Vancomycin

Revision as of 01:10, 6 September 2019 by Ilyaalek (talk | contribs) (Community-Acquired Pneumonia)

General

  • Type: Glycopeptides
  • Dosage Forms:
    • IV
    • PO: Mix IV form with 30mL water
    • PR: Mix IV form with 100mL NS
  • Common Trade Names: Vancocin

Adult Dosing

Loading Doses

  • 15-20mg/kg IV loading dose[1]
  • Sample Loading Dose Table (individual ED guidelines may differ)
    • >40kg: 750mg IV
    • 40-59kg: 1000mg IV
    • 60-90kg: 1500mg IV
    • >90kg: 2000mg IV
  • Alternative loading dose for serious infections: 20-25mg/kg IV
  • Loading doses of 30mg/kg has shown improved target trough levels at 12 hrs with no difference in nephrotoxicity[2][3]
  • Adjust maintenance dose based on serum levels

Maintenance

All: Adjust repeat doses based on serum levels

  • <50kg: 500mg IV q12h
  • 50-69kg: 750mg IV q12h
  • >70kg: 1000mg IV q12h
  • Alternative (All Weights): 10-15mg/kg IV q12
  • Adjust dose based on serum levels

Clostridium Difficile

  • 1st occurrence
    • Uncomplicated: 125mg PO q6h x 10-14 days
    • Complicated: 500mg PO/NG q6h
      • May use in combo with metronidazole IV
      • Consider adding vancomycin 500mg PR q6 if complete ileus
  • 2nd occurrence
    • Uncomplicated: 125mg PO q6h x 10-14 days
    • Complicated: 500mg PO/NG q6h
      • May use in combo with metronidazole IV
      • Consider adding vancomycin 500mg PR q6 if complete ileus
  • 3rd+ occurrence
    • 125mg PO q6h x 10-14 days, then daily x 7 days, then q2-3 days x 2-8 wk

Staphylococcal Enterocolitis

  • 500-2000mg/day PO divided q6-8h x 7-10 days
  • First Dose: 500mg PO x 1

Pediatric Dosing

All: Adjust repeat doses based on serum levels

General (<7 Days Old)

  • <1.2kg
    • 15mg/kg IV q24h
    • First Dose: 15mg/kg IV x 1
  • 1.2-2kg
    • 10-15mg/kg IV q12-18h
    • First Dose: 10-15mg/kg IV x 1
  • >2.1kg
    • 10-15mg/kg IV q8-12h
    • First Dose: 10-15mg/kg IV x 1

General (7 Days - 1 Month Old)

  • <1.2kg
    • 15mg/kg IV q24h
    • First Dose: 15mg/kg IV x 1
  • 1.2-2kg
    • 10-15mg/kg IV q8-12h
    • First Dose: 10-15mg/kg IV x 1
  • >2.1kg
    • 15-20mg/kg IV q8
    • First Dose: 15-20mg/kg IV x 1

General (1 Month - 11 Years)

  • 10-15mg/kg IV q6-8h
  • First Dose: 10-15mg/kg IV x 1
  • Max: 1 gram per dose

General (12 - 16 Years)

  • 1000mg IV q12h
  • First Dose: 1000mg IV x 1
  • Alt: 10-15mg/kg IV q12
  • Info: Repeat dosing may require up to 1200-1500mg IV q12h or 10mg/kg IV q8

Clostridium Difficile

  • 40mg/kg/day PO divided q6-8h x 7-10 days
  • First Dose: 10-13mg/kg x 1
  • Max 500mg/dose, 2000mg/day
  • For severe infection or recurrence
  • May use in combination with metronidazole PO

Staphylococcal Enterocolitis

  • 40mg/kg/day PO divided q6-8h x 7-10 days
  • First Dose: 10-13mg/kg x 1
  • Max 500mg/dose, 2000mg/day

Community-Acquired Pneumonia

  • 40mg/kg/day PO divided q6-8h x 10-14 days
  • First Dose: 10-13mg/kg x 1
  • Info: Switch to appropriate oral regiment when possible

