vancomycin (Rx)

Brand and Other Names:Vancocin
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

capsule

  • 125mg
  • 250mg

injectable solution

  • 5mg/mL

powder for injection

  • 500mg
  • 750mg
  • 1g
  • 5g
  • 10g
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Pseudomembranous Colitis/Staphylococcal Enterocolitis

C. difficile: 125 mg PO q6hr for 10 days

S. enterocolitis: 0.5-2 g/day PO divided q6-8hr for 7-10 days

Because of cost of capsules, IV solution is sometimes compounded for PO use

Endocarditis

Treatment: 500 mg IV q6hr or 1 g IV q12hr 

Used for staphylococcal, streptococcal, and diphtheroid endocarditis; current American Heart Association (AHA) guidelines recommend using only for high-risk patients

Preoperative Antimicrobial Prophylaxis (Off-label)

Gastrointestinal [GI] and genitourinary [GU] procedures: 1 g IV 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 IV or IM <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 hr; begin administration within 2 hr before incision; duration of prophylaxis for most procedures should be <24 hr

Dosing Modifications

Renal impairment: 15 mg/kg initially; further doses are based on renal function, serum drug level, and institutional protocol; dosing intervals range from q24hr to q96hr, depending on severity of impairment

Dosing Considerations

General dosing recommendation: 2 g/day IV divided q6-12hr; may be increased on basis of body weight or to achieve higher trough values; increased toxicity at dosage >4 g/day

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

Dosage Forms & Strengths

capsule

  • 125mg
  • 250mg

injectable solution

  • 5mg/mL

powder for injection

  • 750mg
  • 500mg
  • 1g
  • 5g
  • 10g
more...

Endocarditis

<1 month: 15 mg/kg followed by 10 mg/kg IV q12hr for neonates in first week of life and q8hr thereafter up to 1 month of age; longer dosing intervals recommended in premature infants  

>1 month: 10 mg/kg/day IV divided q6hr; individual dose not to exceed 1 g

Current AHA guidelines recommend using only for high-risk patients

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 <30 minutes before procedure)

Bacterial Meningitis

15-20 mg/kg IV q6hr  

Pseudomembranous Colitis

40 mg/kg/day PO divided q6-8hr for 7-10 days; not to exceed 2 g/day  

Other Infections

40 mg/kg/day IV divided q6hr  

Dosing Considerations

Neonatal dosing

  • <7 days and <1.2 kg: 15 mg/kg IV once daily; monitor serum levels and adjust dose  
  • <7 days and 1.2-2 kg: 10-15 mg/kg IV q12-18hr; monitor serum levels and adjust dose
  • <7 days and >2.1 kg:: 10-15 mg/kg IV q8-12hr; monitor serum levels and adjust dose
  • >7 days and <1.2 kg: 15 mg/kg IV q24hr; monitor serum levels and adjust dose
  • >7 days and 1.2-2 kg: 10-15 mg/kg IV q8-12hr; monitor serum levels and adjust dose
  • >7 days and >2.1 kg: 15-20 mg/kg IV q8hr; monitor serum levels and adjust dose
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Interactions

Interaction Checker

and vancomycin

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    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            >10%

            Bitter taste (PO)

            Erythematous rash on face and upper body (IV; red neck or red man syndrome; related to infusion rate)

            Hypotension accompanied by flushing (IV)

            Nausea and vomiting (PO)

            1-10%

            Chills (IV)

            Drug fever (IV)

            Eosinophilia (IV)

            Rash (IV)

            Fatique (PO)

            Peripheral edema (PO)

            Urinary tract infection (PO)

            Back pain (PO)

            Headache (PO)

            Reversible neutropenia (IV)

            Phlebitis (IV)

            <1%

            Nephrotoxicity

            Ototoxicity (especially with large doses)

            Stevens-Johnson syndrome

            Thrombocytopenia

            Vasculitis

            Postmarketing Reports

            Ototoxicity: Hearing loss associated IV administration (most cases had coexisting renal impairment or pre-existing hearing loss, or were coadministered an ototoxic drug), vertigo, dizziness, and tinnitus

            Hematopoietic: Reversible neutropenia, thrombocytopenia

            Miscellaneous: Anaphylaxis, drug fever, chills, nausea, eosinophilia, rashes, Stevens-Johnson syndrome, toxic epidermal necrolysis, and vasculitis

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            Warnings

            Contraindications

            Hypersensitivity

            Cautions

            Rapid IV administration may result in flushing, pruritus, hypotension, erythema, and urticaria

