ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد ایتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Vancomycin: Pediatric drug information

Vancomycin: Pediatric drug information
(For additional information see "Vancomycin: Drug information" and see "Vancomycin: Patient drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Risk of embryo-fetal toxicity due to excipients:

A formulation of vancomycin injection contains the excipients polyethylene glycol (PEG 400) and N-acetyl D-alanine (NADA), which resulted in fetal malformations in animal reproduction studies at dose exposures approximately 8 and 32 times, respectively, higher than the exposures at the human equivalent dose. If use of vancomycin is needed during the first or second trimester of pregnancy, use other available formulations of vancomycin.

Brand Names: US
  • Firvanq;
  • Vancocin;
  • Vancosol Pack [DSC]
Brand Names: Canada
  • JAMP Vancomycin;
  • JAMP-Vancomycin;
  • PMS-Vancomycin;
  • Vancocin;
  • Vancomycin HCl
Therapeutic Category
  • Antibiotic, Miscellaneous
Dosing: Neonatal

Note: Dosing presented in mg/kg/dose and mg/kg/day; routes of administration may vary (IV, oral, intrathecal); use caution.

General dosing, susceptible infection:

Note: When determining dosing interval, consider concomitant medications that may impact renal function (eg, ibuprofen, indomethacin), history of birth depression, birth hypoxia/asphyxia, and presence of cyanotic congenital heart disease. Monitor serum vancomycin concentrations closely and adjust doses accordingly. An AUC24 target of 400 mg•hour/L is recommended in neonates with methicillin-resistant S. aureus (MRSA) infection based on adult data; this has generally been associated with trough concentrations of 7 to 11 mg/L in neonates (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Frymoyer 2014; Stockmann 2015). For non-MRSA infections, such as those caused by coagulase-negative staphylococci (CONS), optimal concentration targets are unknown; some suggest target trough concentration 5 to 15 mg/L for CONS (Frymoyer 2019). Utilize local antibiogram and protocols for further guidance.

Optimal dose and frequency not established in patients receiving extracorporeal membrane oxygenation (ECMO); available data are limited (Amaker 1996; Buck 1998; Cies 2017; Moffett 2018). Patient-specific considerations (eg, reason for ECMO) and variability with ECMO procedure itself make extrapolation of pharmacokinetic data and dosing to all patients receiving ECMO difficult; closely monitor serum concentrations and determine individual dosing needs in these patients.

Initial dosage recommendations in patients with PNA ≤60 days:

Kidney function-based dosing (Bradley 2021; Capparelli 2001; Red Book [AAP 2021]): Note: Serum creatinine fluctuates and may be influenced by maternal concentrations during the first week of life; use caution and frequently reassess renal function in neonates ≤7 days old receiving vancomycin (Bradley 2021). Dosing regimen was designed for a target trough concentration of 5 to 10 mg/L (Capparelli 2001):

Loading dose: All patients: IV: 20 mg/kg once, followed by maintenance dose.

Maintenance dose: IV:

Gestational

Age

Serum

Creatinine

Dose

≤28 weeks

<0.5 mg/dL

15 mg/kg/dose every 12 hours

0.5 to 0.7 mg/dL

20 mg/kg/dose every 24 hours

0.8 to 1 mg/dL

15 mg/kg/dose every 24 hours

1.1 to 1.4 mg/dL

10 mg/kg/dose every 24 hours

>1.4 mg/dL

15 mg/kg/dose every 48 hours

>28 weeks

<0.7 mg/dL

15 mg/kg/dose every 12 hours

0.7 to 0.9 mg/dL

20 mg/kg/dose every 24 hours

1 to 1.2 mg/dL

15 mg/kg/dose every 24 hours

1.3 to 1.6 mg/dL

10 mg/kg/dose every 24 hours

>1.6 mg/dL

15 mg/kg/dose every 48 hours

Age-directed dosing (Radu 2018): IV: Note: Dosing regimen was designed with a target trough concentration of 10 to 20 mg/L.

Postmenstrual Age

Postnatal Age

Dose

≤29 weeks

≤21 days

15 mg/kg/dose every 18 hours

>21 days

15 mg/kg/dose every 12 hours

30 to <37 weeks

≤14 days

15 mg/kg/dose every 12 hours

>14 days

15 mg/kg/dose every 8 hours

37 to <45 weeks

≤7 days

15 mg/kg/dose every 12 hours

>7 days

15 mg/kg/dose every 8 hours

Meningitis; treatment: Note: For neonates <2 kg, consider use of smaller doses and longer intervals (IDSA [Tunkel 2004]):

PNA ≤7 days and ≥2 kg: IV: Initial: 20 to 30 mg/kg/day divided every 8 to 12 hours (IDSA [Tunkel 2004]).

PNA >7 days and ≥2 kg: IV: Initial: 30 to 45 mg/kg/day divided every 6 to 8 hours (IDSA [Tunkel 2004]).

Ventriculitis (including health care-associated ventriculitis and cerebrospinal fluid [CSF] shunt infections): Limited data available: Intraventricular or intrathecal: Use a preservative-free preparation: 3 to 20 mg/day (IDSA [Tunkel 2004]; IDSA [Tunkel 2017]; Matsunaga 2015; Parasuraman 2018); a dose of 5 mg is likely sufficient in neonates based on a study of 13 neonates which compared CSF vancomycin concentrations in patients receiving 5, 10, and 20 mg doses (Matsunaga 2015).

Dosing adjustment in renal impairment: Consider single-dose administration with serum concentration monitoring rather than scheduled dosing in patients with urine output <1 mL/kg/hour or if serum creatinine significantly increases from baseline.

Dosing: Pediatric

Note: For IV dosing, initial dosage recommendations for patients with normal kidney function presented; doses should be adjusted based on serum concentration monitoring; doses require adjustment in renal impairment. Consider single-dose administration with serum concentration monitoring rather than scheduled dosing in patients with urine output <1 mL/kg/hour or if serum creatinine significantly increases from baseline. Dosing presented in mg/kg/dose and mg/kg/day; routes of administration may vary (eg, IV, oral, intrathecal, intracatheter, intraperitoneal, rectal); use caution.

Optimal dose and frequency not established in patients receiving extracorporeal membrane oxygenation (ECMO); available data are limited (Amaker 1996; Buck 1998; Hoie 1990; Moffett 2018; Mulla 2005; Zylbersztajn 2018). Patient-specific considerations (eg, reason for ECMO) and variability with ECMO procedure itself make extrapolation of pharmacokinetic data and dosing to all patients receiving ECMO difficult; closely monitor serum concentrations and determine individual dosing needs in these patients.

General dosing, susceptible infection: Infants, Children, and Adolescents: IV: Initial: 45 to 60 mg/kg/day divided every 6 to 8 hours; dose and frequency should be individualized based on serum concentrations (Red Book [AAP 2021]). Note: Based on adult data, an AUC24 target of 400 mg•hour/L is recommended in patients with serious methicillin-resistant S. aureus (MRSA) infections; specific dosing recommendations may be higher when targeting this range (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). See "MRSA infection, serious; treatment".

In general, monitoring of serum concentrations and assurance of adequate hydration status is recommended; utilize local antibiogram and protocols for further guidance.

Antibiotic lock therapy; catheter salvage: Limited data available: Optimal dose not established:

Note: For infections caused by susceptible organisms when the vascular catheter cannot be removed; use in addition to systemic antibiotics. Catheter salvage not effective in all cases; removal of catheter is recommended for infections with S. aureus (Hecht 2020; IDSA [Mermel 2009]; Wolf 2014). Dosing regimens variable; consider age and size of patient and catheter size (including number of lumens) when determining dose due to potential for lock to be delivered intravenously.

Infants, Children, and Adolescents: Intracatheter: Usual concentrations of lock solution: 2 to 5 mg/mL of vancomycin with or without heparin additive; most common concentrations reported: vancomycin 2 mg/mL, 2.5 mg/mL, or 5 mg/mL; refer to institutional protocol if available (Denaburg 2013; IDSA [Mermel 2009]; Tsai 2015). Concentrations described in literature range from 0.025 to 10 mg/mL with or without heparin or citrate (Justo 2014); a vancomycin concentration of 5 mg/mL has been shown to be more efficacious than 1 mg/mL when biofilm present (Lee 2006). Instill into each lumen of the catheter access port using a volume sufficient to fill the catheter, with a dwell time of ideally ≥8 to 12 hours and up to 72 hours, depending on frequency of catheter use. Withdraw lock solution prior to catheter use; replace with fresh vancomycin lock solution after catheter use. Antibiotic lock therapy is given for the same duration as systemic antibiotics (Denaburg 2013; IDSA [Mermel 2009]; Justo 2014; Tsai 2015). Note: If heparin is utilized in the lock solution, the dose used should not approach therapeutic unit/kg dose.

C. difficile infection; treatment:

Manufacturer's labeling: Infants, Children, and Adolescents: Oral: 40 mg/kg/day divided every 6 to 8 hours for 7 to 10 days; maximum daily dose: 2,000 mg/day.

Guideline recommendations:

Non-severe infection, initial or first recurrence: Children and Adolescents: Oral: 10 mg/kg/dose 4 times daily for 10 days; maximum dose: 125 mg/dose (IDSA/SHEA [McDonald 2018]).

Severe/fulminant infection, initial: Children and Adolescents:

Oral: 10 mg/kg/dose 4 times daily for 10 days; maximum dose: 500 mg/dose; may consider adding IV metronidazole in critically ill patients (IDSA/SHEA [McDonald 2018]). If patient is unable to tolerate oral therapy, may use nasogastric administration (ASID [Trubiano 2016]).

Rectal: Note: Consider use when ileus is present. Limited data available: Rectal enema: 500 mg in 100 mL NS; dose volume is determined by age (IDSA/SHEA [McDonald 2018]); the optimal doses have not been established in pediatric patients; suggested volumes for children: 1 to 3 years: 50 mL; 4 to 9 years: 75 mL; >10 years: 100 mL (ASID [Trubiano 2016]); administer 4 times daily with or without IV metronidazole (IDSA/SHEA [McDonald 2018]).

Second or subsequent recurrence: Children and Adolescents: Pulsed-tapered regimen: Oral: 10 mg/kg/dose 4 times daily for 10 to 14 days; then 10 mg/kg/dose twice daily for 7 days, then 10 mg/kg/dose once daily for 7 days, then 10 mg/kg/dose every 2 or 3 days for 2 to 8 weeks; maximum dose: 125 mg/dose (IDSA/SHEA [McDonald 2018]).

Endocarditis, treatment: Note: Dosage adjustment to target trough serum concentrations of 10 to 15 mg/L is recommended in pediatric endocarditis by the AHA (AHA [Baltimore 2015]). Dosage adjustment to target AUC24 of 400 mg•hour/L has been recommended in the treatment of proven or suspected MRSA infections based on adult data (ASHP/IDSA/SIDP/PIDS [Rybak 2020]).

Empiric therapy/culture negative: Children and Adolescents: IV: Initial: 60 mg/kg/day divided every 6 hours; initial maximum daily dose: 2,000 mg/day; use in combination with other antibiotics for at least 4 to 6 weeks; longer duration may be required if prosthetic material is present or in cases of recurrent endocarditis (AHA [Baltimore 2015]).

Streptococcus (including enterococcus): Children and Adolescents: IV: Initial: 40 mg/kg/day divided every 8 to 12 hours; initial maximum daily dose: 2,000 mg/day; treat for at least 4 to 6 weeks; a longer duration and additional antibiotics may be required depending on organism and presence of prosthetic material (AHA [Baltimore 2015]).

S. aureus:

Non-methicillin resistant: Children and Adolescents: IV: Initial: 40 mg/kg/day divided every 8 to 12 hours; initial maximum daily dose: 2,000 mg/day; treat for at least 4 to 6 weeks; a longer duration and additional antibiotics may be required depending on organism and presence of prosthetic material (AHA [Baltimore 2015]).

