic parameters in pediatric patients receiving ECMO vary widely based on ECMO circuitry/filters, age, weight, kidney function, and underlying diseases. In general, volume of distribution may be increased and clearance may be increased or decreased; reported parameters vary significantly; elimination half-life appears to be dependent upon renal function (Amaker 1996; Buck 1998; Cies 2017; Moffett 2018; Mulla 2005; Zylbersztajn 2018).

Special Populations Note

Anti-infective considerations:

Parameters associated with efficacy: Note: Ratios, including the minimum inhibitory concentration (MIC), depend upon the methodology used; MIC determined by E-test is typically 1.5 to 2 times MIC determined by broth microdilution (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Staphylococcus aureus: AUC/MICBMD ≥400 mg•hour/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Kullar 2011; Lodise 2014; Moise-Broder 2004); specific cutoff for efficacy has varied slightly between studies.

Enterococcus spp.: AUC/MICEtest ≥389 (Jumah 2018).

Parameters associated with toxicity: Nephrotoxicity: AUC ≥600 to 650 mg•hour/L; risk continues to increase along AUC continuum (Aljefri 2019; ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Fiorito 2018; Le 2015; Lodise 2020); Cmin ≥15 mg/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; van Hal 2013).

Postantibiotic effect: A short postantibiotic effect has been observed in E. faecalis (0.5 to 1 hour) and S. aureus (0.6 to 2 hours); slightly longer in S. epidermidis (4.3 to 6.5 hours) (Hanberger 1991; Löwdin 1998).

Use: Labeled Indications

Clostridioides (formerly Clostridium) difficile infection (oral): Treatment of C. difficile infection (CDI) in adults and pediatric patients <18 years of age.

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) in adults and pediatric patients <18 years of age. 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.

Off Label Uses

Catheter-related bloodstream infection, antibiotic lock technique (catheter-salvage therapy)

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 infection

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)

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.

Cystic fibrosis, acute pulmonary exacerbation

Clinical experience suggests the utility of vancomycin in the treatment of acute pulmonary exacerbations of cystic fibrosis [Pettit 2017], [Simon 2019].

Diabetic foot infection, moderate to severe

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, treatment

Data from a limited number of patients studied suggest that intravitreal vancomycin may be beneficial for the treatment of postoperative endophthalmitis [Gan 2001]. Clinical experience based on data from peer-reviewed scientific literature also suggests the utility of vancomycin in the management of bacterial endophthalmitis [Packer 2011].

Intra-abdominal infection

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 abscess

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, bacterial

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)

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 infection

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 disease

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 prophylaxis

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.

Contraindications

Hypersensitivity to vancomycin or any component of the formulation

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 therapeutic monitoring. Trough monitoring has traditionally been used for therapeutic monitoring; however, for serious methicillin-resistant S. aureus (MRSA) infections (eg, bacteremia, infective endocarditis, meningitis, osteomyelitis, pneumonia, sepsis), AUC monitoring is preferred (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). For patients with uncomplicated skin and soft tissue infections who are not obese and have normal renal function, therapeutic monitoring is generally not needed (IDSA [Liu 2011]). Risk of toxicity (eg, acute kidney injury) increases as a function of trough concentration, especially when trough is maintained above 15 to 20 mg/L; recent data suggest risk increases along the vancomycin AUC continuum, especially when daily AUC exceeds 650 to 1,300 mg•h/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

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

IV: Note: Ineffective for treating C. difficile infections.

Intermittent infusion: 15 to 20 mg/kg/dose (rounded to the nearest 250 mg) every 8 to 12 hours initially; for serious MRSA infections (eg, bacteremia, infective endocarditis, meningitis, osteomyelitis, pneumonia, sepsis), adjust based on therapeutic monitoring to achieve a target AUC/minimum inhibitory concentration (MIC) determined by broth microdilution (MICBMD) ratio of 400 to 600 (assuming a vancomycin MICBMD of 1 mg/L; see "Reference Range" for more information). Trough-only monitoring (target trough: 15 to 20 mg/L) is no longer recommended in patients with serious MRSA infections (ASHP/IDSA/PIDS/SIDP [Rybak 2020]), but may be needed in nonserious MRSA or non-MRSA infections. Early and frequent monitoring for dosage adjustments is recommended, especially when empiric doses exceed 4 g/day (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Loading dose: Seriously ill patients with documented/suspected MRSA infection: A loading dose of 20 to 35 mg/kg (based on actual body weight; maximum: 3 g/dose) may be considered to rapidly achieve target concentrations. After administration of the loading dose, the initiation of the maintenance dose should occur at the next dosing interval (eg, for a prescribed interval of every 8 hours, initiate the maintenance dose 8 hours after the start of the loading dose) (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Continuous infusion: Note: May be considered for critically ill patients who are unable to achieve AUC target with intermittent infusion dosing. Loading dose: 15 to 20 mg/kg, followed by a maintenance continuous infusion dose of 30 to 40 mg/kg/day (up to 60 mg/kg/day) to achieve a target steady state concentration of 20 to 25 mg/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Indication-specific dosing:

