vancomycin

General

Pronunciation
van-koe-MYE-sin [Pronunciation]

Trade Name(s)

• Vancocin

Indications

• IV: Treatment of potentially life-threatening infections when less toxic anti-infectives are contraindicated. Particularly useful in staphylococcal infections, including:

» Endocarditis,

» Meningitis,

» Osteomyelitis,

» Pneumonia,

» Septicemia,

» Soft-tissue infections in patients who have allergies to penicillin or its derivatives or when sensitivity testing demonstrates resistance to methicillin.

• PO: Treatment of staphylococcal enterocolitis or pseudomembranous colitis due to Clostridium difficile .

• IV: Part of endocarditis prophylaxis in high-risk patients who are allergic to penicillin.

Action

Binds to bacterial cell wall, resulting in cell death.

Therapeutic Effect(s):
Bactericidal action against susceptible organisms.

Spectrum:
Active against gram-positive pathogens, including:

» Staphylococci (including methicillin-resistant strains of Staphylococcus aureus ),

» Group A beta-hemolytic streptococci,

» Streptococcus pneumoniae ,

» Corynebacterium ,

» Clostridium difficile ,

» Enterococcus faecalis ,

» Enterococcus faecium .

Pharmacokinetics

Absorption: Poorly absorbed from the GI tract.

Distribution: Widely distributed. Some penetration (20–30%) of CSF; crosses placenta.

Metabolism and Excretion: Oral doses excreted primarily in the feces; IV vancomycin eliminated almost entirely by the kidneys.

Half-life: Neonates: 6–10 hr; Children 3 mo–3 yr: 4 hr; Children >3 yr: 2–2.3 hr; Adults: 5–8 hr (↑ in renal impairment).

TIME/ACTION PROFILE (blood levels)

Contraindication/Precautions

Contraindicated in:
Hypersensitivity.

Use Cautiously in:

• Renal impairment (dosage reduction required if CCr ≤80 mL/min);

• Hearing impairment;

• Intestinal obstruction or inflammation (↑ systemic absorption when given orally);

• OB: Lactation: Safety not established.

Adverse Reactions/Side Effects

EENT: ototoxicity.

CV: hypotension.

GI: nausea, vomiting.

GU: nephrotoxicity.

Derm: rashes.

Hemat: eosinophilia, leukopenia.

Local: phlebitis.

MS: back and neck pain.

Misc: HYPERSENSITIVITY REACTIONS INCLUDING ANAPHYLAXIS , chills, fever, "red man" syndrome (with rapid infusion), superinfection.

*CAPITALS indicates life-threatening.
*italic indicates most frequent.

Interactions

Drug-Drug

• May cause additive ototoxicity and nephrotoxicity with other ototoxic and nephrotoxic drugs ( aspirin , aminoglycosides , cyclosporine , cisplatin , loop diuretics ).

• May enhance neuromuscular blockade from nondepolarizing neuromuscular blocking agents .

• ↑ risk of histamine flush when used with general anesthetics in children.

Route/Dosage

Serious Systemic Infections

• IV (Adults): 500 mg q 6 hr or 1 g q 12 hr (up to 4 g/day)..

• IV (Children >1 mo): 40 mg/kg/day divided q 6–8 hr Staphylococcal CNS infection—60 mg/kg/day divided q 6 hr, maximum dose: 1 g/dose..

• IV (Neonates 1 wk–1 mo): <1200 g: 15 mg/kg/day q 24 hr. 1200–2000 g: 10–15 mg/kg/dose q 8–12 hr. >2000 g: 15–20 mg/kg/dose q 8 hr..

• IV (Neonates <1 wk): <1200 g: 15 mg/kg/day q 24 hr. 1200–2000 g: 10–15 mg/kg/dose q 12–18 hr. >2000 g: 10–15 mg/kg/dose q 8–12 hr..

• IT (Adults): 20 mg/day..

• IT (Children): 5–20 mg/day..

• IT (Neonates): 5–10 mg/day..

• IV (Adults and Adolescents): 1-g single dose 1-hr preprocedure..

• IV (Children): 20-mg/kg single dose 1-hr preprocedure..

• PO (Adults): 125–500 mg q 6 hr..

• PO (Children): 40 mg/kg/day divided q 6 hr for 7–10 days (not to exceed 2 g/day)..

• IV (Adults): An initial loading dose of 750 mg–1 g (not less than 15 mg/kg); serum level monitoring is optimal for choosing maintenance dose in patients with renal impairment; these guidelines may be helpful. CCr 50–80 mL/min—1 g q 1–3 days; CCr 10–50 mL/min—1 g q 3–7 days; CCr <10 mL/min—1 g q 7–14 days..

Availability

• Capsules: 125 mg, 250 mg

• Injection: 500-mg, 750-mg, 1-, 5-, 10-g vials

Assessment

• Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.

• Obtain specimens for culture and sensitivity prior to initiating therapy. First dose may be given before receiving results.

• Monitor IV site closely. Vancomycin is irritating to tissues and causes necrosis and severe pain with extravasation. Rotate infusion site.

• Monitor BP throughout IV infusion.

• Evaluate eighth cranial nerve function by audiometry and serum vancomycin levels prior to and throughout therapy in patients with borderline renal function or those >60 yr of age. Prompt recognition and intervention are essential in preventing permanent damage.

• Monitor intake and output ratios and daily weight. Cloudy or pink urine may be a sign of nephrotoxicity.

• Assess patient for signs of superinfection (black, furry overgrowth on tongue; vaginal itching or discharge; loose or foul-smelling stools). Report occurrence.

• Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction.

• Assess bowel status (bowel sounds, frequency and consistency of stools, presence of blood in stools) throughout therapy.

• Monitor for casts, albumin, or cells in the urine or decreased specific gravity, CBC, and renal function periodically during therapy.