Methicillin-resistant: Children and Adolescents: IV: Initial: 40 mg/kg/day divided every 8 to 12 hours for at least 6 weeks; usual initial maximum daily dose: 2,000 mg/day (AHA [Baltimore 2015]); however, higher initial doses have been recommended for patients with serious MRSA infection with normal renal function, though dosing based on studies and models that were not specific to endocarditis (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). See "MRSA infection, serious; treatment".

Enterocolitis (S. aureus): Infants, Children, and Adolescents: Oral: 40 mg/kg/day divided every 6 to 8 hours for 7 to 10 days; maximum daily dose: 2,000 mg/day.

Meningitis, including health care-associated meningitis: Infants, Children, and Adolescents: IV: Initial: 15 mg/kg/dose every 6 hours (IDSA [Tunkel 2004]; IDSA [Tunkel 2017]). Higher initial doses have been recommended for patients with serious MRSA infection with normal renal function, though dosing based on studies and models that were not specific to meningitis (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). See "MRSA infection, serious; treatment".

MRSA infection, serious; treatment:

Note: Doses should be adjusted based on patient-specific serum concentrations to a target AUC24 of 400 mg•hour/L, but potentially up to 600 mg•hour/L, based on adult data. In pediatric patients, an AUC24 of ≥400 mg•hour/L has been associated with trough concentrations of 7 to 10 mg/L, though trough concentrations do not clearly predict AUC on an individual level and trough-only monitoring is not recommended (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Frymoyer 2013; Le 2013). Some studies have indicated that doses on the lower end of the range (ie, 60 mg/kg/day divided every 6 hours) will achieve target AUC24 in most children (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Frymoyer 2013). To minimize risk of acute kidney injury, maintain AUC24 <800 mg•hour/L and trough <15 mg/L. For obese patients, start with a one-time loading dose of 20 mg/kg (based on total body weight), then start maintenance dosing (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Infants ≥3 months and Children <12 years: IV: Initial: 60 to 80 mg/kg/day in divided doses every 6 hours; initial maximum daily dose: 3,600 mg/day.

Children ≥12 years and Adolescents: IV: Initial: 60 to 70 mg/kg/day in divided doses every 6 to 8 hours; initial maximum daily dose: 3,600 mg/day.

Peritonitis (peritoneal dialysis) (ISPD [Warady 2012]): Limited data available:

Prophylaxis: Infants, Children, and Adolescents:

Touch contamination of PD line (if known MRSA colonization): Intraperitoneal: 25 mg per liter.

High-risk gastrointestinal procedures: Note: Use should be reserved for patients at high risk for MRSA: IV: 10 mg/kg administered 60 to 90 minutes before procedure; maximum dose: 1,000 mg.

Treatment: Infants, Children, and Adolescents:

Intermittent: Intraperitoneal: Initial dose: 30 mg/kg in the long dwell; subsequent doses: 15 mg/kg/dose every 3 to 5 days during the long dwell; Note: Increased clearance may occur in patients with residual renal function; subsequent doses should be based on serum concentration obtained 2 to 4 days after the previous dose; redosing should occur when serum concentration <15 mcg/mL.

Continuous: Intraperitoneal: Loading dose: 1,000 mg per liter of dialysate; maintenance dose: 25 mg per liter.

Pneumonia, community-acquired: Infants >3 months, Children, and Adolescents: IV: Initial: 40 to 60 mg/kg/day in divided doses every 6 to 8 hours; (IDSA/PIDS [Bradley 2011]). Note: Higher doses may be necessary when treating MRSA infections; doses should be adjusted based on patient-specific serum concentrations to a target AUC24 of 400 mg•hour/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). See "MRSA infection, serious; treatment".

Skin and skin structure infections, complicated: Note: Duration of treatment should be individualized and is dependent on severity of infection, adequacy of source control, and clinical improvement. For necrotizing fasciitis, continue treatment until further debridement is not necessary, patient has clinically improved, and patient is afebrile for 48 to 72 hours.

Necrotizing infections, mixed (non-MRSA): Infants, Children, and Adolescents: IV: Initial: 10 to 13 mg/kg/dose every 8 hours (IDSA [Stevens 2014]).

Serious MRSA infection, including necrotizing infection and pyomyositis: Note: Dosage adjustment to target AUC24 of 400 mg•hour/L recommended for serious MRSA infections based on adult data. A loading dose of 20 mg/kg (based on total body weight) is recommended in obese patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Infants ≥3 months and Children <12 years: IV: Initial: 60 mg/kg/day in divided doses every 6 hours; maximum daily dose: 3,600 mg/day (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Stevens 2014]). Based on pharmacokinetic modeling studies, doses up to 80 mg/kg/day may be necessary to achieve target AUC24 (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Children ≥12 years and Adolescents: IV: Initial: 60 mg/kg/day in divided doses every 6 to 8 hours; maximum daily dose: 3,600 mg/day (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Stevens 2014]). Based on pharmacokinetic modeling studies, doses up to 70 mg/kg/day may be necessary to achieve target AUC24 (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Surgical (perioperative) prophylaxis: Infants, Children, and Adolescents: IV: 15 mg/kg/dose within 120 minutes prior to surgical incision. May be administered in combination with other antibiotics depending upon the surgical procedure (ASHP/IDSA/SIS/SHEA [Bratzler 2013]).

Ventriculitis (including health care-associated ventriculitis and cerebrospinal fluid [CSF] shunt infections):

Infants, Children, and Adolescents: Limited data available: Intraventricular or intrathecal: Use a preservative-free preparation: 5 to 20 mg/day; usual dose: 10 or 20 mg/day (IDSA [Tunkel 2004]; IDSA [Tunkel 2017]); due to the smaller CSF volume in infants, some guidelines recommend decreasing the infant dose; adult dosage recommendations are based on ventricle size (IDSA [Tunkel 2017]).

Continuous infusion dosing: Limited data available; optimal dosing unknown:

Infants, Children, and Adolescents: IV: Loading dose: 10 to 15 mg/kg/dose administered over 1 to 2 hours, followed by maintenance infusion of 40 to 60 mg/kg/day; adjust dose to achieve target serum concentration (Berthaud 2019; Genuini 2018; Girand 2020; Guilhaumou 2016; Hurst 2019; McKamy 2012). Note: Required dose to achieve target concentration varies significantly between patients and depending on age, renal function, and target concentration; total daily doses of 30 to 110 mg/kg/day have been reported (Berthaud 2019; Hurst 2019). Pediatric patients with cancer or who are critically ill may require higher doses to achieve target concentrations (Genuini 2018; Guilhaumou 2016). Note: When transitioning from intermittent to continuous infusion, an initial loading dose may not be required; the total daily dose will likely need reduced depending on patient-specific factors, concentrations achieved during intermittent dosing, and clinical considerations (Hurst 2019).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

Oral: There are no dosage adjustments provided in manufacturer's labeling; however, dosage adjustment unlikely due to low systemic absorption.

IV: Note: Vancomycin levels should be monitored in patients with any renal impairment:

Infants, Children, and Adolescents: The following adjustments have been recommended (Aronoff 2007): Note: Renally-adjusted dose recommendations are based on intravenous doses of 10 mg/kg/dose every 6 hours or 15 mg/kg/dose every 8 hours.

GFR 30 to 50 mL/minute/1.73 m2: 10 mg/kg/dose every 12 hours.

GFR 10 to 29 mL/minute/1.73 m2: 10 mg/kg/dose every 18 to 24 hours.

GFR <10 mL/minute/1.73 m2: 10 mg/kg/dose; redose based on serum concentrations.

Intermittent hemodialysis: 10 mg/kg/dose; redose based on serum concentrations.

Peritoneal dialysis (PD): 10 mg/kg/dose; redose based on serum concentrations.

Continuous renal replacement therapy (CRRT): 10 mg/kg/dose every 12 to 24 hours; monitor serum concentrations.

Dosing: Hepatic Impairment: Pediatric

Oral: There are no dosage adjustments provided in the manufacturer's labeling; however, dosage adjustment unlikely needed due to low systemic absorption.

IV: There are no dosage adjustments provided in the manufacturer's labeling; however, degrees of hepatic dysfunction do not affect the pharmacokinetics of vancomycin (Marti 1996).

Dosing: Adult

(For additional information see "Vancomycin: Drug information")

Usual dosage range: Note: Initial IV dosing in nonobese patients should be based on actual body weight; subsequent dosing should generally be adjusted based on therapeutic monitoring. Trough monitoring has traditionally been used for therapeutic monitoring; however, for serious methicillin-resistant S. aureus (MRSA) infections (eg, bacteremia, infective endocarditis, meningitis, osteomyelitis, pneumonia, sepsis), AUC monitoring is preferred (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). For patients with uncomplicated skin and soft tissue infections who are not obese and have normal renal function, therapeutic monitoring is generally not needed (IDSA [Liu 2011]). Risk of toxicity (eg, acute kidney injury) increases as a function of trough concentration, especially when trough is maintained above 15 to 20 mg/L; recent data suggest risk increases along the vancomycin AUC continuum, especially when daily AUC exceeds 650 to 1,300 mg•h/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Oral: Note: Ineffective for treating systemic infections: 125 to 500 mg 4 times daily.

IV: Note: Ineffective for treating C. difficile infections.

Intermittent infusion: 15 to 20 mg/kg/dose (rounded to the nearest 250 mg) every 8 to 12 hours initially; for serious MRSA infections (eg, bacteremia, infective endocarditis, meningitis, osteomyelitis, pneumonia, sepsis), adjust based on therapeutic monitoring to achieve a target AUC/minimum inhibitory concentration (MIC) determined by broth microdilution (MICBMD) ratio of 400 to 600 (assuming a vancomycin MICBMD of 1 mg/L; see "Reference Range" for more information). Trough-only monitoring (target trough: 15 to 20 mg/L) is no longer recommended in patients with serious MRSA infections (ASHP/IDSA/PIDS/SIDP [Rybak 2020]), but may be needed in nonserious MRSA or non-MRSA infections. Early and frequent monitoring for dosage adjustments is recommended, especially when empiric doses exceed 4 g/day (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Loading dose: Seriously ill patients with documented/suspected MRSA infection: A loading dose of 20 to 35 mg/kg (based on actual body weight; maximum: 3 g/dose) may be considered to rapidly achieve target concentrations. After administration of the loading dose, the initiation of the maintenance dose should occur at the next dosing interval (eg, for a prescribed interval of every 8 hours, initiate the maintenance dose 8 hours after the start of the loading dose) (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Continuous infusion: Note: May be considered for critically ill patients who are unable to achieve AUC target with intermittent infusion dosing. Loading dose: 15 to 20 mg/kg, followed by a maintenance continuous infusion dose of 30 to 40 mg/kg/day (up to 60 mg/kg/day) to achieve a target steady state concentration of 20 to 25 mg/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Indication-specific dosing:

Bloodstream infection

Bloodstream infection:

Empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Liu 2011]). Treat uncomplicated S. aureus infection for ≥14 days from first negative blood culture, with longer courses warranted for endocarditis or metastatic sites of infection (IDSA [Liu 2011]; IDSA [Mermel 2009]).

Empiric therapy or pathogen-specific therapy for methicillin-resistant coagulase-negative staphylococci: IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring. Treat uncomplicated bacteremia for 5 to 7 days from day of first negative blood culture, with longer courses warranted for endocarditis or metastatic sites of infection (IDSA [Mermel 2009]; Tufariello 2020). For catheter-related bloodstream infections, consider antibiotic lock therapy for catheter salvage, in addition to systemic therapy (IDSA [Mermel 2009]).

Antibiotic lock technique (catheter-salvage strategy) (off-label use): Note: For infections caused by susceptible organisms when the catheter cannot be removed; use in addition to systemic antibiotics. Catheter salvage is not recommended for S. aureus (Girand 2019; IDSA [Mermel 2009]).

