Vancomycin

TREATMENT

• Vancomycin (usual starting dose is 15 mg/kg IV q12h) is a glycopeptide antibiotic that interferes with cell wall synthesis by binding to d-alanyl-d-alanine precursors that are critical for peptidoglycan cross-linking in most gram-positive bacterial cell walls.

• Vancomycin-resistant Enterococcus faecium (VRE) and vancomycin intermediate-resistant S. aureus (VISA) present increasing treatment challenges. Vancomycin-resistant S. aureus has been reported but remains rare. Indications for use are listed in Table 15-2.

TABLE 15-2

INDICATIONS FOR VANCOMYCIN USE

Treatment of serious infections caused by documented or suspected MRSA

Treatment of serious infections caused by ampicillin-resistant, vancomycin-sensitive

enterococci

Treatment of serious infections caused by gram-positive bacteria in patients who are allergic to other appropriate therapies

Surgical prophylaxis for placement of prosthetic devices at institutions with known high rates of MRSA or in patients who are known to be colonized with MRSA

Empiric use in suspected gram-positive meningitis until an organism has been identified and sensitivities confirmed

Oral treatment of Clostridioides difficile colitis

MRSA, methicillin-resistant Staphylococcus aureus.

• The goal trough concentration is 15-20 μg∕mL for treatment of serious infections. Lower troughs of 10-20 μg∕mL may be appropriate for less severe infections.

• Dose adjusting to a target AUC: Minimum inhibitory concentration (MIC) range of 400-600 mg*h∕L, assuming an MIC of 1 mg∕L, is recommended for the treatment of serious MRSA infections where pharmacokinetic monitoring and adjustments can be provided quickly and reliably.

SPECIAL CONSIDERATIONS

• Vancomycin is typically administered by IV infusion at ≥1 hour per gram per dose. Rapid infusion rates can cause vancomycin infusion reaction, a histamine-mediated reaction characterized by flushing and redness of the upper body. Vancomycin infusion reaction can be adequately managed by premedicating with antihistamines, such as diphenhydramine.

• Adverse events: Nephrotoxicity, neutropenia, thrombocytopenia, and rash may also occur.