Antibiotic · Glycopeptide
Vancomycin (Vancocin)
Also called Vancocin, vanc
Indications
- Serious infections from methicillin-resistant staphylococci: septicemia, endocarditis, bone, lower respiratory tract and skin infections (label)
- Serious staphylococcal infection in penicillin-allergic patients or when other drugs fail (label)
- Empiric MRSA coverage in sepsis, pneumonia, meningitis and line infection, with a beta-lactam, stopped when cultures exclude it
- C. difficile colitis and staphylococcal enterocolitis, by mouth (label)
Dosing
| Where | Dose |
|---|---|
| Antimicrobials | Vancomycin: Load by weight; maintenance by AUC or levels |
On the quick cards
Mechanism of action
Vancomycin is a glycopeptide whose bactericidal action comes mainly from blocking cell-wall synthesis; it also alters membrane permeability and RNA synthesis (label). It binds the D-alanyl-D-alanine end of peptidoglycan precursors, which stops their transfer and cross-linking. It is inactive against gram-negative bacilli (label), because the large molecule cannot cross their outer membrane. Enterococci with vanA or vanB genes build D-Ala-D-lactate ends instead, the basis of VRE.
Pharmacology
- Infectious: staphylococci including MRSA, streptococci and enterococci (enterococcal endocarditis only with an aminoglycoside); inactive against gram-negative bacilli, mycobacteria and fungi (label)
- Skin and cardiovascular: rapid infusion can cause flushing, itching and exaggerated hypotension, including shock and rarely cardiac arrest (label); histamine-mediated, formerly red man syndrome
- Renal: AKI rises with exposure, and trough-guided dosing caused more nephrotoxicity than AUC dosing (IDSA/ASHP 2020)
- Ear and blood: ototoxicity, mostly with excessive doses, prior hearing loss or other ototoxic drugs; reversible neutropenia, usually after a week or more (label)
Pharmacokinetics
| Half-life | 4–6 h with normal kidneys; about 7.5 days if anephric (label) |
|---|---|
| Distribution | 0.3–0.43 L/kg (label) |
| Protein binding | About 55% (label) |
| Metabolism | None apparent (label) |
| Elimination | About 75% in urine within 24 h by glomerular filtration (label) |
| Target | AUC 400–600 mg·h/L assuming an MIC of 1, best by Bayesian software; trough-only 15–20 mg/L no longer recommended (IDSA/ASHP 2020) |
| Loading | 20–35 mg/kg actual weight in critical illness, at most 3,000 mg (IDSA/ASHP 2020) |
| Dialysis | Poorly removed by standard dialysis (label); keep pre-dialysis levels 15–20 mg/L (IDSA/ASHP 2020) |
| CRRT | Load 20–25 mg/kg, then 7.5–10 mg/kg every 12 h at 20–25 mL/kg/h effluent (IDSA/ASHP 2020) |
Chemistry
- Tricyclic glycopeptide from Amycolatopsis orientalis; C₆₆H₇₅Cl₂N₉O₂₄·HCl, MW 1485.74 (label)
- Large and polar: no metabolism, renal elimination and no gram-negative penetration
- Reconstituted pH 2.5–4.5 (label); acidic, so dilute to no more than 5 mg/mL and infuse over at least 60 min, no faster than 10 mg/min (label)
- Physically incompatible with beta-lactam solutions (label)
Adverse effects and cautions
In the one-pagers
- Meningitis and EncephalitisEmpiric antibiotics and dexamethasone: Community, age 18–50: Ceftriaxone 2 g IV q12h + vancomycin 15–20 mg/kg q8–12h
- Endocarditis and Valve EmergenciesAntibiotics: Native or late prosthetic: Cover staph, strep, enterococci: e.g. vancomycin + ceftriaxone
- Acute Kidney InjuryNephrotoxins and ICU causes: Vancomycin: AUC-guided dosing (400–600 mg·h/L) causes less AKI than trough dosing (IDSA 2020)
- CEN: Musculoskeletal and Wound EmergenciesDislocations, open fractures and children's fractures: Open fractures (Gustilo-Anderson types): type I, wound 1 cm or less and clean, infection 0-2%; type II, larger wound without extensive soft-tissue damage, 2-10%; type III, extensive soft-tissue injury, segmental fracture or traumatic amputation, 10-50% (IIIC has an arterial injury needing repair). Cefazolin 2 g IV is the base regimen (Kolinsky
- Oncologic EmergenciesNeutropenic fever: Vancomycin only for shock, pneumonia, line or skin infection, MRSA or gram-positive cultures
- Preventing ICU InfectionsHand hygiene and SSI: Prophylaxis ≤60 min before incision (120 for vancomycin, fluoroquinolones); redose long cases
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In the algorithms
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Sources
- FDA label: Vancomycin HCl for Injection (Xellia, 2022)
- FDA label: Vancomycin HCl for Injection (Hospira, 2021)
- Rybak 2020 (IDSA/ASHP/PIDS/SIDP vancomycin guideline)
For education and exam preparation only. Follow your institution’s protocols. Typical adult values for study. Follow the order, the label and your institution's protocols.