Intracatheter: Prepare lock solution to final concentration of vancomycin 2.5 to 5 mg/mL; may be combined with heparin. Instill into each lumen of the catheter access port using a volume sufficient to fill the catheter (2 to 5 mL) with a dwell time of up to 72 hours, depending on frequency of catheter use. Withdraw lock solution prior to catheter use; replace with fresh vancomycin lock solution after catheter use. Antibiotic lock therapy is given for the same duration as systemic antibiotics (IDSA [Mermel 2009]; LaPlante 2007).

Cerebrospinal fluid shunt infection

Cerebrospinal fluid shunt infection (off-label use): As a component of empiric therapy or pathogen-specific therapy (eg, methicillin-resistant S. aureus or coagulase-negative staphylococci):

IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (IDSA [Tunkel 2017]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Intraventricular (adjunct to systemic therapy; use a preservative-free preparation): 5 to 20 mg/day; some experts recommend adjusting dosage and administration interval based on cerebrospinal fluid (CSF) vancomycin concentrations (goal: 10 to 20 times MIC of causative organism), ventricular size, and daily output from ventricular drain (IDSA [Tunkel 2017]); data for monitoring are limited (Smetana 2018). When intraventricular vancomycin is administered via a ventricular drain, clamp drain for 15 to 60 minutes after administration (allows solution to equilibrate in CSF) (IDSA [Tunkel 2004]; IDSA [Tunkel 2017]). Note: Intraventricular administration is generally reserved for use in patients who fail parenteral therapy despite removal of CSF shunt or when CSF shunt cannot be removed (Baddour 2019).

Clostridioides difficile infection, prophylaxis

Clostridioides difficile infection, prophylaxis (off-label use):

Note: For patients with a recent history of C. difficile infection (CDI) who subsequently require systemic antibiotics. Some experts reserve for patients who are older (≥65 years of age) or are significantly immunocompromised who have been hospitalized with severe CDI in the past 3 months (ACG [Kelly 2021b]); other experts consider use for any patients with CDI in the prior 12 months (Kelly 2021a).

Oral: 125 mg once daily; continue for 5 to 7 days after completion of systemic antibiotics (ACG [Kelly 2021b]; Kelly 2021a).

Clostridioides difficile infection, treatment

Clostridioides difficile infection, treatment:

Note: Criteria for disease severity is based on expert opinion and should not replace clinical judgment. There is no role for vancomycin doses other than 125 mg and 500 mg (ACG [Kelly 2021b]; IDSA/SHEA [Johnson 2021]).

Initial, nonfulminant infection (alternative agent): Oral: 125 mg 4 times daily (ACG [Kelly 2021b]; IDSA/SHEA [Johnson 2021]). Usual duration is 10 days; if delayed response to treatment, a longer duration (eg, up to 14 days) may be considered (IDSA/SHEA [McDonald 2018]). If antibiotic(s) for a primary infection are essential, some experts extend CDI treatment one week beyond other antibiotic(s) (Kelly 2021a).

Recurrent, nonfulminant infection (alternative agent): Note: Regimen selection depends on prior treatment (ACG [Kelly 2021b]; IDSA/SHEA [Johnson 2021]).

Oral: 125 mg 4 times daily (IDSA/SHEA [Johnson 2021]). Some experts reserve for patients who did not receive vancomycin for the initial episode (IDSA/SHEA [Johnson 2021]). Usual duration is 10 days; if delayed response to treatment, a longer duration (eg, up to 14 days) may be considered (IDSA/SHEA [McDonald 2018]). If antibiotic(s) for a primary infection are essential, some experts extend CDI treatment one week beyond other antibiotic(s) (Kelly 2021a).

Pulsed-tapered regimen: Oral: 125 mg 4 times daily for 10 to 14 days, then 125 mg twice daily for 7 days, then 125 mg once daily for 7 days, then 125 mg every 2 or 3 days for 2 to 8 weeks (ACG [Kelly 2021b]; IDSA/SHEA [Johnson 2021]).

Combination regimen with rifaximin: Note: Rifaximin resistance may be a concern; some experts avoid in patients who have previously received rifamycins, and others do not routinely recommend this regimen (ACG [Kelly 2021b]; Kelly 2021a).

Oral: 125 mg 4 times daily for 10 days followed by rifaximin (IDSA/SHEA [Johnson 2021]).

Fulminant infection (ie, ileus, megacolon, and/or hypotension/shock): Oral or via nasogastric tube: 500 mg 4 times daily with IV metronidazole; if ileus is present, may consider vancomycin retention enema (ACG [Kelly 2021b]; IDSA/SHEA [Johnson 2021]). Usual duration is 10 days; if delayed response to treatment, a longer duration (eg, up to 14 days) may be considered (Kelly 2021a). If antibiotic(s) for a primary infection are essential, some experts extend CDI treatment one week beyond other antibiotic(s) (Kelly 2021a).

Fulminant infection with ileus: Rectal retention enema (off-label route): 500 mg in 100 mL NS; retained for as long as possible and replaced every 6 hours. Use in combination with oral vancomycin (if the ileus is partial) or in place of oral vancomycin (if the ileus is complete) plus IV metronidazole (ACG [Kelly 2021b]). Note: Optimal regimen not established. Use of rectal vancomycin should be reserved for patients who have not responded to standard therapy and performed by individuals with expertise in administration, as there is risk of colonic perforation. Usual duration is 10 days; if delayed response to treatment, a longer duration (eg, up to 14 days) may be considered. If antibiotic(s) for a primary infection are essential, some experts extend CDI treatment one week beyond other antibiotic(s) (Kelly 2021a).

Cystic fibrosis, acute pulmonary exacerbation, moderate to severe

Cystic fibrosis, acute pulmonary exacerbation, moderate to severe (off-label use): Empiric or pathogen-directed therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose every 8 hours initially; adjust based on therapeutic monitoring (Pettit 2017; Simon 2022). Duration is usually 10 to 14 days depending on clinical response (Flume 2009; Goss 2021).

Diabetic foot infection, moderate to severe

Diabetic foot infection, moderate to severe (off-label use): Empiric or pathogen-directed therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). Duration (which may include appropriate oral step-down therapy) is usually 2 to 4 weeks in the absence of osteomyelitis (IDSA [Lipsky 2012]; Weintrob 2019).

Endocarditis, treatment

Endocarditis, treatment:

Enterococcus (native or prosthetic valve) (penicillin-resistant strains or patients unable to tolerate beta-lactams): IV: 15 mg/kg/dose every 12 hours initially; adjust to obtain a trough concentration of 10 to 20 mg/L (AHA [Baddour 2015]); some experts favor a trough of 15 to 20 mg/L (BSAC [Gould 2012]; ESC [Habib 2015]). Administer in combination with gentamicin for 6 weeks (AHA [Baddour 2015]).

S. aureus, methicillin-resistant or methicillin-susceptible (severe-beta lactam hypersensitivity) (alternative agent): IV:

Native valve: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (AHA [Baddour 2015]; ASHP/IDSA/PIDS/SIDP [Rybak 2020]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). Duration of therapy is 6 weeks (AHA [Baddour 2015]).

Prosthetic valve: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (AHA [Baddour 2015]; ASHP/IDSA/PIDS/SIDP [Rybak 2020]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). Duration of therapy is at least 6 weeks (combine with rifampin for the entire duration of therapy and gentamicin for the first 2 weeks) (AHA [Baddour 2015]; IDSA [Liu 2011]).

Viridans group streptococci and S. bovis (native or prosthetic valve) (penicillin or ceftriaxone intolerance): IV: 15 mg/kg/dose every 12 hours initially; adjust based on therapeutic monitoring. Duration of therapy is 4 weeks (native valve) or 6 weeks (prosthetic valve) (AHA [Baddour 2015]).

Endophthalmitis, treatment

Endophthalmitis, treatment (off-label use): Intravitreal: Usual dose: 1 mg per 0.1 mL NS or sterile water injected into vitreum, usually in combination with ceftazidime (Durand 2020; Endophthalmitis Vitrectomy Study Group 1995). A repeat dose(s) may be considered at 24 to 48 hours based on culture result, severity of the infection, and response to treatment (Durand 2020).

Intra-abdominal infection, health care–associated

Intra-abdominal infection, health care–associated (off-label use): Empiric or pathogen-directed therapy for Enterococcus spp. in high-risk patients (eg, postoperative infection or health careassociated infection in patients with prior use of antibiotics that select for Enterococcus, immunocompromising condition, valvular heart disease, or prosthetic intravascular material): IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; SIS/IDSA [Solomkin 2010]). Use as part of an appropriate combination regimen (Barshak 2021; SIS [Mazuski 2017]; SIS/IDSA [Solomkin 2010]). Total duration of therapy (which may include transition to oral antibiotics) is 4 to 5 days following adequate source control (Sawyer 2015; SIS [Mazuski 2017]).

Intracranial abscess or spinal epidural abscess

Intracranial abscess (brain abscess, intracranial epidural abscess) or spinal epidural abscess (off-label use): As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus : IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring. A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Liu 2011]). Duration generally ranges from 4 to 8 weeks for brain abscess and spinal epidural abscess and 6 to 8 weeks for intracranial epidural abscess (Bodilsen 2018; Sexton 2021; Sexton 2019b; Southwick 2020).

Meningitis, bacterial

Meningitis, bacterial (off-label use): As a component of empiric therapy or pathogen-specific therapy (eg, methicillin-resistant S. aureus or penicillin- and cephalosporin-resistant S. pneumoniae): IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Tunkel 2004]; IDSA [Tunkel 2017]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Liu 2011]).

Osteomyelitis

Osteomyelitis : As a component of empiric therapy or pathogen-specific therapy (eg, methicillin-resistant S. aureus): IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially (IDSA [Berbari 2015]; IDSA [Liu 2011]); adjust based on therapeutic monitoring. A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). Duration is generally ≥6 weeks; shorter courses are appropriate if the affected bone is completely resected (IDSA [Berbari 2015]; Osmon 2019).

Peritonitis, treatment

Peritonitis, treatment (peritoneal dialysis patients) (off-label use): Note: Intraperitoneal administration is preferred to IV administration. Adjust to obtain a trough concentration between 15 and 20 mg/L (ISPD [Li 2016]). Consider a 25% dose increase in patients with significant residual renal function (urine output >100 mL/day) (ISPD [Li 2010]; ISPD [Li 2016]; Mancini 2018; Szeto 2018).

Intermittent (preferred): Intraperitoneal: 15 to 30 mg/kg added to one exchange of dialysate every 5 to 7 days (allow to dwell for ≥6 hours); supplemental doses and more frequent monitoring of serum levels may be needed for patients receiving automated peritoneal dialysis (ISPD [Li 2016]).

Continuous (with every exchange): Intraperitoneal: Loading dose: 30 mg/kg added to first exchange of dialysate; maintenance dose: 1.5 mg/kg/bag for each subsequent exchange of dialysate (Bunke 1983; ISPD [Li 2016]).

Pneumonia

Pneumonia, as a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Liu 2011]; IDSA/ATS [Metlay 2019]). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2009]; IDSA [Liu 2011]). Note: Duration of therapy varies based on disease severity and response to therapy; treatment is typically given for 7 days. When used for empiric therapy, give as part of an appropriate combination regimen (IDSA/ATS [Metlay 2019]; IDSA/ATS [Kalil 2016]; IDSA [Liu 2011]).

Prosthetic joint infection

Prosthetic joint infection (off-label use): IV:

Pathogen-specific therapy for methicillin-resistant or susceptible S. aureus (alternative agent in beta-lactam intolerance): 15 to 20 mg/kg/dose every 8 to 12 hours initially (Berbari 2019; IDSA [Liu 2011]; IDSA [Osmon 2013]); adjust based on therapeutic monitoring. A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). Duration ranges from 2 to 6 weeks depending on prosthesis management, use of rifampin, and other patient-specific factors (IDSA [Osmon 2013]).