Bloodstream infection:

Empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; 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 every 8 to 12 hours initially; adjust based on therapeutic monitoring. 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 2020). 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 every 8 to 12 hours initially; adjust based on therapeutic monitoring (IDSA [Tunkel 2017]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

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 2020).

Cystic fibrosis, acute pulmonary exacerbation, moderate to severe (off-label use): Empiric or pathogen-directed therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose every 8 hours initially; adjust based on therapeutic monitoring (Pettit 2017; Simon 2019). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). 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 every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). 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 every 12 hours initially; adjust to obtain a trough concentration of 10 to 20 mg/L (AHA [Baddour 2015]); some experts favor a trough of 15 to 20 mg/L (BSAC [Gould 2012]; ESC [Habib 2015]). Administer in combination with gentamicin for 6 weeks (AHA [Baddour 2015]).

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

Native valve: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (AHA [Baddour 2015]; ASHP/IDSA/PIDS/SIDP [Rybak 2020]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). Duration of therapy is 6 weeks (AHA [Baddour 2015]).

Prosthetic valve: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (AHA [Baddour 2015]; ASHP/IDSA/PIDS/SIDP [Rybak 2020]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). Duration of therapy is 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 every 12 hours initially; adjust based on therapeutic monitoring. Duration of therapy is 4 weeks (native valve) or 6 weeks (prosthetic valve) (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 2020; 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 2020).

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 every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; 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 every 8 to 12 hours initially; adjust based on therapeutic monitoring. A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; 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 every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Tunkel 2004]; IDSA [Tunkel 2017]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; 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 every 8 to 12 hours initially (IDSA [Berbari 2015]; IDSA [Liu 2011]); adjust based on therapeutic monitoring. A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). 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 to obtain a trough concentration between 15 and 20 mg/L (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 every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Liu 2011]; ATS/IDSA [Metlay 2019]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2009]; IDSA [Liu 2011]). Note: Duration of definitive therapy 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 every 8 to 12 hours initially (Berbari 2019; IDSA [Liu 2011]; IDSA [Osmon 2013]); adjust based on therapeutic monitoring. A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). 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 every 12 hours initially; adjust based on therapeutic monitoring. Duration: 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 every 8 to 12 hours; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). A loading dose is recommended; administer within 1 hour of suspected or confirmed sepsis (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; SCCM [Rhodes 2017]). Usual duration of therapy is dependent on underlying source, but is typically 7 to 10 days or longer, depending on clinical response (SCCM [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 every 8 to 12 hours initially; adjust dose on therapeutic monitoring. A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). Total treatment duration is 3 to 4 weeks (in the absence of osteomyelitis), including appropriate oral step-down therapy (Goldenberg 2020; IDSA [Liu 2011]); some experts recommend 4 weeks of parenteral therapy for patients with concomitant bacteremia (Goldenberg 2020).

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 every 12 hours initially (IDSA [Stevens 2014]). For patients with uncomplicated skin and soft tissue infections who are not obese and have normal renal function, therapeutic monitoring is generally not needed; for complicated or severe infections, adjust based on therapeutic monitoring (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 797 2020).

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 797 2020). Some experts prefer vancomycin 2 g initially and then 1 g every 12 hours thereafter until delivery (Baker 2020). 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 797 2020).

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 [Anderson 2020]) 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 every 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; 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 every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Chu 2019). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). 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).

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Note: For IV dosing, initial dosage recommendations for patients with normal kidney function presented; doses should be adjusted based on serum concentration monitoring; 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. Dosing presented in mg/kg/dose and mg/kg/day; routes of administration may vary (eg, IV, oral, intrathecal, intracatheter, intraperitoneal, rectal); use caution.

