Vancomycin IV

C difficile risk
None
Oral Bioavailability
N/A
Cost
$$

Dosing

Consult pharmacy for dosing recommendations15-25mg/kg load then 5-10mg/kg IV after each HD

Monitoring required

Consult pharmacy for dosing recommendations15mg/kg load then 10mg/kg IV q24h

Monitoring required

25-30mg/kg IV loading dose rounded to nearest 250mg (max of 2g per dose).

15mg/kg IV q8-12h maintenance depending on trough goal.

PreparationDosingVancomycin 2500mg in 500mL NS (5mg/mL)30-50 mg/kg/24hr (1.25-2 mg/kg/hr)

Expiration 48 hoursRoom temperature

General Information

Antimicrobial Stewardship approved criteria must be indicated at ORDER ENTRY.

Approved Indications:

  1. PRE-OP Dose
  2. Bacteremia [Severe]
  3. Endocarditis [Severe]
  4. Meningitis, Community-onset [Severe]
  5. Meningitis, Hospital-onset [Severe]
  6. Neutropenic fever [Severe]
  7. Osteomyelitis [Severe]
  8. Pneumonia [Severe]
  9. Sepsis (e.g. qSOFA >2) [Severe]
  10. SSTI –Necrotizing fasciitis [Severe]
  11. SSTI –Comp cellulitis/abscess [Moderate]
  12. SSTI –Uncomp cellulitis/abscess [Mild]
  13. Urinary tract infection [Mild]
  14. Clostridium difficile

  • Treatment in response to SINGLE blood culture positive for coagulase negative staphylococcus, if other blood cultures drawn in same time frame are negative

  • Treatment of infections due to β-lactam sensitive bacteria in patients with renal failure chosen for dosing convenience

  • Eradication of MRSA colonization

  • Primary treatment of antibiotic-associated colitis

  • Selective decontamination of the digestive tract

  • Routine surgical prophylaxis other than in a patient with life-threatening allergy to β-lactam antibiotics

Collect trough 0-1h before 3rd dose if abnormal/fluctuating renal function.

Target trough 15-20mcg/mL for most serious infections, 20-25mcg/mL for meningitis

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

If trough >20, increase dosing interval or decrease dose

  • Nephrotoxicity

  • Cytopenias

  • Rash including Stevens-Johnson Syndrome

  • Red man syndrome (histamine release- slow down infusion)

Aminoglycosides may potentiate nephrotoxicity.

May enhance neuromuscular blockade of NM blocking agents.

Careful with concomitant nephrotoxins.

-Treatment of serious infections due to β-lactam resistant Gram positive microorganisms documented by cultures
- For methicillin sensitive coagulase positive Staphylococci, nafcillin is the drug of choice

  • Treatment of infections due to Gram positive microorganisms in patients with history of serious type I allergy to β-lactam antimicrobials when other agents are not adequate

  • Treatment of antibiotic-associated colitis when it fails to respond to metronidazole, is severe and potentially life-threatening, or occurs in setting in which metronidazole cannot be used

  • Prophylaxis for endocarditis as recommended by the American Heart Association, specifically genitourinary and gastrointestinal procedures in moderate to high risk patients allergic to ampicillin/amoxicillin

  • Prophylaxis for major surgical procedures involving implantation of prosthetic materials or devices

    • A single dose administered immediately before surgery is sufficient unless procedure lasts longer than six hours, in which case the dose should be repeated
    • Prophylaxis should be discontinued after two doses
  • Empiric therapy of unexplained fever in neutropenic patients who have severe mucositis, previous quinolone prophylaxis, known colonization with MRSA or PRSP, clinically obvious catheter related infection or hypotension

  • Empiric therapy for sepsis in patients with indwelling intravascular catheters or for life-threatening infections likely to involve MRSA, MRSE or PRSP

    • Therapy should be limited to 72 hours unless cultures reveal organism for which vancomycin is the drug of choice

Antimicrobial class: Glycopeptide

Pregnancy category: C

Average serum half life: 8 hours

Biliary penetration: Moderate

CSF penetration: Moderate

Lung penetration: Therapeutic

Urine penetration: Therapeutic