Pathogen-specific therapy for Enterococcus spp (penicillin susceptible [alternative agent] or penicillin resistant): 15 mg/kg/dose every 12 hours initially; adjust based on therapeutic monitoring. Duration: 4 to 6 weeks (Berbari 2019; IDSA [Osmon 2013]).

Note: In select cases (eg, debridement and retention of prosthesis or one-stage arthroplasty), give oral suppressive antibiotic therapy with an appropriate regimen following completion of initial treatment (Berbari 2019; IDSA [Osmon 2013]).

Sepsis/septic shock

Sepsis/septic shock: As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus: IV: 15 to 20 mg/kg/dose every 8 to 12 hours; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). A loading dose is recommended; administer within 1 hour of suspected or confirmed sepsis (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; SCCM [Rhodes 2017]). Usual duration of therapy is dependent on underlying source, but is typically 7 to 10 days or longer, depending on clinical response (SCCM [Rhodes 2017]).

Septic arthritis, without prosthetic material

Septic arthritis, without prosthetic material: As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus or coagulase-negative staphylococci: IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust dose on therapeutic monitoring. A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). Total treatment duration is 3 to 4 weeks (in the absence of osteomyelitis), including appropriate oral step-down therapy (Goldenberg 2020; IDSA [Liu 2011]); some experts recommend 4 weeks of parenteral therapy for patients with concomitant bacteremia (Goldenberg 2020).

Skin and soft tissue infection

Skin and soft tissue infection (hospitalized patient): As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus : IV: 15 mg/kg/dose every 12 hours initially (IDSA [Stevens 2014]). For patients with uncomplicated skin and soft tissue infections who are not obese and have normal renal function, therapeutic monitoring is generally not needed; for complicated or severe infections, adjust based on therapeutic monitoring (IDSA [Liu 2011]; IDSA [Stevens 2014]). Note: For empiric therapy of necrotizing infection, must be used in combination with other agents (IDSA [Stevens 2014]).

Streptococcus, maternal prophylaxis for prevention of neonatal disease

Streptococcus (group B), maternal prophylaxis for prevention of neonatal disease (alternative agent) (off-label use):

IV: 20 mg/kg at the onset of labor or prelabor rupture of membranes, then every 8 hours until delivery; maximum single dose: 2 g (ACOG 2020). Some experts prefer vancomycin 2 g initially and then 1 g every 12 hours thereafter until delivery (Baker 2020). Note: Vancomycin is reserved for patients with penicillin allergy at high risk for anaphylaxis that have documented clindamycin-resistant group B Streptococcus or no available susceptibility data (ACOG 2020).

Surgical prophylaxis

Surgical prophylaxis (in combination with other appropriate agents when coverage for methicillin-resistant S. aureus is indicated or for gram-positive coverage in patients unable to tolerate beta-lactams) (off-label use): IV: 15 mg/kg (usual maximum: 2 g/dose initially [Anderson 2020]) started within 60 to 120 minutes prior to initial surgical incision. Vancomycin doses may be repeated intraoperatively in 2 half-lives (approximately 8 to 12 hours in patients with normal renal function) if procedure is lengthy or if there is excessive blood loss (ASHP/IDSA/SIS/SHEA [Bratzler 2013]). In cases where an extension of prophylaxis is warranted postoperatively, total duration should be ≤24 hours (Anderson 2014). Postoperative prophylaxis is not recommended in clean and clean-contaminated surgeries (CDC [Berrios-Torres 2017]).

Surgical site infection

Surgical site infection: As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus: IV: 15 mg/kg/dose every 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; IDSA [Stevens 2014]).

Toxic shock syndrome, staphylococcal

Toxic shock syndrome, staphylococcal: As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus : IV: 15 to 20 mg/kg/dose every 8 to 12 hours initially; adjust based on therapeutic monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Chu 2021). A loading dose may be considered in seriously ill patients (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). Duration varies based on underlying etiology; 10 to 14 days of treatment is recommended in the absence of bacteremia or other distinct focus of infection (Chu 2021).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Oral: There are no dosage adjustments provided in the manufacturer's labeling. However, dosage adjustment unlikely due to low systemic absorption.

IV:

Note: Initial IV dosing in nonobese patients should be based on actual body weight; subsequent dosing should generally be adjusted based on therapeutic monitoring. Trough monitoring has traditionally been used for therapeutic monitoring; however, for serious methicillin-resistant S. aureus (MRSA) infections (eg, bacteremia, infective endocarditis, meningitis, osteomyelitis, pneumonia, sepsis), AUC monitoring is preferred (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). A ratio of AUC over 24 hours to minimum inhibitory concentration (AUC/MIC) of ≥400 is the primary pharmacokinetic/pharmacodynamic predictor of vancomycin efficacy in serious MRSA infections (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Holmes 2013; Kullar 2011). Serum concentration monitoring should be conducted within the first 48 hours of therapy for patients with suspected or documented serious infections due to MRSA, with subsequent dosing adjusted to maintain AUC/MIC between 400 to 600 in order to maximize efficacy and minimize risk of vancomycin nephrotoxicity (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Moise-Broder 2004; Suzuki 2012; Zasowski 2017).

Altered kidney function:

Intermittent infusion: Note: The following table provides general recommendations (expert opinion derived from ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Golightly 2013). Refer to institution-specific policies and procedures for more detailed guidance.

Vancomycin Initial Dose Adjustments in Altered Kidney Function

CrCl (mL/minute)

Suggested loading dose (when applicable)a

Suggested initial maintenance dose

Suggested dosing interval

aLoading doses recommended in critically ill patients with suspected/documented serious MRSA infections. A loading dose of up to 35 mg/kg may be considered in critically ill patients with sepsis. Obese patients usually require 20 to 25 mg/kg loading doses. Maximum recommended loading dose is 3 g (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

bMonitor vancomycin serum concentrations more frequently, especially early on in therapy, to achieve target concentrations as these patients may have unstable or less predictable drug clearance. Care should be taken not to administer maintenance doses when serum concentrations remain >20 mg/L (Golightly 2013; expert opinion).

>90 to <130

25 to 30 mg/kg

15 to 20 mg/kg

8 to 12 hours

50 to 90

20 to 25 mg/kg

15 to 20 mg/kg

12 hours

15 to <50

20 to 25 mg/kg

10 to 15 mg/kg

24 hours

<15b

20 to 25 mg/kg

10 to 15 mg/kg

48 to 72 hours

Continuous infusion:

Loading dose: Administer an appropriate loading dose (eg, 15 to 20 mg/kg) (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Baptista 2014; Pea 2009); higher loading doses may be considered in critically ill patients with sepsis (Cristallini 2016; Ocampos-Martinez 2012); also refer to institution-specific policies and procedures.

Maintenance dose: Various protocols have been developed (Baptista 2014; Cristallini 2016; Ocampos-Martinez 2012; Pea 2009; Spadaro 2015); recommendations may vary based on the population studied. The following is an example protocol (Cristallini 2016), and doses should be adjusted to achieve a target steady state concentration of 20 to 25 mg/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]); also refer to institution-specific policies and procedures.

CrCl >80 to 119 mL/minute: 30 mg/kg administered over 24 hours.

CrCl >50 to 80 mL/minute: 25 mg/kg administered over 24 hours.

CrCl 25 to 50 mL/minute:14 mg/kg administered over 24 hours.

CrCl <25 mL/minute: 7 mg/kg administered over 24 hours.

Augmented renal clearance (measured urinary CrCl ≥130 mL/minute/1.73 m2): Augmented renal clearance (ARC) is a condition that occurs in certain critically ill patients without organ dysfunction and with normal serum creatinine concentrations. Young patients (<55 years of age) admitted post-trauma or major surgery are at highest risk for ARC, as well as those with sepsis, burns, or hematologic malignancies. An 8- to 24-hour measured urinary CrCl is necessary to identify these patients (Bilbao-Meseguer 2018; Udy 2010).

Intermittent infusion: Loading dose (when applicable): 25 to 35 mg/kg (expert opinion) followed by 15 to 20 mg/kg every 8 hours depending on degree of augmented kidney function; some patients may require more frequent dosing (eg, 15 mg/kg every 6 hours) to attain target concentrations (Kim 2016; Lin Wu 2015; expert opinion); utilize frequent serum concentration monitoring.

Continuous infusion:

Loading dose: Administer an appropriate loading dose (eg, 15 to 20 mg/kg) (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Baptista 2014; Pea 2009); higher loading doses (eg, 25 mg/kg) have been used in some protocols and may vary based on population studied (Cristallini 2016; Vu 2019); also refer to institution-specific policies and procedures.

Maintenance dose: 40 to 60 mg/kg/day depending on degree of augmented kidney function with frequent serum concentration monitoring; adjust to achieve a target steady state concentration of 20 to 25 mg/L (Baptista 2014; Cristallini 2016; Pea 2009; Schmelzer 2013; Vu 2019; expert opinion).

Hemodialysis, intermittent (thrice weekly): Dialyzable (25% to 40% depending on dialyzer permeability) (Lucksiri 2002; Nyman 2018; Scott 1997).

Vancomycin Dosing Depending on Dose Timing and Dialyzer Permeabilitya

Dose timing and dialyzer permeability

Vancomycin doseb

aASHP/IDSA/PIDS/SIDP [Rybak 2020]

bInitial recommended loading/maintenance doses. The optimal pharmacokinetic/pharmacodynamic target in this population is unknown, but targeting predialysis concentrations of 15 to 20 mg/L are likely to achieve AUCs of 400 to 600 mg•hour/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Crew 2015). Predialysis serum concentrations should be obtained no less than weekly and should determine subsequent dosing (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

cThrice-weekly dose administration. Typically, patients may require ~25% larger doses for the 3-day interdialytic period (eg, Friday to Monday) to maintain sufficient vancomycin exposure on the third day.

Dose given after dialysis ends

Low permeability (low flux)

Loading dose: 25 mg/kg

Maintenance dose: 7.5 mg/kgc

High permeability (high flux)

Loading dose: 25 mg/kg

Maintenance dose: 10 mg/kgc

Dose given during last hours of dialysis (intradialytic)

Low permeability (low flux)

Loading dose: 30 mg/kg

Maintenance dose: 7.5 to 10 mg/kgc

High permeability (high flux)

Loading dose: 35 mg/kg

Maintenance dose: 10 to 15 mg/kgc

Peritoneal dialysis:

Loading dose: 20 to 25 mg/kg (expert opinion). A vancomycin serum concentration should be obtained ~48 to 72 hours after the loading dose, and subsequent doses (usually 10 to 15 mg/kg) should be administered based on attainment of goal serum concentrations (expert opinion). Doses may vary based on infection site and severity, as well as the presence or absence of residual renal function. Some experts use maintenance doses of up to 20 mg/kg/dose (Drew 2019).

CRRT: Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Recommendations are based on high-flux dialyzers and effluent flow rates of 20 to 25 mL/kg/hour (or ~1,500 to 3,000 mL/hour) unless otherwise noted. Close monitoring of response and adverse reactions due to drug accumulation is important.

Loading dose: 20 to 25 mg/kg followed by 7.5 to 10 mg/kg every 12 hours with more frequent serum concentration monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). In patients with suspected or confirmed serious MRSA infections, dose adjustments should be made based on AUC monitoring occurring in the first 24 to 48 hours of therapy (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

PIRRT (eg, sustained, low-efficiency diafiltration): Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Close monitoring of response and adverse reactions due to drug accumulation is important.