Optimal dose and frequency not established in patients receiving extracorporeal membrane oxygenation (ECMO); available data are limited (Amaker 1996; Buck 1998; Hoie 1990; Moffett 2018; Mulla 2005; Zylbersztajn 2018). 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: Initial: 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: Based on adult data, an AUC24 target of 400 mg•hour/L is recommended in patients with serious methicillin-resistant S. aureus (MRSA) infections; specific dosing recommendations may be higher when targeting this range (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). See "MRSA infection, serious; treatment".

In general, monitoring of serum concentrations and assurance of adequate hydration status is recommended; utilize local antibiogram and protocols for further guidance.

Antibiotic lock therapy; catheter salvage: Limited data available: Optimal dose not established:

Note: For infections caused by susceptible organisms when the vascular catheter cannot be removed; use in addition to systemic antibiotics. Catheter salvage not effective in all cases; removal of catheter is recommended for infections with S. aureus (Hecht 2020; IDSA [Mermel 2009]; Wolf 2014). Dosing regimens variable; consider age and size of patient and catheter size (including number of lumens) when determining dose due to potential for lock to be delivered intravenously.

Infants, Children, and Adolescents: Intracatheter: Usual concentrations of lock solution: 2 to 5 mg/mL of vancomycin with or without heparin additive; most common concentrations reported: vancomycin 2 mg/mL, 2.5 mg/mL, or 5 mg/mL; refer to institutional protocol if available (Denaburg 2013; IDSA [Mermel 2009]; Tsai 2015). Concentrations described in literature range from 0.025 to 10 mg/mL with or without heparin or citrate (Justo 2014); a vancomycin concentration of 5 mg/mL has been shown to be more efficacious than 1 mg/mL when biofilm present (Lee 2006). Instill into each lumen of the catheter access port using a volume sufficient to fill the catheter, with a dwell time of ideally ≥8 to 12 hours and 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 (Denaburg 2013; IDSA [Mermel 2009]; Justo 2014; Tsai 2015). Note: If heparin is utilized in the lock solution, the dose used should not approach therapeutic unit/kg dose.

C. difficile infection; treatment:

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]).

Endocarditis, treatment: Note: Dosage adjustment to target trough serum concentrations of 10 to 15 mg/L is recommended in pediatric endocarditis by the AHA (AHA [Baltimore 2015]). Dosage adjustment to target AUC24 of 400 mg•hour/L has been recommended in the treatment of proven or suspected MRSA infections based on adult data (ASHP/IDSA/SIDP/PIDS [Rybak 2020]).

Empiric therapy/culture negative: Children and Adolescents: IV: Initial: 60 mg/kg/day divided every 6 hours; initial maximum daily dose: 2,000 mg/day; use in combination with other antibiotics for at least 4 to 6 weeks; longer duration may be required if prosthetic material is present or in cases of recurrent endocarditis (AHA [Baltimore 2015]).

Streptococcus (including enterococcus): Children and Adolescents: IV: Initial: 40 mg/kg/day divided every 8 to 12 hours; initial maximum daily dose: 2,000 mg/day; treat for at least 4 to 6 weeks; a longer duration and additional antibiotics may be required depending on organism and presence of prosthetic material (AHA [Baltimore 2015]).

S. aureus:

Non-methicillin resistant: Children and Adolescents: IV: Initial: 40 mg/kg/day divided every 8 to 12 hours; initial maximum daily dose: 2,000 mg/day; treat for at least 4 to 6 weeks; a longer duration and additional antibiotics may be required depending on organism and presence of prosthetic material (AHA [Baltimore 2015]).

Methicillin-resistant: Children and Adolescents: IV: Initial: 40 mg/kg/day divided every 8 to 12 hours for at least 6 weeks; usual initial maximum daily dose: 2,000 mg/day (AHA [Baltimore 2015]); however, higher initial doses have been recommended for patients with serious MRSA infection with normal renal function, though dosing based on studies and models that were not specific to endocarditis (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). See "MRSA infection, serious; treatment".

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.

Meningitis, including health care-associated meningitis: Infants, Children, and Adolescents: IV: Initial: 15 mg/kg/dose every 6 hours (IDSA [Tunkel 2004]; IDSA [Tunkel 2017]). Higher initial doses have been recommended for patients with serious MRSA infection with normal renal function, though dosing based on studies and models that were not specific to meningitis (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). See "MRSA infection, serious; treatment".

