Dosing & Uses
Dosage Forms & Strengths
capsule (Vancocin)
- 125mg
- 250mg
injection, lyophilized powder for reconstitution (generic)
- 500mg
- 750mg
- 1g
- 5g
- 10g
kit, powder for oral solution (Firvanq)
- 3.75g
- 7.5g
- 10.5g
- 15g
injection, single-dose flexible bag (generic)
- 500mg/100mL
- 750mg/150mL
- 1g/200mL
- 1.25g/250mL
- 1.5g/300mL
- 1.75g/350mL
- 2g/400mL
Staphylococcal Enterocolitis
Vancocin and Firvanq
Indicated for enterocolitis caused by Staphylococcus aureus (including methicillin-resistant strains)
Firvanq: Indicated for treatment of enterocolitis in adults and pediatric patients <18 years
0.5-2 g/day PO divided q6-8hr for 7-10 days
Clostridium difficile-associated Diarrhea
Vancocin and Firvanq
Indicated for treatment of Clostridium difficile (C. difficile)-associated diarrhea
Firvanq: Indicated for treatment of C. difficile-associated diarrhea in adults and pediatric patients <18 years
125 mg PO q6hr for 10 days
Infective Endocarditis
Indicated for treatment of infective endocarditis due to: susceptible isolates of MRSA, viridans group streptococci Streptococcus gallolyticus, Enterococcus species, and Corynebacterium species
For enterococcal endocarditis, use in combination with an aminoglycoside
Methicillin-susceptible staphylococci in penicillin-allergic patients, or those patients who cannot receive or who have failed to respond to other therapies
Indicated for treatment of early-onset prosthetic valve endocarditis caused by Staphylococcus epidermidis in combination with rifampin and an aminoglycoside
Usual dosage: 2 g divided either as 500 mg q6hr or 1 gram q12hr
Initial daily dose should be no less than 15 mg/kg
Septicemia
Indicated for treatment of septicemia due to: susceptible isolates of methicillin-resistant Staphylococcus aureus (MRSA) and coagulase negative staphylococci, methicillin-susceptible staphylococci in penicillin-allergic patients, or patients who cannot receive or who have failed to respond to other drugs, including penicillins or cephalosporins
Usual dosage: 2 g divided either as 500 mg q6hr or 1 gram q12hr
Initial daily dose should be no less than 15 mg/kg
Skin and Skin Structure Infections
Indicated for treatment of skin and skin structure infections due to: susceptible isolates of MRSA and coagulase negative staphylococci, methicillin-susceptible staphylococci in penicillin-allergic patients, or those patients who cannot receive or have failed to respond to other therapies
Usual dosage: 2 g divided either as 500 mg q6hr or 1 g q12hr
Initial daily dose should be no less than 15 mg/kg
Bone Infections
Indicated for treatment of bone infections due to: susceptible isolates of MRSA and coagulase negative staphylococci, methicillin-susceptible staphylococci in penicillin-allergic patients, or those patients who cannot receive or have failed to respond to other therapies
Usual dosage: 2 g divided either as 500 mg q6hr or 1 gram q12hr
Initial daily dose should be no less than 15 mg/kg
Lower Respiratory Tract Infections
Indicated for treatment of lower respiratory tract infections due to: susceptible isolates of MRSA and coagulase negative staphylococci, methicillin-susceptible staphylococci in penicillin-allergic patients, or those patients who cannot receive or have failed to respond to other therapies
Usual dosage: 2 g divided either as 500 mg q6hr or 1 gram q12hr
Initial daily dose should be no less than 15 mg/kg
Preoperative Antimicrobial Prophylaxis (Off-label)
Gastrointestinal [GI] and genitourinary [GU] procedures: 1 g 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
- Mild-to-severe: Initial dose should be no less than 15 mg/kg
- Functionally anephric patients: Initial dose of 15 mg/kg of body weight to achieve prompt therapeutic serum concentration; start at 1.9 mg/kg/24 hr after the initial dose of 15 mg/kg
Dosing Considerations
Peak values 18-26 mg/L; trough values 5-10 mg/L; however, Infectious Diseases Society of America and other guidelines urge troughs 15-20 mg/L
Only treat or prevent infections proven or strongly suspected to be caused by susceptible bacteria to reduce development of drug-resistant bacteria
Limitations of use
- Oral vancomycin: Not effective for other types of infections
- IV vancomycin: Not effective for treatment of staphylococcal enterocolitis and C. difficile-associated diarrhea
Dosage Forms & Strengths
capsule (Vancocin)
- 125mg
- 250mg
injection, lyophilized powder for reconstitution (generic)
- 500mg
- 750mg
- 1g
- 5g
- 10g
kit, powder for oral solution (Firvanq)
- 3.75g
- 7.5g
- 10.5g
- 15g
injection, single-dose flexible bag (generic)
- 500mg/100mL
- 750mg/150mL
- 1g/200mL
- 1.25g/250mL