Loading dose (administer even if PIRRT is occurring): 20 to 25 mg/kg, followed by 15 mg/kg after each PIRRT session ends (or during the final 60 to 90 minutes of the session) with more frequent serum concentration monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]). In patients with suspected or confirmed serious MRSA infections, dose adjustments should be made based on AUC monitoring occurring in the first 24 to 48 hours of therapy (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Dosing: Hepatic Impairment: Adult

Oral: There are no dosage adjustments provided in the manufacturer’s labeling. However, dosage adjustment unlikely due to low systemic absorption.

IV: There are no dosage adjustments provided in the manufacturer’s labeling. However, degrees of hepatic dysfunction do not affect the pharmacokinetics of vancomycin (Marti 1996).

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Capsule, Oral, as hydrochloride:

Vancocin: 125 mg, 250 mg [contains fd&c blue #2 (indigotine)]

Generic: 125 mg, 250 mg

Kit, Intravenous, as hydrochloride:

Vancosol Pack: 1 g/100 mL in NaCl 0.9% [DSC]

Solution, Intravenous, as hydrochloride:

Generic: 750 mg/150 mL (150 mL); 1000 mg/200 mL (200 mL); 1250 mg/250 mL (250 mL); 1500 mg/300 mL (300 mL); 1750 mg/350 mL (350 mL)

Solution, Intravenous, as hydrochloride [preservative free]:

Generic: 500 mg/100 mL (100 mL); 2000 mg/400 mL (400 mL); 1 g/200 mL in Dextrose 5% (200 mL); 1 g/200 mL in NaCl 0.9% (200 mL); 500 mg/100 mL in Dextrose 5% (100 mL); 750 mg/150 mL in Dextrose 5% (150 mL)

Solution Reconstituted, Intravenous [preservative free]:

Generic: 1.25 g (1 ea)

Solution Reconstituted, Intravenous, as hydrochloride:

Generic: 500 mg (1 ea); 1 g (1 ea); 1.5 g (1 ea); 10 g (1 ea)

Solution Reconstituted, Intravenous, as hydrochloride [preservative free]:

Generic: 250 mg (1 ea [DSC]); 500 mg (1 ea); 750 mg (1 ea); 1 g (1 ea); 1.5 g (1 ea); 5 g (1 ea); 10 g (1 ea); 100 g (1 ea)

Solution Reconstituted, Oral, as hydrochloride:

Firvanq: 25 mg/mL (150 mL, 300 mL); 50 mg/mL (150 mL, 300 mL) [contains fd&c red #40, fd&c yellow #10 (quinoline yellow), sodium benzoate; grape flavor]

Firvanq: 50 mg/mL (150 mL, 300 mL) [contains fd&c red #40, fd&c yellow #10 (quinoline yellow), sodium benzoate; white grape flavor]

Generic: 250 mg/5 mL (80 mL, 150 mL, 300 mL)

Generic Equivalent Available: US

Yes

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Capsule, Oral, as hydrochloride:

Vancocin: 125 mg, 250 mg [contains fd&c blue #2 (indigotine)]

Generic: 125 mg, 250 mg

Solution, Intravenous, as hydrochloride:

Generic: 1 g/200 mL in NaCl 0.9% (200 mL)

Solution Reconstituted, Intravenous, as hydrochloride:

Generic: 500 mg (1 ea, 10 mL); 1000 mg (1 ea); 1 g (1 ea, 20 mL, 30 mL); 5 g (1 ea); 10 g (1 ea)

Dosage Forms Considerations

First-Vancomycin oral solution is a compounding kit. Refer to manufacturer’s labeling for compounding instructions.

Administration: Pediatric

Oral:

Oral solution (Firvanq): Shake reconstituted oral solution well before each use.

Powder for injection: Reconstituted powder for injection (not premixed solution) may be diluted and used for oral administration; common flavoring syrups may be added to improve taste. The unflavored, diluted solution may also be administered via nasogastric tube.

Parenteral:

IV:

Intermittent: Administer intermittent IV infusion over 60 minutes. Vancomycin infusion reaction (formerly "red man syndrome") may occur if the infusion is too rapid. It is not an allergic reaction, but may be characterized by hypotension and/or a maculopapular rash appearing on the face, neck, trunk, and/or upper extremities; if this should occur, slow the infusion rate to administer dose over 90 to 120 minutes (Healy 1990; PIDS 2021; Szymusiak-Mutnick 1996) and increase the dilution volume; the reaction usually dissipates in 30 to 60 minutes; administration of antihistamines just before the infusion may also prevent or minimize this reaction.

Continuous: Administer over 24 hours (Girand 2020; Hurst 2019).

Irritant; ensure proper needle or catheter placement prior to and during infusion. Avoid extravasation. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity. Information varies regarding the use of dry cold or dry warm compresses (Hurst 2004; Reynolds 2014); however, dry warm compresses may be of benefit in increasing local blood flow to enhance drug removal from the extravasation site. Intradermal hyaluronidase may be considered for refractory cases (Reynolds 2014).

Intrathecal/Intraventricular: Use preservative-free preparations only. Administer as diluted solution (1 to 10 mg/mL) over 1 to 2 minutes (Al-Jeraisy 2004; Cook 2009; Parasuraman 2018; Pfausler 1997). When administered through a ventricular drain, clamp drain for 15 to 60 minutes to allow vancomycin solution to equilibrate in the cerebrospinal fluid (CSF) (IDSA [Tunkel 2017]).

Intracatheter (vascular); antibiotic lock technique: Instill prepared vancomycin lock solution into each lumen of the catheter access port using a volume sufficient to fill the catheter with a dwell time of ≥8 to 12 hours and up to 72 hours (dependent on frequency of catheter use). Withdraw lock solution prior to catheter use; replace with fresh vancomycin lock solution after catheter use (Denaburg 2013; IDSA [Mermel 2009]; Justo 2014).

Rectal: Instill vancomycin enema solution via rectal foley; retain for 1 hour. In pediatric patients the optimal doses have not been established; suggested volumes for pediatric patients: 1 to 3 years of age: 50 mL; 4 to 9 years of age: 75 mL; >10 years of age: 100 mL (ASID [Trubiano 2016]).

Administration: Adult

Intravenous: Administer vancomycin with a final concentration not to exceed 5 mg/mL by IV intermittent infusion over at least 60 minutes (recommended infusion period of ≥30 minutes for every 500 mg administered [ASHP/IDSA/SIDP {Rybak 2009}]); in adult patients in need of fluid restriction, a concentration up to 10 mg/mL may be used, but risk of infusion-related reactions is increased. Not for IM administration.

If a maculopapular rash appears on the face, neck, trunk, and/or upper extremities (vancomycin infusion reaction [formerly “red man syndrome”]), slow the infusion rate to over 11/2 to 2 hours and increase the dilution volume (Austin 2020; Healy 1990; Rybak 1986; Szymusiak-Mutnick 1996). Hypotension, shock, and cardiac arrest (rare) have also been reported with too rapid of infusion. Administration of antihistamines prior to infusion may prevent or minimize this reaction (Rybak 1986; Wilhem 1999).

Irritant; ensure proper needle or catheter placement prior to and during infusion. Avoid extravasation.

Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity. Information conflicts regarding the use of dry cold or dry warm compresses (Hurst 2004; Reynolds 2014); however, dry warm compresses may be of benefit in increasing local blood flow to enhance drug removal from the extravasation site. Intradermal hyaluronidase may be considered for refractory cases (Reynolds 2014).

Hyaluronidase: Intradermal: Inject a total of 1 mL (15 units/mL) as 5 separate 0.2 mL injections (using a tuberculin syringe) along injection site and edematous area (Reynolds 2014).

Antibiotic lock technique (off-label use): Instill prepared vancomycin lock solution into each lumen of the catheter access port using a volume sufficient to fill the catheter (2 to 5 mL) with a dwell time of 48 to 72 hours (dependent on frequency of catheter use). Withdraw lock solution prior to catheter use; replace with fresh vancomycin lock solution after catheter use (IDSA [Mermel 2009]; LaPlante 2007).

Intraventricular (off-label route): Use preservative-free preparations only. May be administered intraventricularly with a final concentration of 2.5 to 10 mg/mL for the treatment of CSF shunt infections. When administered through a ventricular drain, clamp drain for 15 to 60 minutes before opening the drain to allow vancomycin solution to equilibrate in the CSF (IDSA [Tunkel 2004; Tunkel 2017]; Ng 2014).

Intravitreal (off-label route): May administer vancomycin intravitreally with a final concentration of 1 mg/0.1 mL NS or sterile water (Durand 2020; Kelsey 1995).

Oral:

Solution (Firvanq): Shake reconstituted oral solution well before each use.

Injection: Reconstituted powder for injection (not premixed solution) may be diluted and used for oral administration; common flavoring syrups may be added to improve taste. The unflavored, diluted solution may also be administered via nasogastric tube.

Rectal (off-label route): May be administered as a retention enema per rectum (IDSA/SHEA [McDonald 2018]); 500 mg in 100 to 500 mL of NS, volume may depend on length of segment being treated. If sodium chloride causes hyperchloremia could use solution with lower chloride concentration (eg, LR) (ACG [Surawicz 2013]).

Storage/Stability

Capsules: Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F).

Flexible bags: Store below 25°C (77°F) in the original package. Use within 28 days of removal from aluminum overpouch. Stable at room temperature for 28 days.

Galaxy containers: Store Galaxy containers at or below -20°C (-4°F). Handle frozen product containers with care; may be fragile in the frozen state. Thaw frozen containers at 25°C (77°F) or 5°C (41°F). Do not immerse in water bath or microwave. Thawed solution in remains chemically stable for 72 hours at 25°C (77°F) or for 30 days when stored at 5°C (41°F). Do not refreeze thawed antibiotics.

Oral solution (Firvanq): Store at 2°C to 8°C (36°F to 46°F) prior to and following reconstitution; discard reconstituted solution after 14 days or if appears hazy or contains particulates. Protect from light.

Vials: Store intact vials at 20°C to 25°C (68°F to 77°F). Reconstitute vial using an appropriate diluent; recommendations may vary by product; refer to manufacturer's labeling for choice of diluent and for appropriate storage conditions and timeframes. Prior to administration, further dilution in a compatible solution is required; recommendations may vary by product; refer to manufacturer's labeling for list of compatible solutions and appropriate storage conditions and timeframes.

Pharmacy bulk packages: Store at 20°C to 25°C (68°F to 77°F). Discard pharmacy bulk packages no later than 4 hours after initial closure puncture.

Use

Parenteral: Treatment of patients with the following infections or conditions: Infections due to documented or suspected methicillin-resistant Staphylococcus aureus or beta-lactam resistant coagulase negative Staphylococcus; serious or life-threatening infections (eg, endocarditis, meningitis, osteomyelitis) due to documented or suspected staphylococcal or streptococcal infections in patients who are allergic to penicillins and/or cephalosporins; empiric therapy of infections associated with central lines, VP shunts, hemodialysis shunts, vascular grafts, prosthetic heart valves (FDA approved in all ages). Has also been used for prophylaxis of peritonitis in patients with peritoneal dialysis (PD) catheters undergoing invasive gastrointestinal procedure, touch contamination prophylaxis of PD catheter, and for the treatment of peritonitis in patients with peritoneal catheters.

Oral: Treatment of Clostridioides difficile infection and treatment of enterocolitis caused by S. aureus (including methicillin-resistant strains) (All indications: FDA approved in pediatric patients [age not specified] and adults).

Medication Safety Issues
Sound-alike/look-alike issues:

IV vancomycin may be confused with INVanz

Vancomycin may be confused with clindamycin, gentamicin, tobramycin, valACYclovir, vecuronium, Vibramycin

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication (intrathecal administration) among its list of drug classes which have a heightened risk of causing significant patient harm when used in error.

Adverse Reactions (Significant): Considerations
Anaphylaxis

Vancomycin may rarely cause life-threatening immune-mediated anaphylaxis, which may present as generalized and extensive pruritus and/or erythema of skin, respiratory distress, bronchospasm, hypoxia, and hypotension. Clinical presentation is similar to vancomycin infusion reaction (a nonimmune-mediated anaphylactoid infusion-related reaction; formerly called “red man syndrome”), making it difficult for clinicians to distinguish between the 2 reactions (Ref).