            Endocarditis prophylaxis: Use only for high-risk patients, per AHA guidelines

            Unclear whether drug is nephrotoxic or neurotoxic in regular doses, but increased nephrotoxicity and ototoxicity are associated with pre-existing renal impairment, advanced age, dehydration; also appears to potentiate nephro-/neurotoxic effects of other drugs

            Ototoxicity may occur; toxicity proportional to amount of drug given and duration of treatment; presence of tinnitus or vertigo may indicate vestibular injury; discontiue if signs of ototoxicity occur

            Risk of neutropenia increases with doses >25 g (reversible following discontinuation of therapy)

            Avoid extravasation; necrosis may occur

            Prolonged use may result in fungal or bacterial superinfection

            Use caution in patients with renal impairment; monitor trough concentrations if multiple oral doses administered

            Oral vancomycin only indicated for treatment of pseudomembranous colitis due to C. difficile and enterocolitis due to S. aureus; not effective for systemic infections

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            Pregnancy & Lactation

            Pregnancy category: C (injection); B (oral)

            Lactation: Drug enters breast milk; not recommended

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Inhibits cell-wall biosynthesis; blocks glycopeptide polymerization by binding tightly to D-alanyl-D-alanine portion of cell wall precursor

            Absorption

            PO, poor; IM, erratic; intraperitoneal, ~38%

            Peak serum time (IV): Immediately after completion of infusion

            Distribution

            Distributed widely in body tissues and fluid, except for cerebrospinal fluid (CSF)

            Relative diffusion from blood into CSF: Good only with inflammation (exceeds usual minimal inhibitory concentrations); CSF level nil with normal meninges, 20-30% of blood level with inflamed meninges

            Protein bound: ~50%

            Elimination

            Half-life; 5-11 hr (adults); 6-10 hr (newborns); 2-2.3 hr (children); 4 hr (infants and children 3 months to 4 years); 200-250 hr (renal impairment or end-stage renal disease)

            Excretion: Urine (IV; 80-90% as unchanged drug); primarily feces (PO)

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            Administration

            IV Compatibilities

            Solution: D5/NS, D5W, D10W, LR, sodium bicarbonate 3.75%, NS, sodium lactate 1/6M

            Additive: Amikacin, atracurium, calcium gluconate, cefepime, cimetidine, corticotropin, dimenhydrinate, erythromycin, famotidine, hydrocortisone, meropenem, ofloxacin, potassium chloride, ranitidine, verapamil, vitamins B and C

            Syringe: Caffeine

            Y-site (partial list): Acyclovir, alatrofloxacin, aldesleukin, allopurinol, amifostine, amiodarone, ampicillin, ampicillin-sulbactam, cefpirome, ceftizoxime, clarithromycin, diltiazem, esmolol, fluconazole, insulin, labetalol, lorazepam, linezolid, magnesium sulfate, midazolam, morphine, nicardipine, ondansetron, paclitaxel, pancuronium, perphenazine, remifentanil, sargramostim, sodium bicarbonate, tacrolimus, teniposide

            IV Incompatibilities

            Additive: Aminophylline(?), amobarbital, aztreonam (may be compatible at low concentrations of vancomycin and aztreonam), chlorothiazide, chloramphenicol, dexamethasone, dexamethasone sodium phosphate, heparin(?), pentobarbital, phenobarbital, sodium bicarbonate(?)

            Syringe: Heparin

            Y-site: Heparin, albumin, amphotericin B cholesteryl sulfate, aztreonam(?), bivalirudin, cefazolin(?), cefotaxime(?), cefotetan(?), cefoxitin(?), ceftazidime(?), ceftriaxone(?), cefuroxime(?), foscarnet, gatifloxacin, idarubicin, methotrexate(?), nafcillin, omeprazole, piperacillin(?), piperacillin-tazobactam (?), propofol(?), sargramostim, ticarcillin (may be compatible at low concentrations of vancomycin), ticarcillin-clavulanate (may be compatible at low concentrations of vancomycin), warfarin (may be compatible at low concentrations of warfarin)

            IV Preparation

            Add 10 mL of SWI to 500-mg vial and 20 mL of SWI to 1-g vial to yield 50 mg/mL solution; further dilution is required, depending on method of administration

            Intermittent infusion: Dilute 500 mg with ≥100 mL of diluent and 1 g with ≥200 mL of diluent (NS or D5W)

            Continuous infusion: Dilute in sufficient amount to permit infusion over 24 hours

            IV Administration

            Intermittent (preferred): Administer over 60 minutes; not to exceed 10 mg/min

            Continuous: Administer over 24 hours

            Stability

            Reconstituted solutions stable at 2-8°C for at least 4 days

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            Formulary

            FormularyPatient Discounts

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
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            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
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