- 1.5g/300mL
- 1.75g/350mL
- 2g/400mL
Staphylococcal Enterocolitis
Vancocin and Firvanq
Indicated for enterocolitis caused by Staphylococcus aureus (including methicillin-resistant strains)
Firvanq: Indicated for treatment of enterocolitis in adults and pediatric patients <18 years
0.5-2 g/day PO divided q6-8hr for 7-10 days
Clostridium difficile-associated Diarrhea
Vancocin and Firvanq
Firvanq: Indicated for treatment of C. difficile-associated diarrhea in adults and pediatric patients <18 years
125 mg PO q6hr for 10 days
Preoperative Antimicrobial Prophylaxis
GI and GU procedures: 20 mg/kg IV by slow infusion over 1 hour, beginning 1 hour before procedure (with or without gentamicin 1.5 mg/kg; not to exceed 120 mg IV or IM <30 minutes before procedure)
Infective Endocarditis
Indicated for treatment of infective endocarditis due to: susceptible isolates of MRSA, viridans group streptococci Streptococcus gallolyticus, Enterococcus species, and Corynebacterium species
For enterococcal endocarditis, use in combination with an aminoglycoside
Methicillin-susceptible staphylococci in penicillin-allergic patients, or those patients who cannot receive or who have failed to respond to other therapies
Indicated for treatment of early-onset prosthetic valve endocarditis caused by Staphylococcus epidermidis in combination with rifampin and an aminoglycoside
<1 month: See dosing considerations
≥1 month: 10 mg/kg/dose q6hr
Current AHA guidelines recommend using only for high-risk patients
Septicemia
Indicated for treatment of septicemia due to: susceptible isolates of methicillin-resistant Staphylococcus aureus (MRSA) and coagulase negative staphylococci, methicillin-susceptible staphylococci in penicillin-allergic patients, or patients who cannot receive or who have failed to respond to other drugs, including penicillins or cephalosporins
<1 month: See dosing considerations
Skin and Skin Structure Infections
Indicated for treatment of skin and skin structure infections due to: susceptible isolates of MRSA and coagulase negative staphylococci, methicillin-susceptible staphylococci in penicillin-allergic patients, or those patients who cannot receive or have failed to respond to other therapies
<1 month: See dosing considerations
Bone Infections
Indicated for treatment of bone infections due to: susceptible isolates of MRSA and coagulase negative staphylococci, methicillin-susceptible staphylococci in penicillin-allergic patients, or those patients who cannot receive or have failed to respond to other therapies
<1 month: See dosing considerations
Lower Respiratory Tract Infections
Indicated for treatment of lower respiratory tract infections due to: susceptible isolates of MRSA and coagulase negative staphylococci, methicillin-susceptible staphylococci in penicillin-allergic patients, or those patients who cannot receive or have failed to respond to other therapies
<1 month: See dosing considerations
Bacterial Meningitis
Other Infections
Dosing Considerations
Neonatal dosing
- After 20 mg/kg IV loading dose, give maintenance dose according to gestational age (GA) and serum creatinine (Scr)
-
GA ≤28 wk
- Scr <0.5: 15 mg/kg q12hr
- Scr 0.5-0.7: 20 mg/kg q24hr
- Scr 0.8-1: 15 mg/kg q24hr
- Scr 1.1-1.4: 10 mg/kg q24hr
- Scr >1.4: 15 mg/kg q48hr
-
GA >28 wk
- Scr <0.7: 15 mg/kg q12hr
- Scr 0.7-0.9: 20 mg/kg q24hr
- Scr 1-1.2: 15 mg/kg q24hr
- Scr 1.3-1.6: 10 mg/kg q24hr
- Scr >1.6: 15 mg/kg q48hr
Vancomycin is excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function
Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection and monitor renal function
Patients >65 years: Monitor during and following treatment to detect potential vancomycin induced nephrotoxicity; may take longer to respond to therapy compared to patients ≤65 years
Interactions
Interaction Checker
No Results

Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor

Adverse Effects
10% (Oral)
capsule
- Nausea (17%)
- Abdominal pain (15%)
- Hypokalemia (13%)
1-10% (Oral)
capsule
- Vomiting (9%)
- Diarrhea (9%)
- Pyrexia (9%)
- Flatulence (8%)
- Urinary tract infection (8%)
- Headache (7%)
- Peripheral edema (6%)
- Back pain (6%)
- Fatigue (5%)
- Nephrotoxicity (5%)
Frequency Not Defined (IV)
Immune system disorders: Hypersensitivity reactions (eg, anaphylaxis, “red man syndrome”)
Skin and subcutaneous tissue disorders: Erythema and pruritus which are manifestations of rashes including exfoliative dermatitis, linear IgA bullous dermatosis, Stevens-Johnson syndrome, toxic epidermal necrolysis
Renal and urinary disorders: Acute kidney injury and interstitial nephritis
Ear and labyrinth disorders: Tinnitus, hearing loss, vertigo