Mechanism: Non-dose-related; immunologic; IgE-mediated with specific antibodies formed against a drug allergen following initial exposure (immunologically mediated) or result in direct mast cell stimulation (Ref). IgE binding and cross-linking of the high affinity IgE receptor (FcεRI) on the surface of mast cells causes release of histamine and other mediators that can result in urticaria, flushing, airway obstruction, hypotension, and tachycardia (Ref).

Onset: Rapid; IgE-mediated reactions generally occur within 1 hour of administration but may occur up to 6 hours after exposure (Ref). In a systematic review analyzing 7 case reports of vancomycin-induced anaphylaxis, the median time to onset of signs/symptoms was 2 minutes (range: 1 to 35 minutes) (Ref).

Risk factors:

• Previous exposure to vancomycin (necessary for IgE-mediated anaphylaxis) (Ref)

Clostridioides difficile infection

Although oral vancomycin is used for the treatment of Clostridioides difficile infection (CDI), Clostridioides difficile-associated diarrhea and Clostridioides difficile colitis have been reported with intravenous vancomycin (Ref). Clinical symptoms range from mild diarrhea to life-threatening colitis, toxic megacolon, and sepsis. In patients with severe CDI, frequent symptoms include watery diarrhea, abdominal pain, fever, nausea, anorexia, and malaise (Ref).

Mechanism: Non-dose-related; antibiotics disrupt the indigenous gut microbiota which promotes C. difficile spore germination, growth, and toxin production, leading to epithelial damage and colitis (Ref).

Onset: Varied; may start on the first day of antibiotic therapy or up to 3 months postantibiotic (Ref).

Risk factors:

• Antibiotic exposure (highest risk factor); antibiotics most frequently associated with C. difficile include clindamycin, fluoroquinolones, and third-/fourth-generation cephalosporins (Ref)

• Long durations in a hospital or other health care setting (recent or current) (Ref)

• Advanced age (Ref)

• Immunocompromised conditions or a serious underlying condition (Ref)

• GI surgery/manipulation (Ref)

• Antiulcer medications, such as proton pump inhibitors and H2 blockers (suggested risk factors) (Ref)

• Chemotherapy (suggested risk factor) (Ref)

Drug-induced immune thrombocytopenia

Drug-induced immune thrombocytopenia (DITP) has been associated with use. Vancomycin-induced ITP has been associated with severe bleeding characterized by petechial hemorrhages, ecchymoses, and oozing from the buccal mucosa. Rarely, acutely-ill patients have experienced gross hematuria, lower GI hemorrhage, intrapulmonary hemorrhage, and excessive bleeding from venipuncture sites (Ref).

Mechanism: Non-dose-related; immunologic; platelet-reactive antibodies of the IgG class, the IgM class, or both, have been detected in patients with thrombocytopenia while receiving vancomycin. These antibodies reacted with platelets only in the presence of vancomycin, suggesting that the mechanism is similar to quinine-induced thrombocytopenia rather than a hapten-specific antibody (Ref).

Onset: Varied; DITP; typically occurs within 1 to 2 weeks after initiating therapy or longer in patients with intermittent exposure (Ref). In case reports, the mean time to platelet nadir count was ~8 days following first exposure. However, there are rare case reports describing a rapid onset (within 24 hours) of acute severe thrombocytopenia, primarily in settings of reexposure to vancomycin (Ref).

Hypersensitivity reactions (delayed)

Maculopapular rash and severe cutaneous adverse reactions (SCARs), including drug rash with eosinophilia and systemic symptoms (DRESS), toxic epidermal necrosis (TEN), Stevens-Johnson syndrome (SJS), and acute generalized exanthematous pustulosis (AGEP), have occurred rarely with use and may be life-threatening (Ref). In addition, vancomycin-induced dermatologic disorder (linear IgA bullous dermatosis [LABD]) has been reported rarely and clinical presentation may mimic TEN, making it difficult to distinguish (Ref). Other reactions include erythema multiforme, exfoliative dermatitis, and hypersensitivity angiitis (Ref).

Mechanism: Non-dose-related; immunologic. Delayed hypersensitivity reactions are mediated by T-cells or antibodies other than IgE (eg, IgG-mediated, such as some cytopenias) (Ref). SCARs are delayed type IV hypersensitivity reactions involving a T-cell mediated drug-specific immune response (Ref). The mechanism behind vancomycin-induced LABD is unknown; LABD is a rare immune-mediated blistering disorder resulting in linear deposition of IgA at the basement membrane zone (Ref).

Onset: Delayed; type IV reactions are delayed hypersensitivity reactions that typically occur days to weeks after drug exposure but may occur more rapidly (usually within 1 to 4 days) upon reexposure (Ref). DRESS usually does not develop until after 2 weeks of administration (Ref). In a systematic case review, a median onset of 9 days and 21 days was observed for SJS/TEN and DRESS, respectively (Ref). In vancomycin-induced LABD, lesions typically appear 1 to 15 days after the first vancomycin dose (Ref); a median latency of 7 days was observed in a systematic review (Ref).

Risk factors:

• Patients with end-stage renal disease (suggested risk factor) (Ref)

• In DRESS, a strong association was observed for patients with the HLA-A*32:01 allele in a study involving predominantly European ancestry (Ref)

• Cross-reactivity with teicoplanin (Ref)

Nephrotoxicity

Systemic exposure is associated with nephrotoxicity (usually reversible), which may result in acute kidney injury (or acute renal failure), predominantly occurring in patients with multiple risk factors (Ref). Cases of systemic absorption and nephrotoxicity with oral vancomycin have been reported (Ref).

Mechanism: Non-dose-related; most commonly attributed to acute tubular necrosis (or renal tubular necrosis), resulting from direct oxidative stress on proximal tubule cells or obstructive tubular cast formation. In addition, acute interstitial nephritis has also been described, characterized by tubular and interstitial inflammation, resulting from an immunologically mediated (non-IgE) process (Ref).

Onset: Intermediate; usually occurs 5 to 7 days and up to 14 days following monotherapy (Ref). Acute interstitial nephritis was observed at a median onset of 26 days in a systematic case review (Ref).

Risk factors:

• Vancomycin exposure (trough levels ≥15 mg/L, larger AUC [>650 to 1,300 mg-h/L], high daily doses [>4 g/day]) (Ref)

• Duration of therapy >7 days (Ref)

• Obesity (Ref)

• Preexisting kidney dysfunction (Ref)

• Critical illness (Ref)

• Concurrent nephrotoxin therapy or concurrent prolonged use of piperacillin/tazobactam (Ref)

• Older adults >65 years:

• Parenteral: Less commonly associated risk factor (Ref)

• Oral: Increases the risk of systemic absorption from oral vancomycin

Neutropenia/pancytopenia

Neutropenia (severe) and agranulocytosis have been observed in numerous case reports and case series; in some cases, drug fever also accompanied the neutropenia (Ref). Reversible pancytopenia has also been reported in case reports (Ref).

Mechanism: Non-dose-related; available data suggest a peripheral mechanism mediated by antibodies and direct toxicity to the bone marrow (Ref).

Onset: Varied; usually occurs after 7 to 12 days of treatment, with most cases occurring after 20 days (Ref). However, 1 case report described an onset of 8 weeks following discontinuation of a 3-week course, and then upon rechallenge, neutropenia recurred 3 days following reinitiation (Ref).

Risk factors:

• Prolonged exposure (ie, >7 days) (Ref)

• Teicoplanin: In patients experiencing neutropenia who were switched to teicoplanin (another glycopeptide), 50% of these patients also developed teicoplanin-induced neutropenia (Ref)

Ototoxicity

Vancomycin is infrequently associated with ototoxicity, manifested as tinnitus, sensorineural hearing loss, dizziness, or vertigo; some cases have reported irreversible hearing loss (Ref). Of note, vancomycin has not been found to be ototoxic in animal models (Ref).

Mechanism: Non-dose-related; proposed to be via direct damage to the auditory branch of the eighth cranial nerve, although data are conflicting and unclear if ototoxicity is directly attributable to vancomycin or to other confounding factors (Ref).

Risk factors:

• Older adults (Ref)

• Coadministration with ototoxic agents (eg, aminoglycosides) (Ref)

• Kidney dysfunction (potential risk factor) (Ref)

Vancomycin infusion reaction

Vancomycin infusion reaction, a non-IgE-mediated drug reaction most often characterized by an erythematous rash, generalized flushing, and pruritus, may occur. Severe reactions, which are uncommon, may also include hypotension, chest pain, and dyspnea. Rarely, RMS may be life-threatening and cause severe hypotension and cardiac arrest or cardiovascular collapse. Clinical presentation can be similar to IgE-mediated anaphylaxis making it difficult for clinicians to distinguish between the 2 reactions (Ref). Reactions usually cease promptly after infusion is stopped.

Mechanism: Non-IgE-mediated drug reaction caused by histamine release from mast cells and basophils found in the skin, lung, GI tract, myocardium, and vascular system (Ref). The mast cell receptor MRGPRX2 has also been identified as a cause of non-IgE-mediated drug reactions (Ref).

Onset: Rapid; usually occurs 4 to 10 minutes after the start of the infusion with the first dose but may also occur at any time (Ref).

Risk factors:

• Typically caused by rapid IV infusion (<1 hour) of large doses (Ref)

• Concomitant medications that also induce histamine release including ciprofloxacin; barbiturates; opioids (except fentanyl which rarely induces histamine); certain neuromuscular antagonists (atracurium, cisatracurium, doxacurium, mivacurium, succinylcholine, tubocurarine); propofol; plasma expanders (dextran, polygeline); and radiocontrast agents (Ref).

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

IV:

Frequency not defined:

Cardiovascular: Chest pain, flushing, hypotension, shock, vasculitis

Dermatologic: Bullous dermatitis, erythema of skin, exfoliative dermatitis (Forrence 1990), pruritus, Stevens-Johnson syndrome (Lin 2014)

Hematologic & oncologic: Agranulocytosis (di Fonzo 2018), eosinophilia, leukopenia, thrombocytopenia

Hypersensitivity: Hypersensitivity reaction (Kupstaite 2010)

Local: Injection site phlebitis, irritation at injection site, pain at injection site

Nervous system: Chills, dizziness, malaise, vertigo

Neuromuscular & skeletal: Myalgia

Otic: Hearing loss (Klibanov 2003), ototoxicity (Forouzesh 2009), tinnitus (Traber 1981)

Renal: Increased blood urea nitrogen (Bergman 1988), increased serum creatinine, interstitial nephritis (Bergman 1988), renal tubular necrosis (Shah-Khan 2011)

Respiratory: Dyspnea, wheezing

Miscellaneous: Fever (Smith 1999)

Postmarketing:

Cardiovascular: Hypersensitivity angiitis (rare: <1%) (Pingili 2017)

Dermatologic: Acute generalized exanthematous pustulosis (rare: <1%) (Mawri 2015), dermatologic disorder (linear IgA bullous dermatosis) (rare: <1%) (Tashima 2014), erythema multiforme (rare: <1%) (Khicher 2019), maculopapular rash (Marik 1997), toxic epidermal necrolysis (rare: <1%) (Changela 2013)

Gastrointestinal: Clostridioides difficile associated diarrhea (rare: <1%) (Hecht 1989), Clostridioides difficile colitis (rare: <1%) (Hecht 1989), peritonitis (following intraperitoneal administration during CAPD) (Freiman 1992)

Hematologic & oncologic: Henoch-Schonlein purpura (Min 2017), immune thrombocytopenia (Al Jafar 2015; Mohammadi 2017), neutropenia (reversible) (literature suggests an incidence ranging from 2% to 12%) (Black 2011; di Fonzo 2018), pancytopenia (rare: <1%) (Carmichael 1986)

