vancomycin (Vancocin)
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Introduction
Tradename: Vancocin.
Indications
- treatment of serious gram positive bacterial infections for which penicillins & cephalosporins are NOT effective*
- treatment of gram positive bacterial infections in patients with serious allergies to penicillins & cephalosporins
- gastrointestinal infection
- C difficile colitis treatment that has failed proper metronidazole therapy
- empiric treatment of febrile neutropenia[16]
- empiric treatment for fever of unknown origin[16]
- endocarditis
- prophylaxis for perioperative infection
- procedures involving prosthetic devices/materials at institutions with a high rate of MRSA
- myocarditis[16]
- infectious arthritis, osteomyelitis[16]
- anthrax, cutaneous anthrax[16]
- brain abscess[16]
* vancomycin inferior to penicillins & cephalosporins when antibiotic sensitivity not at issue[11]
Dosage
- adults:
- children & infants (> 1 month)
- 40 mg/kg/day divided every 6 hours
- 60 mg/kg/day divided every 6 hours (CNS Staphylococcus)
- intrathecal
- Clostridium difficile:
- post-operative infections
- single dose prior to surgery
- may be repeated if surgery > 6 hours
- 2 dose max
Tabs: 125 & 250 mg.
Powder for oral solution: 10 g.
Powder for injection: 500 mg, 1 g.
Injectable vancomycin can be given orally[10] Dose adjustment in renal failure:
| creatinine clearance | dose |
|---|---|
| > 60 mL/min | 1 g every 12 hours |
| 40-59 mL/min | 1.0-1.5 g every 24 hour |
| 20-39 mL/min | 1.0 g every 24 hours |
| 10-19 mL/min | 1 g every 36-48 hours |
| < 9 mL/min | 0.5-1.0 g with serial trough levels |
| hemodialysis | dose after dialysis, trough 15-20 ug/mL |
Pharmacokinetics
- oral form is not absorbed
- widely distributed
- CSF penetration is poor
- 80% is eliminated unchanged in the urine
- 1/2life is 4-6 hours (200-250 hours ESRD)
- dose adjustment with renal insufficiency
- therapeutic range:
elimination via kidney
1/2life = 4.7-7.8 hours
protein binding = 55 %
elimination by hemodialysis = -
elimination by peritoneal dialysis = -
Monitor
Therapeutic drug monitoring: indicated
Antimicrobial activity
- Streptococcus
- Enterococcus faecalis
- Enterococcus faecium (+/-)
- Staphylococcus aureus (MSSA)
- Staphylococcus aureus (MRSA)
- Staphylococcus epidermidis
- Neisseria gonorrhoeae (+/-)
Adverse effects
- common (> 10%)
- bitter taste, nausea/vomiting (oral)
- "red man" syndrome (parenteral)
- hypotension
- flushing
- erythematous rash on face & upper body
- diminished by
- increasing infusion time (up to 90 min)
- diphenhydramine (Benadryl)
- less common (1-10%)
- uncommon (< 1%)
- ototoxicity, interstitial nephritis*, vasculitis, immune thrombocytopenia[12]
- unlikely to develop within 5 days of hospital discharge[23]
- drug-induced thrombocytopenia[20]
- ototoxicity, interstitial nephritis*, vasculitis, immune thrombocytopenia[12]
- other
* more likely to cause acute tubular necrosis than acute interstitial nephritis[22]
Drug interactions
- levels may be increased when given with aminoglycosides
- increased nephrotoxicity when used in combination with piperacillin tazobactam (Zosyn)[19]
- drug interaction(s) anticonvulsants with anti-bacterial agents
- drug interaction(s) of antibiotics with warfarin
Laboratory
- specimen: serum, plasma (EDTA, heparin)
- methods: RIA, HPLC, MB, FPIA, FIA
- see vancomycin in serum or plasma
- vancomycin resistance gene
Mechanism of action
- concentration independent
- bactericidal
- binds to bacterial cell walls causing blockage of glycopeptide polymerization at a different site than that of penicillins
More general terms
Additional terms
- antibiotic prophylaxis for bacterial endocarditis
- vancomycin in serum/plasma
- vancomycin resistant enterococcus (VRS)
References
- ↑ The Pharmacological Basis of Therapeutics, 9th ed. Gilman et al, eds. Permagon Press/McGraw Hill, 1996
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 165
- ↑ Jump up to: 3.0 3.1 Sanford Guide to antimicrobial therapy 1997, 2003
- ↑ Medical Knowledge Self Assessment Program (MKSAP) 11, 18. American College of Physicians, Philadelphia 1998, 2018.