Blood and lymphatic system disorders: Agranulocytosis, neutropenia, pancytopenia, leukopenia, thrombocytopenia, eosinophilia
Gastrointestinal disorders: Pseudomembranous colitis Cardiac disorders: Cardiac arrest, chest pain
General disorders and administration site conditions: General discomfort, fever, chills, phlebitis, injection site irritation, injection site pain and necrosis following intramuscular injection, chemical peritonitis following intraperitoneal administration (Vancomycin not approved for IM and intraperitoneal administration)
Laboratory abnormalities: Elevated blood urea nitrogen, elevated serum creatinine
Musculoskeletal and connective tissue disorders: Muscle pain
Nervous system disorders: Dizziness
Respiratory, thoracic and mediastinal disorders: Wheezing, dyspnea
Vascular disorders: Hypotension, shock, vasculitis
Postmarketing Reports (All Formulations)
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
Single-dose flexible bags only
- Skin and subcutaneous tissue disorders: Drug rash with eosinophilia and systemic symptoms (DRESS)
Warnings
Black Box Warnings
Embryo-fetal toxicity due to excipients
- Single-dose flexible bags are not recommended for use during pregnancy because it contains the excipients polyethylene glycol (PEG) 400 and N-acetyl-D-alanine (NADA), which caused fetal malformations in animal reproduction studies
- If vancomycin is needed during pregnancy, use other available formulations of vancomycin
Contraindications
Hypersensitivity
Cautions
Rapid IV administration may result in flushing, pruritus, hypotension, erythema, and urticaria
Systemic vancomycin exposure may result in acute kidney injury (AKI) and interstitial nephritis; risk of AKI increases as systemic exposure increases; additional risk factors for AKI include concomitant use of nephrotoxic drugs, patients with pre-existing renal impairment, or with comorbidities that predispose to renal impairment
Endocarditis prophylaxis: Use only for high-risk patients, per AHA guidelines
Ototoxicity may occur; toxicity proportional to amount of drug given and duration of treatment; presence of tinnitus or vertigo may indicate vestibular injury; discontinue 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
Hemorrhagic occlusive retinal vasculitis, including permanent loss of vision, occurred in patients receiving intracameral or intravitreal administration of vancomycin during or after cataract surgery; safety and efficacy of vancomycin administered by intracameral or intravitreal route not established by adequate and well- controlled trials; vancomycin not indicated for prophylaxis of endophthalmitis
Oral vancomycin only indicated for treatment of pseudomembranous colitis due to C. difficile and enterocolitis due to S. aureus; not effective for systemic infections
Clinically significant serum concentrations reported in some patients who have taken multiple oral doses of vancomycin for active C. difficile-associated diarrhea
Prescribe vancomycin only for a proven or strongly suspected bacterial infection to prevent the development of drug resistant bacteria
Hypotension, including shock and cardiac arrest, wheezing, dyspnea, urticaria, muscular and chest pain may occur with rapid IV administration; reactions may be more severe in younger patients, particularly children, and in patients receiving concomitant muscle relaxant anesthetics
Inflammation at the site of injection reported; vancomycin is irritating to tissue and must be given by a secure IV route to reduce the risk of local irritation and phlebitis
Drug interactions overview
- Concomitant administration of vancomycin and anesthetic agents has been associated with erythema and histamine-like flushing and anaphylactoid reactions
- Monitor renal function in patients receiving vancomycin and concurrent and/or sequential systemic or topical use of other potentially neurotoxic and/or nephrotoxic drugs, (eg, amphotericin B, aminoglycosides, bacitracin, polymyxin B, colistin, viomycin, or cisplatin)
Pregnancy & Lactation
Pregnancy
Animal reproduction studies have not been conducted with vancomycin
Unknown whether vancomycin can affect reproduction capacity
In a controlled clinical study, potential ototoxic and nephrotoxic effects of vancomycin on infants were evaluated when administered to pregnant women for serious staphylococcal infections complicating IV drug abuse
Single-dose flexible bags only
- This formulation is not recommended for use during pregnancy because it contains the excipients, PEG 400 and NADA, which caused fetal malformations in animal reproduction studies (see Contraindications)