» May cause increased BUN levels.

• Trough concentrations should not exceed 10 mcg/mL (mild-moderate infections) or 15–20 mcg/mL (for severe infections).

Potential Nursing Diagnoses

• Risk for infection (Indications)

• Disturbed sensory perception (auditory) (Side Effects)

Implementation

PO: Use calibrated measuring device for liquid preparations. IV dose form may be diluted in 30 mL of water for oral or nasogastric tube administration. Resulting solution has bitter, unpleasant taste. May mix with a flavoring syrup to mask taste. Stable for 14 days if refrigerated.

IV Adminstration:

• pH:
2.5–5.0.

• Intermittent Infusion:

Diluent: To reconstitute, add 10 mL of sterile water for injection to 500-mg vial or 20 mL of sterile water for injection to 1-g vial for a concentration of 50 mg/mL. Dilute further with at least 100 mL of 0.9% NaCl, D5W, D5/0.9% NaCl, or LR for every 500 mg of vancomycin being administered. Reconstituted vials stable for 14 days if refrigerated. Infusion is stable for 96 hr if refrigerated.
Concentration: ≤5 mg/mL.

• Rate:
Infuse over at least 60 min (90 min for doses >1 g). Do not administer rapidly or as a bolus, to minimize risk of thrombophlebitis, hypotension, and "red-man (neck)" syndrome (sudden, severe hypotension; flushing and/or maculopapular rash of face, neck, chest, and upper extremities). May need to slow infusion further to 1.5–2 hr if red-man syndrome occurs.

• IT:

Diluent: Dilute with preservative-free NS.
Concentration: 1–5 mg/mL.

• Rate:
Directly instill into ventricular cerebrospinal fluid.

• Y-Site Compatibility:

» acyclovir

» aldesleukin

» allopurinol

» amifostine

» aldesleukin

» alfentanil

» allopurinol

» alprostadil

» amifostine

» amikacin

» amiodarone

» amsacrine

» anidulafungin

» atracurium

» atropine

» bumetanide

» buprenorphine

» butorphanol

» calcium chloride

» calcium gluconate

» carboplatin

» caspofungin

» chlorpromazine

» cimetidine

» cisatracurium

» cisplatin

» clindamycin

» cyanocobalamin

» cyclophosphamide

» cyclosporine

» cytarabine

» dactinomycin

» dexamethasone

» dexmedetomidine

» digoxin

» diltiazem

» diphenhydramine

» dobutamine

» docetaxel

» dopamine

» doripenem

» doxacurium

» doxapram

» doxorubicin hydrochloride

» doxorubicin liposome

» doxycycline

» enalaprilat

» ephedrine

» epinephrine

» epirubicin

» ertapenem

» erythromycin

» esmolol

» etoposide

» etoposide phosphate

» famotidine

» fenoldopam

» fentanyl

» filgrastim

» fluconazole

» fludarabine

» folic acid

» gemcitabine

» gentamicin

» glycopyrrolate

» granisetron

» hetastarch

» hydromorphone

» ifosfamide

» imipenem/cilastatin

» insulin

» isoproterenol

» labetalol

» levofloxacin

» lidocaine

» linezolid

» lorazepam

» magnesium sulfate

» mannitol

» mechlorethamine

» melphalan

» meperidine

» meropenem

» metaraminol

» methoxamine

» methyldopate

» methylprednisolone

» metoclopramide

» metoprolol

» metronidazole

» midazolam

» milrinonemitoxantrone

» morphine

» mycophenolate

» nalbuphine

» naloxone

» nesiritide

» nicardipine

» nitroglycerin

» nitroprusside

» norepinephrine

» octreotide

» ondansetron

» oxacillin

» oxaliplatin

» oxytocin

» paclitaxel

» palonosetron

» pancuronium

» papaverine

» pemetrexed

» penicillin G

» pentamidine

» pentazocine

» pentobarbital

» perphenazine

» phenobarbital

» phentolamine

» phenylephrine

» phytonadione

» potassium chloride

» procainamide

» prochlorperazine

» promethazine

» propranolol

» protamine

» pyridoxime

» ranitidine

» remifentanil

» sodium acetate

» sodium bicarbonate

» sodium citrate

» succinylcholine

» sufentanil

» tacrolimus

» teniposide

» theophylline

» thiamine

» thiotepa

» tigecycline

» tirofiban

» tobramycin

» tolazoline

» trastuzumab

» trimethaphan

» vasopressin

» vecuronium

» verapamil

» vincristine

» vinorelbine

» voriconazole

» zidovudine

• Y-Site Incompatibility:

» albumin

» amphotericin B cholesteryl

» amphotericin B colloidal

» amphotericin B liposome

» azithromycin

» bivalirudin

» cefoperazone

» chloramphenicol

» dantrolene

» daptomycin

» diazepam

» diazoxide

» epoetin alfa

» fluorouracil

» furosemide

» ganciclovir

» heparin

» idarubicin

» indomethacin

» ketorolac

» pantoprazole

» phenytoin

» rituximab

» streptokinase

» trimethoprim/sulfamethoxazole

Patient/Family Teaching

• Advise patients on oral vancomycin to take as directed. Take missed doses as soon as remembered unless almost time for next dose; do not double dose.

• Instruct patient to report signs of hypersensitivity, tinnitus, vertigo, or hearing loss.

• Advise patient to notify health care professional if no improvement is seen in a few days.

• Patients with a history of rheumatic heart disease or valve replacement need to be taught importance of using antimicrobial prophylaxis prior to invasive dental or medical procedures.

Evaluation/Desired Outcomes

• Resolution of signs and symptoms of infection. Length of time for complete resolution depends on organism and site of infection.

• Endocarditis prophylaxis.