Special Populations

  • Drug ratings in pregnancy: C
  • Lactation: Probably safe
  • Renal Dosing
    • Adult
      • CrCl 50-90: 15mg/kg x1, then usual dose q12-24h
      • CrCl 10-50: 15mg/kg x1, then usual dose q24h-96h
      • CrCl <10: 15mg/kg x1, then usual dose q4-7 days
      • Hemodialysis: Give supplement only if high-flux dialyzer used
      • Peritoneal dialysis: No supplement
    • Pediatric
      • CrCl 10-50: give q18-48h
      • CrCl <10: give q48-96h
      • Hemodialysis: Give supplement only if high-flux dialyzer used
      • Peritoneal dialysis: No supplement
  • Hepatic Dosing (Adult & Pediatric)
    • Not defined

Contraindications

  • Allergy to class/drug

Adverse Reactions

Serious

Common

Pharmacology

  • Half-life: 4-6h (7.5 days ESRD)
  • Metabolism: CYP450
  • Excretion:
    • IV route: Urine
    • PO Route: Minimal systemic absorption unless intestinal inflammation or renal impairment
  • Mechanism of Action
    • Bactericidal against S. aureus and pneumococci
    • Bacteriostatic against enterococci[5]

Antibiotic Sensitivities[6]

Group Organism Sensitivity
Gram Positive Strep. Group A, B, C, G S
Strep. Pneumoniae S
Viridans strep X1
Strep. anginosus gp X1
Enterococcus faecalis S
Enterococcus faecium I
MSSA S
MRSA S
CA-MRSA S
Staph. Epidermidis S
C. jeikeium S
L. monocytogenes S
Gram Negatives N. gonorrhoeae R
N. meningitidis R
Moraxella catarrhalis X1
H. influenzae X1
E. coli R
Klebsiella sp R
E. coli/Klebsiella ESBL+ R
E coli/Klebsiella KPC+ R
Enterobacter sp, AmpC neg R
Enterobacter sp, AmpC pos R
Serratia sp X1
Serratia marcescens R
Salmonella sp R
Shigella sp R
Proteus mirabilis X1
Proteus vulgaris R
Providencia sp. X1
Morganella sp. X1
Citrobacter freundii X1
Citrobacter diversus X1
Citrobacter sp. X1
Aeromonas sp X1
Acinetobacter sp. R
Pseudomonas aeruginosa R
Burkholderia cepacia R
Stenotrophomonas maltophilia R
Yersinia enterocolitica X1
Francisella tularensis X1
Brucella sp. R
Legionella sp. X1
Pasteurella multocida X1
Haemophilus ducreyi R
Vibrio vulnificus X1
Misc Chlamydophila sp X1
Mycoplasm pneumoniae X1
Rickettsia sp R
Mycobacterium avium X1
Anaerobes Actinomyces S
Bacteroides fragilis R
Prevotella melaninogenica R
Clostridium difficile S
Clostridium (not difficile) S
Fusobacterium necrophorum X1
Peptostreptococcus sp. S

Key

  • S susceptible/sensitive (usually)
  • I intermediate (variably susceptible/resistant)
  • R resistant (or not effective clinically)
  • S+ synergistic with cell wall antibiotics
  • U sensitive for UTI only (non systemic infection)
  • X1 no data
  • X2 active in vitro, but not used clinically
  • X3 active in vitro, but not clinically effective for Group A strep pharyngitis or infections due to E. faecalis
  • X4 active in vitro, but not clinically effective for strep pneumonia

See Also

References

  1. Ryback M, et al. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2009; 66(1):82-98.
  2. Rosini JM, et al. A randomized trial of loading vancomycin in the emergency department. Ann Pharmacother. 2015; 49(1):6-13.
  3. Rosini JM, et al. High single-dose vancomycin loading is not associated with increased nephrotoxicity in emergency department sepsis patients. Acad Emerg Med. 2016 Feb 6.
  4. Lyon GD and Bruce DL. Diphenhydramine reversal of vancomycin-induced hypotension. Anesth Analg. 1988 Nov;67(11):1109-10.
  5. Bactericidal agents in the treatment of MRSA infections—the potential role of daptomycin. J. Antimicrob. Chemother. (2006) 58 (6): 1107-1117.
  6. Sanford Guide to Antimicrobial Therapy 2014