MRSA infection, serious; treatment:

Note: Doses should be adjusted based on patient-specific serum concentrations to a target AUC24 of 400 mg•hour/L, but potentially up to 600 mg•hour/L, based on adult data. In pediatric patients, an AUC24 of ≥400 mg•hour/L has been associated with trough concentrations of 7 to 10 mg/L, though trough concentrations do not clearly predict AUC on an individual level and trough-only monitoring is not recommended (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Frymoyer 2013; Le 2013). Some studies have indicated that doses on the lower end of the range (ie, 60 mg/kg/day divided every 6 hours) will achieve target AUC24 in most children (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Frymoyer 2013). To minimize risk of acute kidney injury, maintain AUC24 <800 mg•hour/L and trough <15 mg/L. For obese patients, start with a one-time loading dose of 20 mg/kg (based on total body weight), then start maintenance dosing (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Infants ≥3 months and Children <12 years: IV: Initial: 60 to 80 mg/kg/day in divided doses every 6 hours; initial maximum daily dose: 3,600 mg/day.

Children ≥12 years and Adolescents: IV: Initial: 60 to 70 mg/kg/day in divided doses every 6 to 8 hours; initial maximum daily dose: 3,600 mg/day.

Peritonitis (peritoneal dialysis) (ISPD [Warady 2012]): Limited data available:

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: Infants >3 months, Children, and Adolescents: IV: Initial: 40 to 60 mg/kg/day in divided doses every 6 to 8 hours; (IDSA/PIDS [Bradley 2011]). Note: Higher doses may be necessary when treating MRSA infections; doses should be adjusted based on patient-specific serum concentrations to a target AUC24 of 400 mg•hour/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). See "MRSA infection, serious; treatment".

Skin and skin structure infections, complicated: Note: Duration of treatment should be individualized and is dependent on severity of infection, adequacy of source control, and clinical improvement. For necrotizing fasciitis, continue treatment until further debridement is not necessary, patient has clinically improved, and patient is afebrile for 48 to 72 hours.

Necrotizing infections, mixed (non-MRSA): Infants, Children, and Adolescents: IV: Initial: 10 to 13 mg/kg/dose every 8 hours (IDSA [Stevens 2014]).

Serious MRSA infection, including necrotizing infection and pyomyositis: Note: Dosage adjustment to target AUC24 of 400 mg•hour/L recommended for serious MRSA infections based on adult data. A loading dose of 20 mg/kg (based on total body weight) is recommended in obese patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Infants ≥3 months and Children <12 years: IV: Initial: 60 mg/kg/day in divided doses every 6 hours; maximum daily dose: 3,600 mg/day (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Stevens 2014]). Based on pharmacokinetic modeling studies, doses up to 80 mg/kg/day may be necessary to achieve target AUC24 (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Children ≥12 years and Adolescents: IV: Initial: 60 mg/kg/day in divided doses every 6 to 8 hours; maximum daily dose: 3,600 mg/day (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Stevens 2014]). Based on pharmacokinetic modeling studies, doses up to 70 mg/kg/day may be necessary to achieve target AUC24 (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

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]).

Ventriculitis (including health care-associated ventriculitis and cerebrospinal fluid [CSF] shunt infections):

Infants, Children, and Adolescents: Limited data available: Intraventricular or intrathecal: 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; adult dosage recommendations are based on ventricle size (IDSA [Tunkel 2017]).

Reconstitution

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.

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):366-72.22479004

Administration

Intravenous: 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).

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).

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; Tunkel 2017]; Ng 2014).

Intravitreal (off-label route): May administer vancomycin intravitreally with a final concentration of 1 mg/0.1 mL NS or sterile water (Durand 2020; Kelsey 1995).

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.

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 may depend on length of segment being treated. If sodium chloride causes hyperchloremia could use solution with lower chloride concentration (eg, LR) (ACG [Surawicz 2013]).

Dietary Considerations

May be taken with food.

Storage

Capsules: Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 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.