- Perform a pregnancy test in females of reproductive potential prior to prescribing this formulation
Capsule
- Systemic absorption of vancomycin is low following oral administration of capsule; however, absorption may vary depending on various factors; there are no available data on vancomycin use in pregnant women to assess risk of major birth defects or miscarriage; available published data on intravenous vancomycin use in pregnancy during second and third trimesters have not shown an association with adverse maternal or fetal outcomes
Lactation
Intravenous
- Vancomycin is excreted in human milk
- Exercise caution when vancomycin is administered to a nursing woman
- Because of the potential for adverse events, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother
Vancocin
- There are no data on presence of vancomycin in human milk, effects on breastfed infant, or on milk production following oral administration; systemic absorption of vancomycin is low following oral administration of VANCOCIN; therefore, it is unlikely to result in clinically relevant exposure in breastfeeding infants; developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for therapy and any potential adverse effects on breastfed infant from drug or from underlying maternal condition
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.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
Oral
- Poorly absorbed
- After 250-mg capsules PO q8hr for 7 doses, fecal concentrations of vancomycin in volunteers exceeded 100 mcg/g in majority of samples
IV
- Peak serum time: 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%
Vd: 0.3-0.43 L/kg (IV)
Metabolism
There is no apparent metabolism of the vancomycin
Elimination
Half-life (IV): 4-6 hr (normal renal function); 7.5 days (anephric patients)
Mean clearance (flexible bag): 0.058 L/kg/hr (plasma); 0.048 L/kg/hr (renal)
Excretion: Urine (IV; 80-90% as unchanged drug); primarily feces (PO)
Administration
IV Compatibilities
Solution: D5W/0.9% NaCl, D5W, D10W, LR, sodium bicarbonate 3.75%, 0.9% NaCl, D5W and LR, Normosol and D5W, 0.9% NaCl, Isolyte
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
Vancomycin solution has a low pH and may cause chemical or physical instability when it is mixed with other compounds
Mixtures of solutions of vancomycin and beta-lactam antibacterial drugs have been shown to be physically incompatible
Likelihood of precipitation increases with higher concentrations of vancomycin; adequately flush IV lines between administering these antibacterial drugs
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
Single-dose flexible bags
- Do NOT use in series connections
- Such use could result in an embolism due to residual air being drawn from the primary container before administration of the fluid from the secondary container is complete
Oral Preparation (Firvanq)
Tap bottom edges of bottle to loosen powder
Shake grape-flavored diluent for a few seconds
Open diluent and transfer about half the required volume of diluent into the vancomycin powder bottle
Shake powder bottle vertically for ~45 seconds
Add remaining grape-flavored diluent into powder bottle; shake bottle for ~30 seconds
Instruct patient to shake reconstituted solution well before each use and to use an oral dosing device that measures the appropriate volume of the oral solution in milliliters
Vancomycin concentration and volume after reconstitution
-
Reconstituted vancomycin concentration: 25 mg/mL
- 3.75 g: Dilute with 147 mL of grape-flavored diluent; final reconstituted volume: 150 mL
- 7.5 g: Dilute with 295 mL of grape-flavored diluent; final reconstituted volume: 300 mL
-
Reconstituted vancomycin concentration: 50 mg/mL
- 7.5 g: Dilute with 145 mL of grape-flavored diluent; final reconstituted volume: 150 mL
- 10.5 g: Dilute with 203 mL of grape-flavored diluent; final reconstituted volume: 210 mL
- 15 g: Dilute with 289 mL of grape-flavored diluent; final reconstituted volume: 300 mL
Oral Administration
Take with food
IV Administration
Intermittent (preferred): Administer over 60 minutes; not to exceed 10 mg/min
Continuous: Administer over 24 hours
Storage
Capsules: Store at 15-30°C (59-86°F)
Vials
- Store at room temperature, 15-30°C (59-86°F)
- Reconstituted solutions stable at 2-8°C for at least 4 days
Single-dose bags
- Store below 25°C
Powder for oral solution
- Unopened kits: Refrigerate, 2-8°C (36-46°F); do not freeze; keep container tightly closed
- Protect from light
- Reconstituted solutions: Refrigerate at 2-8°C (36-46°F); discard reconstituted solution after 14 days
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Formulary
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