- ↑ Drug Information & Medication Formulary, Veterans Affairs, Central California Health Care System, 1st ed., Ravnan et al eds, 1998
- ↑ Kaiser Permanente Northern California Regional Drug Formulary, 1998
- ↑ Jump up to: 7.0 7.1 Bamgbola O. Review of vancomycin-induced renal toxicity: an update. Ther Adv Endocrinol Metab. 2016 Jun;7(3):136-47. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27293542 Free PMC Article
- ↑ Clinical Guide to Laboratory Tests, NW Tietz (ed) 3rd ed, WB Saunders, Philadelpha 1995
- ↑ Jump up to: 9.0 9.1 9.2 Micromedex, WLA VA Pharmacy, UpToDate Fekety R et al, Am J Med 86:15, 1989
- ↑ Jump up to: 10.0 10.1 Prescriber's Letter 13(10): 2006 Alternative or 'Off-label' Routes of Drug Administration Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=221012&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Jump up to: 11.0 11.1 Stryjewski ME et al Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysis-dependent patients with methicillin- susceptible Staphylococcus aureus bacteremia. Clin Infect Dis. 2007 Jan 15;44(2):190-6. Epub 2006 Dec 8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17173215
- ↑ Jump up to: 12.0 12.1 Von Drygalski A, Curtis BR, Bougie DW, McFarland JG, Ahl S, Limbu I, Baker KR, Aster RH. Vancomycin-induced immune thrombocytopenia. N Engl J Med. 2007 Mar 1;356(9):904-10. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17329697
Warkentin TE. Drug-induced immune-mediated thrombocytopenia--from purpura to thrombosis. N Engl J Med. 2007 Mar 1;356(9):891-3. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17329695 - ↑ Prescriber's Letter 16(2): 2008 Vancomycin Dosing and Monitoring in Adults Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=250215&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Kullar R et al. Impact of vancomycin exposure on outcomes in patients with methicillin-resistant Staphylococcus aureus bacteremia: Support for consensus guidelines suggested targets. Clin Infect Dis 2011 Apr 15; 52:975 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21460309
Patel N et al. Vancomycin: We can't get there from here. Clin Infect Dis 2011 Apr 15; 52:969. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21460308 - ↑ Jump up to: 15.0 15.1 Shah-Khan F, Scheetz MH, Ghossein C. Biopsy-Proven Acute Tubular Necrosis due to Vancomycin Toxicity. Int J Nephrol. 2011;2011:436856 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21716699
Belen C, Budhiraja P, Bracamonte E, Popovtzer M. Biopsy-proven acute tubular necrosis associated with vancomycin in an adult patient. Ren Fail. 2012;34(4):502-5 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22329801 - ↑ Jump up to: 16.0 16.1 16.2 16.3 16.4 16.5 16.6 Deprecated Reference
- ↑ van Hal SJ, Paterson DL, Lodise TP. Systematic review and meta-analysis of vancomycin-induced nephrotoxicity associated with dosing schedules that maintain troughs between 15 and 20 milligrams per liter. Antimicrob Agents Chemother. 2013 Feb;57(2):734-44. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23165462 Free PMC Article
- ↑ Jump up to: 18.0 18.1 Blumenthal KG et al. Peripheral blood eosinophilia and hypersensitivity reactions among patients receiving outpatient parenteral antibiotics. J Allergy Clin Immunol 2015 Nov; 136:1288. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25981739
- ↑ Jump up to: 19.0 19.1 Rutter WC et al. Acute kidney injury in patients treated with vancomycin and piperacillin-tazobactam: A retrospective cohort analysis. J Hosp Med 2017 Feb; 12:77 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28182801 <Internet> http://www.journalofhospitalmedicine.com/jhospmed/article/130044/hospital-medicine/acute-kidney-injury-patients-treated-vancomycin-and
Luther MK, Timbrook TT, Caffrey AR et al Vancomycin Plus Piperacillin-Tazobactam and Acute Kidney Injury in Adults: A Systematic Review and Meta-Analysis. Crit Care Med. 2018 Jan;46(1):12-20. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29088001 - ↑ Jump up to: 20.0 20.1 NEJM Knowledge+ Question of the Week. Jan 12, 2021 https://knowledgeplus.nejm.org/question-of-week/1082/
- ↑ Alvarez-Arango S, Ogunwole M, Sequist TD et al Vancomycin Infusion Reaction - Moving beyond "Red Man Syndrome". N Engl J Med. 2021. April 3. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33830710 https://www.nejm.org/doi/full/10.1056/NEJMp2031891
- ↑ Jump up to: 22.0 22.1 Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
- ↑ Jump up to: 23.0 23.1 NEJM Knowledge+
Database
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