Drug Interactions

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

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

BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). 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. 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. 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. Consider therapy modification

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

Neuromuscular-Blocking Agents: Vancomycin may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: May increase the serum concentration of Vancomycin. Monitor therapy

Piperacillin: May enhance the nephrotoxic effect of Vancomycin. 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. 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. Consider therapy modification

Adverse Reactions

IV:

Frequency not defined:

Cardiovascular: Chest pain, flushing, hypotension, shock, vasculitis

Dermatologic: Bullous dermatitis, erythema of skin, exfoliative dermatitis (Forrence 1990), pruritus, Stevens-Johnson syndrome (Lin 2014), toxic epidermal necrolysis (Changela 2013)

Gastrointestinal: Clostridioides difficile colitis (Hecht 1989)

Hematologic & oncologic: Agranulocytosis (di Fonzo 2018), eosinophilia, leukopenia, neutropenia (reversible) (Black 2011), pancytopenia (Carmichael 1986), thrombocytopenia

Hypersensitivity: Anaphylaxis (Anne 1994), hypersensitivity reaction (Kupstaite 2010), red man syndrome (Symons 1985)

Local: Injection site phlebitis, irritation at injection site, pain at injection site

Nervous system: Chills, dizziness, malaise, vertigo

Neuromuscular & skeletal: Myalgia

Otic: Hearing loss (Klibanov 2003), ototoxicity (Forouzesh 2009), tinnitus (Traber 1981)

Renal: Increased blood urea nitrogen (Bergman 1988), increased serum creatinine, interstitial nephritis (Bergman 1988), renal tubular necrosis (Shah-Khan 2011)

Respiratory: Dyspnea, wheezing

Miscellaneous: Fever (Smith 1999)

Postmarketing:

Cardiovascular: Hypersensitivity angiitis (Pingili 2017)

Dermatologic: Acute generalized exanthematous pustulosis (Mawri 2015), dermatologic disorder (linear IgA bullous dermatosis) (Tashima 2014), erythema multiforme (Khicher 2019), maculopapular rash (Marik 1997)

Gastrointestinal: Clostridioides difficile associated diarrhea (Hecht 1989), peritonitis (following intraperitoneal administration during CAPD) (Freiman 1992)

Hematologic & oncologic: Henoch-Schonlein purpura (Min 2017), immune thrombocytopenia (Al Jafar 2015)

Hypersensitivity: Fixed drug eruption (Gilmore 2004)

Immunologic: Drug reaction with eosinophilia and systemic symptoms (Cacoub 2011)

Renal: Acute renal failure (Sawada 2018), nephrotoxicity (Lodise 2009)

Oral:

>10%:

Endocrine & metabolic: Hypokalemia (13%)

Gastrointestinal: Abdominal pain (15%), nausea (17%)

1% to 10%:

Cardiovascular: Peripheral edema (6%)

Gastrointestinal: Diarrhea (9%), flatulence (8%), vomiting (9%)

Genitourinary: Urinary tract infection (8%)

Nervous system: Fatigue (5%), headache (7%)

Neuromuscular & skeletal: Back pain (6%)

Renal: Nephrotoxicity (5%)

Miscellaneous: Fever (9%)

Frequency not defined:

Cardiovascular: Flushing, hypotension

Gastrointestinal: Constipation

Hematologic & oncologic: Anemia

Nervous system: Depression, insomnia

Renal: Increased serum creatinine, renal failure syndrome, renal insufficiency

Postmarketing:

Cardiovascular: Vasculitis

Dermatologic: Exfoliative dermatitis, pruritus, skin rash, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria

Hematologic & oncologic: Eosinophilia, thrombocytopenia

Hypersensitivity: Anaphylaxis, nonimmune anaphylaxis, red man syndrome (Arroyo-Mercado 2019)

Nervous system: Chills, drug fever, pain, vertigo

Neuromuscular & skeletal: Muscle spasm (chest and back)

Otic: Tinnitus

Respiratory: Dyspnea, wheezing

ALERT: U.S. Boxed Warning

Risk of embryo-fetal toxicity due to excipients:

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.

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; risk factors include preexisting renal impairment, concomitant nephrotoxic medications (ie, aminoglycosides, loop diuretics, amphotericin B, IV contrast dye, vasopressors, piperacillin/tazobactam, and flucloxacillin), advanced age, increased weight, dehydration, critically ill patients, patients with rapidly changing renal function, sustained high vancomycin serum trough concentrations above 15 to 20 mg/L or daily AUC >650 to 1,300 mg•hour/L, and prolonged exposure (eg, ≥4 days). Studies have defined vancomycin-associated nephrotoxicity as: an increase of 0.5 mg/dL or ≥50% increase from baseline (whichever is greater) in multiple, sequential (≥2) serum creatinine concentrations in the absence of an alternative explanation or an increase in serum creatinine ≥0.3 mg/dL over a 48-hour period (Mehta 2007; Roy 2013; van Hal 2013). Discontinue treatment if signs of nephrotoxicity occur. Nephrotoxicity has also 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 drugs; dosage modification required and close monitoring is recommended in patients with preexisting renal impairment and those at high risk for renal impairment. Accumulation may occur after multiple oral doses of vancomycin in patients with renal impairment; consider monitoring serum 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.

