Vancomycin monograph

Guidelines for use

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1. Spectrum of Activity

Active against:

  • Staphylococci spp. (including methicillin-resistant strains)
  • Streptococci spp.
  • Enterococci spp.
  • Corynebacterium spp.
  • Bacillus spp.
  • Clostridium spp.
  • Actinomyces spp.
  • Propionibacterium spp.
  • Listeria monocytogenes

Not active against:

  • Vancomycin-resistant enterococci (VRE)
  • Gram negative aerobic and anaerobic bacteria

2. Clinical Uses

Appropriate Uses:

  • Serious infections due to β-lactam-resistant Gram-positive microorganisms, (e.g., MRSA infection)
  • Infections due to gram-positive bacteria in patients with serious β-lactam allergy (defined as life-threatening allergic reactions)
  • As part of empiric therapy for community acquired bacterial meningitis until culture and sensitivity are available
  • First-line oral treatment of colitis due to Clostridium difficile
  • As part of empiric therapy of presumed or confirmed bacterial infective endocarditis until culture and sensitivity are available
  • Appropriate surgical prophylaxis in patients with life-threatening allergy to β-lactam antibiotics

Inappropriate Uses:

  • Oral vancomycin is not absorbed and cannot be used to treat systemic infection
  • Treatment (chosen for dosing convenience) of infections in patients with renal failure
  • Treatment of infections due to β-lactam-resistant Gram-positive microorganisms that are not serious
  • Treatment in response to a single blood culture positive for coagulase-negative staphylococci
  • Continued empiric use for presumed infections in patients whose cultures are negative for β-lactam-resistant gram-positive organisms.
  • Empiric antimicrobial therapy for a febrile neutropenic patient unless there is strong evidence at the outset that the infection is due to gram-positive microorganisms and the prevalence of infections due to MRSA in the hospital is substantial
  • Surgical prophylaxis in a patient who does not have a life-threatening allergy to β-lactam antibiotics

3. Precautions

  • Excessive use is a risk factor for colonization and infection with vancomycin-resistant enterococci
  • Pregnancy: Limited human data. Should be used only when benefit outweighs unknown risk to the fetus.
  • Breastfeeding: Limited information; however, amounts in breast milk and oral bioavailability are low. Monitor nursing infant for GI symptoms.

4. Adverse effects

  • "Vancomycin infusion reaction": histamine-mediated erythema and pruritus over neck and upper torso, ± hypotension (associated with rapid drug administration) This is NOT an allergic reaction to vancomycin and does not preclude the use of vancomycin.
  • Management of "Vancomycin infusion reaction":
    1. Extend the infusion duration to ≥ 2 hours
    2. Consider pre-treatment with hydroxyzine 50 mg PO 2 h prior to each dose; for NPO patients, diphenhydramine 25 - 50 mg may be given IV just prior to each dose.
  • Ototoxicity: currently considered to be negligible
  • Nephrotoxicity:
    • When trough is ≤ 15 mg, the incidence is < 10%
    • When trough is 15 - 20 mg/L, the incidence is 10 - 20%
    • Risk is increased when:
      • Duration of therapy exceeds 14 days
      • The dose ≥ 4 g/day
      • Trough levels are > 20 mg/L
      • Concomitant use of nephrotoxic agents (ie., aminoglycosides, amphotericin B, cisplatin, diuretics, NSAIDs, or radio-contrast dye)
  • Neutropenia:
    • Vancomycin-induced neutropenia may occur with prolonged vancomycin exposure of > 7 days
    • If vancomycin induced neutropenia is suspected, discontinue vancomycin
  • Thrombocytopenia:
    • Vancomycin-induced immune thrombocytopenia due to platelet reactive antibodies has been observed following a median of 7 days of vancomycin
    • Severe bleeding due to vancomycin-induced thrombocytopenia may occur
    • If vancomycin-induced thrombocytopenia is suspected, discontinue vancomycin
    • Platelet recovery is expected to occur within 7 – 14 days of discontinuing vancomycin

5. Oral Dosage for C. difficile Colitis (not absorbed systemically)

  • Oral vancomycin is the treatment of choice for C. difficile colitis
  • NOT indicated for any other infection
  • Usual dosage is 125 mg orally QID for 10 – 14 days; data supporting the need for higher doses of vancomycin orally is lacking
  • Oral vancomycin is administered as a solution, usually 125 mg/2.5 mL, prepared from the injectable product and either added to a beverage for the patient to drink or further diluted for administration via enteral feeding tube.

6. Intravenous Dosage

7. References

  • Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Wong-Beringer A, Rotschafer JC, Rodvold KA, Maples HD, Lomaestro B. Therapeutic Monitoring of Vancomycin for Serious Methicillin-resistant Staphylococcus aureus Infections: A Revised Consensus Guideline and Review by the American Society of Health-system Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Clin Infect Dis. 2020;71(6):1361-1364.
  • Dalton BR, Rajakumar I, Langevin A, Ondro C, Sabuda D, Griener TP, Dersch-Mills D, Rennert-May E. Vancomycin area under the curve to minimum inhibitory concentration ratio predicting clinical outcome: a systematic review and meta-analysis with pooled sensitivity and specificity. Clin Microbiol Infect.2020;26(4):436-446.
  • Stewart JJ, Jorgensen SC, Dresser LD, et al. A Canadian perspective on the revised 2020 ASHP/IDSA/PIDS/SIDP guidelines for vancomycin AUC-based therapeutic drug monitoring for serious MRSA infections. J Assoc Med Microbiol Infect Dis.2020;6(1):3-9
  • Jorgensen SCJ, Spellberg B, Shorr AF, Wright WF. Should Therapeutic Drug Monitoring Based on the Vancomycin Area Under the Concentration-Time Curve Be Standard for Serious Methicillin-Resistant Staphylococcus aureus Infections?-No. Clin Infect Dis. 2021 May 4;72(9):1502-1506.
  • Tongsai S, Koomanachai P. The safety and efficacy of high versus low vancomycin trough levels in the treatment of patients with infections caused by methicillin-resistant Staphylococcus aureus: a meta-analysis. BMC Res Notes. 2016;9(1):455.
  • Prybylski JP. Vancomycin Trough Concentration as a Predictor of Clinical Outcomes in Patients with Staphylococcus aureus Bacteremia: A Meta-analysis of Observational Studies. Pharmacotherapy. 2015;35(10):889-98.
  • Lodise TP, Patel N, Lomaestro BM, Rodvold KA, Drusano GL. Relationship between initial vancomycin concentration-time profile and nephrotoxicity among hospitalized patients. Clin Infect Dis. 2009; 15;49(4):507-14.
  • Ma NH, Walker SAN, Elligsen M, Kiss A, Palmay L, Ho G, Powis J, Bansal V, Leis JA. Retrospective multicentre matched cohort study comparing safety and efficacy outcomes of intermittent-infusion versus continuous-infusion vancomycin. J Antimicrob Chemother. 2020;75(4):1038-1046.
  • Wan M, Walker SAN, Martin E, Elligsen M, Palmay L, Leis JA. The impact of vancomycin trough concentrations on outcomes in non-deep seated infections: a retrospective cohort study. BMC Pharmacol Toxicol. 2018;19(1):47.

Last updated: June 6, 2022