Indications
Oral Administration
Intravenous Administration
- Enterococcus (see Enterococcus, [[Enterococcus]])
- Vancomycin and gentamicin (see Gentamicin, [[Gentamicin]]) demonstrate synergism against most Enterococcus species
- Methicillin-Resistant Staphylococcus Aureus (MRSA) (see Staphylococcus Aureus, [[Staphylococcus Aureus]])
- Synergism: vancomycin and gentamicin (see Gentamicin, [[Gentamicin]]) demonstrate synergism against most Staphylococcus species
- Vancomycin is the first line agent: its use has paralleled the increasing emergence of MRSA
- Vancomycin does not inhibit production of PVL cytotoxin and may result in some clinical failures
- Continuous Vancomycin infusion is not associated with an improved outcome in the treatment of MRSA infection
- Methicillin-Sensitive Staphylococcus Aureus (MSSA) (see Staphylococcus Aureus, [[Staphylococcus Aureus]])
- Synergism: vancomycin and gentamicin (see Gentamicin, [[Gentamicin]]) demonstrate synergism against most Staphylococcus species
- Streptococcus Pneumoniae (Pneumococcus) (see Streptococcus Pneumoniae, [[Streptococcus Pneumoniae]])
- Effective against penicillin-resistant Streptococcus Pneumoniae
Contraindications
- Hypersensitivity Reaction to Glycopeptides: excluding red man syndrome
- Problem with Dosing Frequency in Adjustment for Creatinine Clearance
- Strains with Higher MIC to Vancomycin: MIC >2 mg/L
- Situations Where IV Administration is Difficult or Undesirable
- Situations Where Vancomycin Infusion Would Result in an Unnecessary Prolongation of Hospital Stay
- Situations Where Vancomycin Infusion Would Be Complicated By Problematic IV Access
Pharmacology
- Glycopeptide Antibiotic Which Inhibits Cell Wall Synthesis in Gram-Positive Bacteria
- Inhibits the Bacterial Cell Wall Polymer at a Site of Peptidoglycan Synthesis Earlier Than β-Lactam Antibiotics (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]])
- Inhibition of Bacterial RNA Synthesis and Permeability of Cytoplasmic Membranes
- Bactericidal Against Almost All Gram-Positive Bacteria, Except Enterococcus
- Does Not Cross the Outer Cell Wall of Gram-Negative Organisms: ineffective for these organisms
Tissue Penetration
- Central Nervous System/Cerebrospinal Fluid: poor, except when meninges are inflammed
- Lung Penetration: poor
Pharmacokinectics
- High Concentrations of Heparin (see Heparin, [[Heparin]]): may inactivate vancomycin, leading to antibiotic failure
Administration
- IV (For All Indications, Except Clostridium Difficile Colitis): xxx
- Desired Trough Level: 15 mg/L
- PO (For Clostridium Difficile Colitis): xxx
Adverse Effects
Dermatologic Adverse Effects
Red Man Syndrome
- Mechanism: rapid administration of vancomycin with histamine release
- Onset: may occur during or immediately after vancomycin infusion
- Clinical
- Hypotension (see Hypotension, [[Hypotension]])
- Pruritic Erythematous Rash (see Erythroderma, [[Erythroderma]]): over body, face, and neck
- Fever (see Fever, [[Fever]])
- Treatment
- Slow Down Intravenous Vancomycin Infusion Rate to <15 mg/min
- Pre-Treat with H1-Histamine Receptor Antagonists (see H1-Histamine Receptor Antagonists, [[H1-Histamine Receptor Antagonists]]): may be useful
- Pre-Treat with H2-Histamine Receptor Antagonists (see H2-Histamine Receptor Antagonists, [[H2-Histamine Receptor Antagonists]]): may be useful
- Famotidine (Pepcid) (see Famotidine, [[Famotidine]])
- Corticosteroids (see Corticosteroids, [[Corticosteroids]]): not useful
Hematologic Adverse Effects
Neutropenia (see Neutropenia, [[Neutropenia]])
- Epidemiology: occurs in 2% of cases
Renal Adverse Effects
Acute Interstitial Nephritis (see Acute Interstitial Nephritis, [[Acute Interstitial Nephritis]])
Other Adverse Effects
Thrombophlebitis
- Epidemiology: occurs in 5-15% of cases
References
- Therapy for pneumococcal infection at the millennium: doubts and certainties. Am J Med 1999; 107:77S-85S
- The threat of vancomycin resistance. Am J Med 1999; 106:26S-37S
- Nosocomial infections in the ICU: the growing importance of antibiotic-resistant pathogens. Chest 1999; 115(suppl): 34S-41S
- Symposium on antimicrobial agents—part XII. Vancomycin. Mayo Clin Proc 1999; 74:928-935
- Antihistamine prophylaxis permits rapid vancomycin infusion. Crit Care Med 1999; 27:1732-1737