Dosing & Uses
Dosage Forms & Strengths
powder for injection
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
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
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
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
powder for injection
>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)
- <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
Serious - Use Alternative
Significant - Monitor Closely
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)
Drug fever (IV)
Peripheral edema (PO)
Urinary tract infection (PO)
Back pain (PO)
Reversible neutropenia (IV)
Ototoxicity (especially with large doses)
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
Rapid IV administration may result in flushing, pruritus, hypotension, erythema, and urticaria
Systemic vancomycin exposure may result in acute kidney injury (AKI); the risk of AKI increases as systemic exposure/serum levels increase; additional risk factors for AKI in patients vancomycin include receipt of concomitant drugs known to be nephrotoxic, in patients with pre-existing renal impairment or with co-morbidities that predispose to renal impairment; interstitial nephritis also reported in patients receiving vancomycin
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
Pregnancy & Lactation
Pregnancy category: C (injection); B (oral)
Lactation: Drug enters breast milk; not recommended
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.
Mechanism of Action
Inhibits cell-wall biosynthesis; blocks glycopeptide polymerization by binding tightly to D-alanyl-D-alanine portion of cell wall precursor
PO, poor; IM, erratic; intraperitoneal, ~38%
Peak serum time (IV): Immediately after completion of infusion
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%
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)
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
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
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(?)
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)
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
Intermittent (preferred): Administer over 60 minutes; not to exceed 10 mg/min
Continuous: Administer over 24 hours
Reconstituted solutions stable at 2-8°C for at least 4 days
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|1||This drug is available at the lowest co-pay. Most commonly, these are generic drugs.|
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|4||This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.|
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