Vancomycin IV

C. diff Risk

Low

Oral Bioavailability

None

Approximate Cost

$$

Dosing

Adult

10-20 mg/kg IV q8 - 12 h

Final dose depends on trough goal

Recommend dose per pharmacy

General Information

Acceptable Uses

Acceptable Empiric Use

  • Treatment of suspected community-or nosocomial-acquired bacterial meningitis.

  • Treatment of healthcare-associated (including ventilator-associated) pneumonia.

  • Treatment of peritoneal dialysis-related peritonitis in a severely ill patient.

  • Treatment ofsepsis in a patient at risk for MRSA bacteremia [catheter in place, indwelling hardware, known MRSA colonization, transfer from a nursing home or subacute facility, recent (within 3 months) or current prolonged hospitalization >2 weeks, hemodialysis].

  • Treatment of surgical-site infection following placement of hardware.

  • Treatment of severe diabetic foot infection in a patient at risk for MRSA.

  • Treatment of necrotizing fasciitis.

  • Treatment of suspected endocarditis in a moderately or severely ill patient after appropriate blood cultures are obtained.

  • Treatment of Gram-positive cocci in clusters in ≥ 1 set of blood cultures in a moderately or severely ill patient.

  • Treatment of Gram-positive cocci in clusters or chains in ≥ 2 sets of blood cultures in any patient.
    Note: empiric therapy should be discontinued within 72 hours if criteria for definitive therapy (listed below) are not met:

Acceptable Use for Definitive Intravenous Therapy
Proven infection with beta-lactam resistant organisms:

  • MRSA

  • Methicillin-resistant coagulase-negative staphylococcus

  • Ampicillin-resistant enterococcus (if susceptible)

  • Ceftriaxone-resistant S. pneumoniae (CSF only)

Treatment of infections caused by Gram-positive organisms in patients who have severe allergic reactions to beta-lactam antibiotics (see discussion of penicillin allergy).

Acceptable Use for Definitive Oral Therapy
Clostridium difficile infection (see CDI section)

Acceptable Use for Prophylaxis
Prophylaxis for cardiac, vascular, or orthopedic (jointreplacement, spinal fusion, ORIF only) surgery with a documented reason in the chart or in patients with severe beta-lactam allergy (no more than one pre-op and one post-op dose).

Unacceptable Uses

  • Continued empiric use for presumed infection with negative cultures.

  • Treatment of a single-positive blood culture for coagulase-negative staphylococci.

  • Routine surgical prophylaxis except as above.

  • Empiric treatment for first fever in neutropenic patients without evidence of catheterrelated bloodstream infection (e.g. inflamed IV catheter site), severe mucositis, or history of MRSA.

  • Prophylaxis for infection or colonization of indwelling intravascular or intracranial catheters.

  • Selective decontamination of the digestive tract.

  • Eradication of MRSA colonization.

  • Routine prophylaxis for patients on continuous ambulatory peritoneal dialysis or hemodialysis.

  • When chosen only for convenience of dosing for treatment of infections caused by betalactam susceptible organisms in patients who are HD-dependent.

  • Topical application or irrigation.

Common Usage

Suspected or proven MRSA, coagulase-negative Staphylococcal infections, Enterococcal infections

Drug Monitoring

Laboratory

  •  Collect trough 30 min before 4th dose if abnormal/fluctuating renal function.

  • Target trough 10-15 mcg/mL for most serious infections, 15-20 mcg/mL for meningitis or osteomyelitis

  • If trough low, increase dose (do not exceed 2g/dose) OR decrease dosing interval.

  •  If trough >20, increase dosing interval or decrease dose

  •  Recommend dose per pharmacy

  • Cr baseline and weekly (for potential dose adjustment and nephrotoxicity assessment)

  • CBC weekly

Clinical

  • Phlebitis

  • Hypersensitivity

  • GI effects

Adverse Effects

  • Ototoxicity

  • Red man syndrome

  • Nephrotoxicity (usually in combination with other nephrotoxins)

  • Phlebitis

  • Reversible neutropenia

Major Interactions

Aminoglycosides may potentiate nephrotoxicity

May enhance neuromuscular blockade of NM blocking agents

Careful with concomitant nephrotoxins

Additional Information

Target levels vary widely based on site of infection. Consult Infectious Disease or Pharmacy for assistance

ID Consult is strongly advised for proven or suspected MRSA infections and for all S aureus bloodstream infections

Pharmacology

Antimicrobial class: Glycopeptide

Pregnancy category: C

Average serum half life: 8 hours

Biliary penetration: Moderate

CSF penetration: Moderate

Lung penetration: Therapeutic

Urine penetration: Therapeutic