Hypersensitivity: Anaphylaxis (rare: <1%) (Anne 1994), fixed drug eruption (Gilmore 2004), vancomycin infusion reaction (literature suggests an incidence ranging from 4% to as high as 47%) (Alvarez-Arango 2021; Austin 2020; Symons 1985; Wazny 2001)

Immunologic: Drug reaction with eosinophilia and systemic symptoms (rare: <1%) (Cacoub 2011)

Renal: Acute kidney injury (Sawada 2018), nephrotoxicity (common: ≥10%) (Lodise 2009)

Oral:

>10%:

Endocrine & metabolic: Hypokalemia (13%)

Gastrointestinal: Abdominal pain (15%), nausea (17%)

1% to 10%:

Cardiovascular: Peripheral edema (6%)

Gastrointestinal: Diarrhea (9%), flatulence (8%), vomiting (9%)

Genitourinary: Urinary tract infection (8%)

Nervous system: Fatigue (5%), headache (7%)

Neuromuscular & skeletal: Back pain (6%)

Renal: Nephrotoxicity (5%)

Miscellaneous: Fever (9%)

Frequency not defined:

Cardiovascular: Hypotension

Gastrointestinal: Clostridioides difficile colitis, constipation

Hematologic & oncologic: Anemia

Nervous system: Depression, insomnia

Renal: Increased serum creatinine, renal failure syndrome, renal insufficiency

Postmarketing:

Cardiovascular: Vasculitis

Dermatologic: Acute generalized exanthematous pustulosis, dermatologic disorder (linear IgA bullous dermatosis) (Tashima 2014), exfoliative dermatitis (rare: <1%) (Forrence 1990), pruritus, skin rash, Stevens-Johnson syndrome (rare: <1%) (An 2011), toxic epidermal necrolysis (rare: <1%) (An 2011), urticaria

Hematologic & oncologic: Eosinophilia, thrombocytopenia

Hypersensitivity: Anaphylaxis, flushing (Arroyo-Mercado 2019), nonimmune anaphylaxis

Immunologic: Drug reaction with eosinophilia and systemic symptoms (Cacoub 2011)

Nervous system: Chills, dizziness, drug fever, pain, vertigo

Neuromuscular & skeletal: Muscle spasm (chest and back)

Otic: Tinnitus

Respiratory: Dyspnea, wheezing

Contraindications

Hypersensitivity to vancomycin or any component of the formulation

Warnings/Precautions

Concerns related to adverse effects:

• Extravasation and thrombophlebitis: IV vancomycin is an irritant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation. Pain, tenderness, and necrosis may occur with extravasation. If thrombophlebitis occurs, slow infusion rates, dilute solution (eg, 2.5 to 5 g/L) and rotate infusion sites.

• Superinfection: Prolonged use may result in fungal or bacterial superinfection.

Disease-related concerns:

• Inflammatory bowel disease: Clinically significant serum concentrations have been reported in patients with inflammatory disorders of the intestinal mucosa who have taken oral vancomycin (multiple doses) for the treatment of C. difficile-associated diarrhea. Although use may be warranted, the risk for adverse reactions may be higher in this situation; consider monitoring serum trough concentrations in patients with renal insufficiency, severe colitis, and a prolonged course (IDSA/SHEA [McDonald 2018]; Pettit 2015).

• Renal impairment: Use with caution in patients with renal impairment or those receiving other nephrotoxic drugs; dosage modification required and close monitoring is recommended in patients with preexisting renal impairment and those at high risk for renal impairment. Accumulation may occur after multiple oral doses of vancomycin in patients with renal impairment; consider monitoring serum concentrations in this circumstance.

Other warnings/precautions:

• Appropriate use: Oral vancomycin is only indicated for the treatment of CDI or enterocolitis due to S. aureus and is not effective for systemic infections; parenteral vancomycin is not effective for the treatment of enterocolitis.

• Intraocular administration (off-label route): Hemorrhagic occlusive retinal vasculitis (HORV), including permanent visual loss, has been reported in patients receiving intracameral or intravitreal administration of vancomycin during or after cataract surgery.

• Intraperitoneal administration (off-label route): Use caution when administering intraperitoneally (IP); in some continuous ambulatory peritoneal dialysis (CAPD) patients, chemical peritonitis (cloudy dialysate, fever, severe abdominal pain) has occurred. Symptoms are self-limited and usually clear after vancomycin discontinuation.

Metabolism/Transport Effects

None known.

Drug Interactions

Aminoglycosides: Vancomycin may enhance the nephrotoxic effect of Aminoglycosides. Vancomycin may enhance the neurotoxic effect of Aminoglycosides. Management: Consider avoiding coadministration of aminoglycosides and vancomycin unless clinically indicated. If coadministered, monitor closely for signs of nephrotoxicity and neurotoxicity. Risk D: Consider therapy modification

Bacillus clausii: Antibiotics may diminish the therapeutic effect of Bacillus clausii. Management: Bacillus clausii should be taken in between antibiotic doses during concomitant therapy. Risk D: Consider therapy modification

BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination

BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Risk C: Monitor therapy

Bile Acid Sequestrants: May diminish the therapeutic effect of Vancomycin. Management: Avoid concurrent administration of oral vancomycin and bile acid sequestrants when possible. If use of both agents is necessary, consider separating doses by at least 2 hours to minimize the significance of the interaction. Risk D: Consider therapy modification

Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Risk X: Avoid combination

Colistimethate: Vancomycin may enhance the nephrotoxic effect of Colistimethate. Management: Avoid coadministration of colistimethate and vancomycin whenever possible due to the potential for additive or synergistic nephrotoxicity. If coadministration cannot be avoided, closely monitor renal function. Risk D: Consider therapy modification

Immune Checkpoint Inhibitors: Antibiotics may diminish the therapeutic effect of Immune Checkpoint Inhibitors. Risk C: Monitor therapy

Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Risk C: Monitor therapy

Neuromuscular-Blocking Agents: Vancomycin may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: May increase the serum concentration of Vancomycin. Risk C: Monitor therapy

Piperacillin: May enhance the nephrotoxic effect of Vancomycin. Risk C: Monitor therapy

Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Risk D: Consider therapy modification

Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Avoid use of live attenuated typhoid vaccine (Ty21a) in patients being treated with systemic antibacterial agents. Postpone vaccination until 3 days after cessation of antibiotics and avoid starting antibiotics within 3 days of last vaccine dose. Risk D: Consider therapy modification

Dietary Considerations

May be taken with food.

Reproductive Considerations

Pregnancy status should be evaluated in patients who may become pregnant prior to using the IV formulation containing the excipients polyethylene glycol (PEG 400) and N-acetyl D-alanine (NADA).

Pregnancy Considerations

Vancomycin crosses the placenta and can be detected in fetal serum, amniotic fluid, and cord blood (Bourget 1991; Reyes 1989). Adverse fetal effects, including sensorineural hearing loss or nephrotoxicity, have not been reported following maternal use during the second or third trimesters of pregnancy.

The pharmacokinetics of vancomycin may be altered during pregnancy and pregnant patients may need a higher dose of vancomycin. Maternal half-life is unchanged, but the volume of distribution and the total plasma clearance may be increased (Bourget 1991). Individualization of therapy through serum concentration monitoring may be warranted.

Vancomycin is recommended for the treatment of mild, moderate, or severe Clostridioides difficile infections in pregnant patients. Standard doses should be used (ACG [Surawicz 2013]).

Vancomycin is recommended as an alternative option to prevent the transmission of group B streptococcal (GBS) disease from mothers to newborns. Untreated asymptomatic GBS disease can result in maternal urinary tract infection, intraamniotic infection, endometritis, preterm labor, and/or stillbirth. Vertical transmission from the mother can cause sepsis, pneumonia, or meningitis in the newborn. Vancomycin IV is recommended for use in women who are at high risk for anaphylaxis to penicillin (or whose risk is unknown), and the GBS isolate is resistant to clindamycin. Dose and rate of infusion should be based on maternal weight and renal function, similar to nonpregnant patients (ACOG 2020).

In patients known to be colonized with methicillin-resistant S. aureus (MRSA), a single dose of vancomycin is recommended as part of the antibiotic regimen for prophylactic use prior to cesarean delivery. Monotherapy with vancomycin does not provide sufficient coverage for cesarean delivery surgical prophylaxis (ACOG 2018).

Based on limited data, vancomycin is considered likely compatible with pregnancy when used for the treatment of airway diseases, such as cystic fibrosis (ERS/TSANZ [Middleton 2020]).

The formulation of vancomycin injection containing the excipients polyethylene glycol (PEG 400) and N-acetyl D-alanine (NADA) has caused fetal malformations in animal reproduction studies. If use of vancomycin is needed during the first or second trimesters of pregnancy, use other available formulations of vancomycin.

Monitoring Parameters

Periodic renal function tests (especially when targeting higher serum concentrations, or in critically ill patients), urinalysis, serum vancomycin concentrations (See "Reference Range"), WBC; audiogram (in patients who concurrently receive ototoxic chemotherapy); fluid status.

Reference Range

Parenteral therapy:

AUC-based monitoring (ASHP/IDSA/PIDS/SIDP [Rybak 2020]):

Target (for S. aureus only): AUC24:MIC: 400; potentially up to 600.

Note: Evaluate vancomycin exposure using area under the curve over 24 hours (AUC24). AUC can be determined in neonatal and pediatric patients using either a neonatal- or pediatric-specific Bayesian software program with 1 or 2 concentrations (ie, trough only or peak and trough) or standard first-order pharmacokinetic equations using 2 vancomycin concentrations. Target for S. aureus is based on an MIC determined by broth microdilution (BMD); it is recommended to assume an MIC of 1 mg/L, unless MIC is demonstrated to be >1 mg/L by BMD. Decreasing the dose when MIC <1 mg/L by BMD is not recommended. Specific targets for other bacteria are unknown. AUC24 should be ≤800 mg•hour/L and trough concentration ≤15 mg/L to minimize risk of nephrotoxicity.

Trough-based monitoring: Note: Trough concentrations ≥15 mg/L have been associated with increased risk for acute kidney injury, likely due to association with elevated AUCs (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Endocarditis: 10 to 15 mg/L; may target higher trough of 15 to 20 mg/L in patients with methicillin-resistant S. aureus (MRSA) with MIC >1 mg/L or who are not responding to appropriate therapy (AHA [Baltimore 2015]).

Meningitis, including health care-associated ventriculitis/meningitis: 15 to 20 mg/L (IDSA [Tunkel 2004]; IDSA [Tunkel 2017]).

MRSA infections: Though trough-only monitoring is not recommended for serious infections, trough serum concentration might be used as a surrogate marker for AUC when AUC monitoring is not available or for less serious infections; trough concentrations may not accurately predict AUC on an individual level (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Frymoyer 2014; Stockmann 2015).

Neonates: Trough concentrations of 7 to 11 mg/L have been associated with AUCs of ≥400 mg•hour/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Frymoyer 2014; Stockmann 2015).

Infants, Children, and Adolescents: Trough concentrations of 7 to 10 mg/L have been associated with AUCs >400 mg•hour/L; significant variability observed; lower trough concentrations (ie, 6 mg/L) may be associated with AUC >400 mg•hour/L when dose is divided every 8 hours (Frymoyer 2013; Le 2013).

Continuous infusion dosing:

Target steady-state concentration: Optimal target unknown.

General reported range: 15 to 30 mg/L; a variety of target concentrations have been reported in pediatric patients (Cies 2016; Genuini 2018; Guilhaumou 2016; Hurst 2019; McKamy 2012).

