vancomycin hydrochloride
Vancocin, Vancoled

Available forms
Available by prescription only
Powder for injection: 500-mg, 1-g, 5-g vials; 10-g pharmacy bulk package
Powder for oral solution: 1-g, 10-g bottles
Pulvules: 125 mg, 250 mg

Indications and dosages
 Severe staphylococcal infections when other antibiotics are ineffective or contraindicated. Adults: 500 mg I.V. q 6 hours. Or, 1 g q 12 hours.
Children: 40 mg/kg I.V. daily divided q 6 hours.
Neonates: Initially, 15 mg/kg. Then, 10 mg/kg I.V. q 12 hours for first week after birth. Then, q 8 hours up to age 1 month.
 Antibiotic-related pseudomembranous and staphylococcal enterocolitis. Adults: 125 to 500 mg P.O. q 6 hours for 7 to 10 days.
Children: 40 mg/kg P.O. daily divided q 6 to 8 hours for 7 to 10 days. Don’t exceed 2 g daily in children.
 Endocarditis prophylaxis for dental, GI, biliary, and GU instrumentation procedures; surgical prophylaxis in patients allergic to penicillin. Adults: 1 g I.V., given slowly over 1 to 2 hours with the infusion complete within 30 minutes of the start of the procedure.
Children: 20 mg/kg I.V. given slowly over 1 to 2 hours with the infusion complete within 30 minutes of the start of the procedure.
≡ Dosage adjustment. For patients with renal failure, adjust dosage based on degree of renal impairment, severity of infection, and susceptibility of causative organism. Base dosage on serum levels of drug.
 Recommended initial dose is 15 mg/kg. Subsequent doses should be adjusted, p.r.n. Some clinicians use the following schedule.

Creatinine clearance (ml/min) Adult dosage < 1.5 1 g q 12 hr 1.5-5 1 g q 3-6 days > 5 1 g q 10-14 days

Pharmacodynamics
Antibacterial action: Bactericidal. Hinders cell wall synthesis and blocks glycopeptide polymerization. Spectrum of activity includes many gram-positive organisms, including those resistant to other antibiotics. Useful for Staphylococcus epidermidis and methicillin-resistant S. aureus. Also useful for penicillin-resistant S. pneumococcus.

Pharmacokinetics
Absorption: Minimal systemic absorption with oral use. However, drug may accumulate in patients with colitis or renal failure.
Distribution: Distributed widely in body fluids, including pericardial, pleural, ascitic, synovial, and placental fluid. Achieves therapeutic levels in CSF in patients with inflamed meninges. Therapeutic levels are 18 to 26 mcg/ml for 2-hour, postinfusion peaks and 5 to 10 mcg/ml for preinfusion troughs; values may vary depending on laboratory and sampling time.
Metabolism: No information available.
Excretion: When administered parenterally, excreted renally, mainly by filtration. When administered orally, excreted in feces. In patients with normal renal function, plasma half-life is 4 to 6 hours; in those with creatinine clearance of 10 to 60 ml/ minute, plasma half-life is about 32 hours; if creatinine clearance is below 10 ml/minute, plasma half-life is 146 hours.

Contraindications and precautions
Contraindicated in patients hypersensitive to drug. Use cautiously in patients older than age 60; patients with impaired renal or hepatic function, hearing loss, or allergies to other antibiotics; and patients receiving other neurotoxic, nephrotoxic, or ototoxic drugs.

Interactions
Drug-drug. Aminoglycosides, amphotericin B, capreomycin, cisplatin, colistin, methoxyflurane, polymyxin B: Causes additive effect of these drugs. Monitor patient closely; adjust dosages as needed.
Nondepolarizing muscle relaxants: Enhances neuromuscular blockade. Use together cautiously.

Adverse reactions
CNS: fever.
CV: hypotension.
EENT: tinnitus, ototoxicity.
GI: nausea.
GU: nephrotoxicity.
Hematologic: neutropenia, eosinophilia.
Respiratory: wheezing, dyspnea.
Skin: "red-neck" syndrome with rapid I.V. infusion (maculopapular rash on face, neck, trunk, and limbs), pain or thrombophlebitis at injection site.
Other: chills, anaphylaxis, superinfection.

Effects on lab test results
• May increase BUN and creatinine levels.
• May increase eosinophil count. May decrease WBC and neutrophil counts.

Overdose and treatment
Limited information is available on acute toxicity.
 Treatment includes providing supportive care and maintaining glomerular filtration rate. Hemodialysis and hemoperfusion have been used.

Special considerations
• Administer intermittent I.V. infusion over at least 60 minutes.
• Oral form isn’t for systemic infections and can’t be interchanged with I.V. form.
• If patient has auditory dysfunction or needs prolonged therapy, auditory function tests may be indicated before and during therapy.
• Obtain culture and sensitivity tests before starting therapy (unless drug is being used for prophylaxis).
• I.M. administration is contraindicated because drug is highly irritating.
• Hemodialysis and peritoneal dialysis remove only minimal drug amounts. Patients receiving these treatments need usual dose only once every 5 to 7 days; however, some dialysis centers are using high flux hemodialysis, which can remove up to 50% of vancomycin, creating a need for supplemental doses. Base dose on serum level of drug.
• Monitor blood counts and BUN, serum creatinine, and drug levels.
• If patient develops maculopapular rash on face, neck, trunk, and arms, slow infusion rate.
Breast-feeding patients
• Drug appears in breast milk. Use cautiously in breast-feeding women.
Geriatric patients
• Elderly patients may be more susceptible to ototoxic effects. Monitor serum drug levels closely and adjust dosage as needed.

Patient education
• Advise patient receiving drug orally to continue taking as directed for full course of therapy, even when feeling better.
• Advise patient not to take antidiarrheals with drug unless prescribed.
• Instruct patient to promptly report onset of ringing in ears.

Reactions may be common, uncommon, life-threatening, or COMMON AND LIFE THREATENING.
◆ Canada only
◇ Unlabeled clinical use