• 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.

Monitoring Parameters

IV: 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).

AUC monitoring: Frequency of AUC monitoring should be based on clinical judgement; frequent or daily monitoring may be appropriate for hemodynamically unstable patients; hemodynamically stable patients may only require once-weekly monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Trough monitoring:

Hemodynamically stable patients: Draw trough concentrations at least once weekly (ASHP/IDSA/SIDP [Rybak 2009]).

Hemodynamically unstable patients: Draw trough concentrations more frequently or in some instances daily (ASHP/IDSA/SIDP [Rybak 2009]).

Prolonged courses (>3 to 5 days): Draw at least one steady-state trough concentration; repeat as clinically appropriate (ASHP/IDSA/SIDP [Rybak 2009]).

Note: Drawing >1 trough concentration prior to the fourth dose for short course (<3 days) or lower intensity dosing (target trough concentrations <15 mg/L) 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).

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 mild, moderate, or severe Clostridioides (formerly Clostridium) difficile infections in pregnant patients. Standard doses should be used (ACG [Surawicz 2013]).

Vancomycin is recommended as an alternative option to prevent the transmission of group B streptococcal (GBS) disease from mothers to newborns. Untreated asymptomatic GBS disease can result in maternal urinary tract infection, intraamniotic infection, endometritis, preterm labor, and/or stillbirth. Vertical transmission from the mother can cause sepsis, pneumonia, or meningitis in the newborn. Vancomycin IV is recommended for use in women who are at high risk for anaphylaxis to penicillin (or whose risk is unknown), and the GBS isolate is resistant to clindamycin. Dose and rate of infusion should be based on maternal weight and renal function, similar to nonpregnant patients (ACOG 797 2020).

In patients known to be colonized with methicillin-resistant S. aureus (MRSA), a single dose of vancomycin is recommended as part of the antibiotic regimen for prophylactic use prior to cesarean delivery. Monotherapy with vancomycin does not provide sufficient coverage for cesarean delivery surgical prophylaxis (ACOG 199 2018).

Based on limited data, vancomycin is considered likely compatible with pregnancy when used for the treatment of airway diseases, such as cystic fibrosis (ERS/TSANZ [Middleton 2020]).

[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.

Patient Education

What is this drug used for?

Capsules and oral solution:

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

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

Injection:

• It is used to treat or prevent bacterial infections.

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:

All products:

• Upset stomach

• Throwing up

• Stomach pain

• Diarrhea

Capsules and oral solution:

• Passing gas

• Feeling tired or weak

• Back pain

• Headache

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

All products:

• Kidney problems like unable to pass urine, change in how much urine is passed, blood in the urine, or a big weight gain

• Change in hearing

• Hearing loss

Capsules and oral solution:

• Low potassium like muscle pain or weakness, muscle cramps, or a heartbeat that does not feel normal

• Urinary tract infection like blood in the urine, burning or pain when passing urine, feeling the need to pass urine often or right away, fever, lower stomach pain, or pelvic pain

• Swelling of arms or legs

Injection:

• Flushing

• Painful urination

• Chills

• Sore throat

• Change in balance

• Infusion reaction like shortness of breath or wheezing, itching, muscle pain, chest pain, or signs of low blood pressure like dizziness or passing out

• Rash on the face, neck, trunk, or arms during infusion

Clostridioides (formerly Clostridium) difficile-associated diarrhea like stomach pain, cramps, or very loose, watery, or bloody stools

• Severe injection site redness, burning, pain, swelling, blisters, skin sores, or leaking of fluid

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, 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 limited summary of general information about the medicine's uses from the patient education leaflet and is not intended to be comprehensive. This limited summary does NOT include all information available about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not intended to provide medical advice, diagnosis or treatment and does not replace information you receive from the healthcare provider. For a more detailed summary of information about the risks and benefits of using this medicine, please speak with your healthcare provider and review the entire patient education leaflet.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Related questions