Note: Treatment of MRSA: 20 to 25 mg/L is recommended in adults. AUC24 can be estimated by multiplying the steady-state concentration by 24; a target steady-state concentration of 20 to 25 mg/L equates to an AUC24 of 480 to 600 mg•hour/L (ie, a steady-state concentration of ≥16.7 mg/L would equate to an AUC24 of ≥400 mg•hour/L) (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Timing of serum sampling:

AUC: Monitoring may begin within 24 to 48 hours of drug initiation; Bayesian-derived AUC calculation programs do not require steady-state serum concentrations. First-order pharmacokinetic analytic equations to estimate AUC require collection of 2 serum concentrations; postdistributional peak concentration (Cmax) drawn 1 to 2 hours after infusion and trough concentration (Cmin) drawn at the end of the dosing interval. It is preferable that a near steady-state postdistributional peak and trough concentration within the same dosing interval (if possible) are used with the equation-based method. For Bayesian monitoring, 1 (ie, trough only) or 2 concentrations may be used. (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Trough monitoring: Draw trough concentration just before the administration of a dose, at the end of the dosing interval, at steady-state conditions. Steady-state conditions generally occur approximately after the third dose; therefore, may begin monitoring vancomycin trough concentrations before the fourth dose (usually within 1 hour of administration). (ASHP/IDSA/SIDP [Rybak 2009]).

Continuous infusion monitoring: Obtain after steady-state has been reached, ≥24 hours after initiation of infusion; may obtain sooner if Bayesian-derived program is utilized (Berthaud 2019; Hurst 2019; McKamy 2012). Ensure that sample is obtained from a separate line or site than that through which vancomycin is infused; obtaining from the same line, even a separate lumen, or stopping the infusion is not recommended (Hurst 2019).

Frequency of serum sampling: Should be based on clinical judgment; close monitoring (more frequent or daily) recommended for hemodynamically unstable patients, patients with renal dysfunction, and patients with potential augmented renal clearance; hemodynamically stable patients may be monitored less frequently (once weekly) (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Oral/rectal therapy: Serum sample monitoring is not typically required; systemic absorption of enteral vancomycin may occur in patients with mucosal disruption due to colitis, especially in patients with renal failure. Monitoring serum vancomycin levels may be considered for patients with renal failure who have severe colitis and require a prolonged course of enteral vancomycin (IDSA/SHEA [McDonald 2018]; Pettit 2015).

Mechanism of Action

Inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding tightly to D-alanyl-D-alanine portion of cell wall precursor

Pharmacokinetics (Adult data unless noted)

Absorption: Oral: Poor; Rectal: significant absorption through inflamed colonic mucosa may occur; Intraperitoneal (IP): 60% of an IP dose absorbed in 6 hours.

Distribution: Distributes widely in body tissue and fluids, except for CSF.

Vd:

Neonate, term: 0.57 to 0.69 L/kg (de Hoog 2004).

Infants: 0.56 L/kg (Rainkie 2015).

Children ≤6 years of age: 0.61 L/kg (Rainkie 2015).

Children >6 years of age: 0.47 L/kg (Rainkie 2015).

Adolescents: 0.49 L/kg (Rainkie 2015).

Adults: 0.4 to 1 L/kg (ASHP/IDSA/SIDP [Rybak 2009]); 0.3 to 0.5 L/kg in patients who are morbidly obese (Adane 2015; Bauer 1998; Hong 2015).

Relative diffusion from blood into CSF: Good only with inflammation (exceeds usual MICs).

Children:

CSF concentrations: 0.2 to 17.3 mg/L (de Hoog 2004).

CSF:blood level ratio: Normal meninges: Nil; Inflamed meninges: 7.1% to 68% (de Hoog 2004).

Adults:

Uninflamed meninges: 0 to 4 mg/L; serum concentration dependent (ASHP/IDSA/SIDP [Rybak 2009]).

Inflamed meninges: 6 to 11 mg/L; serum concentration dependent (ASHP/IDSA/SIDP [Rybak 2009]).

CSF:serum level ratio: Normal meninges: Nil; Inflamed meninges: ~80% (Shokouhi 2014).

Protein binding: ~55%.

Metabolism: No apparent metabolism.

Half-life elimination: Biphasic: Terminal:

Preterm neonates (GA: 32 to 34 weeks); PNA ~3 to 5 days: 5.9 to 9.8 hours (Schaad 1980).

Term neonates; PNA ~2 to 3 days: 6.7 hours (Schaad 1980).

Infants: 2.8 hours (Rainkie 2015).

Children <6 years of age: 2.4 hours (Rainkie 2015).

Children ≥6 years of age: 2.9 hours (Rainkie 2015).

Adolescents: 3.2 hours (Rainkie 2015).

Adults: 4 to 6 hours; significantly prolonged with renal impairment.

End-stage renal disease: 7.5 days.

Time to peak, serum: IV: Immediately after completion of infusion.

Excretion: Primarily via glomerular filtration; IV: Urine (75% as unchanged drug in the first 24 hours); Oral: Primarily feces.

Clearance: presence of malignancy in children is associated with an increase in vancomycin clearance.

Neonates: 0.63 to 1.5 mL/minute/kg; dependent on GA and/or PMA (de Hoog 2004).

Pediatric patients: Median: 1.1 mL/minute/kg (range: 0.33 to 1.87 mL/minute/kg) (Marsot 2012).

Adults: 1.6 to 6.2 L/hour (Matzke 1984); patients who are obese: ~6 L/hour (rarely exceeds 9 L/hour) (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Pharmacokinetics: Additional Considerations

Pediatric: Extracorporeal membrane oxygenation (ECMO): Reported pharmacokinetic parameters in pediatric patients receiving ECMO vary widely based on ECMO circuitry/filters, age, weight, kidney function, and underlying diseases. In general, volume of distribution may be increased and clearance may be increased or decreased; reported parameters vary significantly; elimination half-life appears to be dependent upon renal function (Amaker 1996; Buck 1998; Cies 2017; Moffett 2018; Mulla 2005; Zylbersztajn 2018).

Geriatric: Total systemic and renal clearance may be reduced.

Anti-infective considerations:

Parameters associated with efficacy: Note: Ratios, including the minimum inhibitory concentration (MIC), depend upon the methodology used; MIC determined by E-test is typically 1.5 to 2 times MIC determined by broth microdilution (ASHP/IDSA/PIDS/SIDP [Rybak 2020]).

Staphylococcus aureus: AUC/MICBMD ≥400 mg•hour/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Kullar 2011; Lodise 2014; Moise-Broder 2004); specific cutoff for efficacy has varied slightly between studies.

Enterococcus spp.: AUC/MICEtest ≥389 (Jumah 2018).

Parameters associated with toxicity: Nephrotoxicity: AUC ≥600 to 650 mg•hour/L; risk continues to increase along AUC continuum (Aljefri 2019; ASHP/IDSA/PIDS/SIDP [Rybak 2020]; Fiorito 2018; Le 2015; Lodise 2020); Cmin ≥15 mg/L (ASHP/IDSA/PIDS/SIDP [Rybak 2020]; van Hal 2013).

Postantibiotic effect: A short postantibiotic effect has been observed in E. faecalis (0.5 to 1 hour) and S. aureus (0.6 to 2 hours); slightly longer in S. epidermidis (4.3 to 6.5 hours) (Hanberger 1991; Löwdin 1998).

Extemporaneous Preparations

Note: A vancomycin oral solution (25 mg/mL or 50 mg/mL) is commercially available (Firvanq).

Oral Solution

Using a vial of vancomycin powder for injection (reconstituted to 50 mg/mL), add the appropriate volume for the dose to 30 mL of water and administer orally or via NG tube. For oral administration, common flavoring syrups may be added to improve taste.

Vancomycin hydrochloride injection [prescribing information]. Lake Zurich, IL: Fresenius Kabi; February 2018.

25 mg/mL Oral Solution

A vancomycin 25 mg/mL solution in Ora-Sweet and water (1:1) may be prepared by reconstituting vancomycin for injection with sterile water, then dilute with a 1:1 mixture of Ora-Sweet and distilled water to a final concentration of 25 mg/mL; transfer to amber prescription bottle. Stable for 75 days refrigerated or for 26 days at room temperature.

Ensom MH, Decarie D, and Lakhani A, “Stability of Vancomycin 25 mg/mL in Ora-Sweet and Water in Unit-Dose Cups and Plastic Bottles at 4°C and 25°C,” Can J Hosp Pharm 2010, 63(5):366-72.22479004
Pricing: US

Capsules (Vancocin Oral)

125 mg (per each): $103.35

250 mg (per each): $190.55

Capsules (Vancomycin HCl Oral)

125 mg (per each): $31.31

250 mg (per each): $57.72

Solution (Vancomycin HCl in Dextrose Intravenous)

1GM/200ML 5% (per mL): $0.16

500 mg/100 mL 5% (per mL): $0.09

750MG/150ML 5% (per mL): $0.10

Solution (Vancomycin HCl in NaCl Intravenous)

1GM/200ML 0.9% (per mL): $0.14

500 mg/100 mL 0.9% (per mL): $0.09

750MG/150ML 0.9% (per mL): $0.10

Solution (Vancomycin HCl Intravenous)

500 mg/100 mL (per mL): $0.11

750 mg/150 mL (per mL): $0.10

1000 mg/200 mL (per mL): $0.10

1250 mg/250 mL (per mL): $0.09

1500MG/300ML (per mL): $0.09

1750MG/350ML (per mL): $0.09

2000MG/400ML (per mL): $0.08

Solution (reconstituted) (Firvanq Oral)

25 mg/mL (per mL): $0.86

50 mg/mL (per mL): $1.14

Solution (reconstituted) (Vancomycin HCl Intravenous)

1 g (per each): $4.14 - $25.15

1.25 g (per each): $24.12

1.5 g (per each): $28.94 - $29.22

5 g (per each): $19.72 - $108.31

10 g (per each): $39.18 - $260.68

100 g (per each): $600.00

500 mg (per each): $2.96 - $13.02

750 mg (per each): $9.10 - $13.37

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Brand Names: International
  • Aekovan (PH);
  • Alvarcin (CR, DO, GT, HN, NI, PA, SV);
  • Celovan (HK);
  • Citerin (MX);
  • Covan (BD);
  • Covancin (IN);
  • Cytovan (IN);
  • Dhacocin (MY, SG);
  • Edicin (BG, CZ, EE, RO, RU, SK, TH, TR, UA);
  • Estavam (MX);
  • Forstaf (IN);
  • Icoplax (AR, PE);
  • Kovan (CL);
  • Levovanox (IT);
  • Mersa (PH);
  • Normedia (SE);
  • Riveran (AR, PE);
  • Vacsol (MX);
  • Vagran (VE);
  • Vamysin (BE);
  • Vanauras (MX);
  • Vanaurus (CR, DO, EC, GT, HN, NI, PA, SV);
  • Vancard (BD);
  • Vancep (ID);
  • Vancin (BD);
  • Vancin-S (TH);
  • Vanco (TW);
  • Vanco-SAAR (DE);
  • Vanco-Teva (IL);
  • Vancoavenir (IL);
  • Vancobac (BD);
  • Vancobact (EG);
  • Vancocid (TH);
  • Vancocin (AE, AT, AU, BB, BG, HU, IE, JO, LB, LK, MT, NL, RU, SA, SI, VN, ZA);
  • Vancocin CP (CN, IN, MX, PK, TW);
  • Vancocin HCl (BF, BJ, CH, CI, DK, ET, GB, GH, GM, GN, HK, KE, LR, MA, ML, MR, MU, MW, NE, NG, PH, SC, SD, SE, SL, SN, TN, TW, TZ, UG, ZM, ZW);
  • Vancocina (IT);
  • Vancocine (FR);
  • Vancodex (ID);
  • Vancoled (AE, KR, KW, VN);
  • Vancolon (AE, BH, EG, ET, KW, LB, PH, QA, SA);
  • Vancomax (PE, PY);
  • Vancomet (PH);
  • Vanconix (BD);
  • Vancorin (TR);
  • Vancorus (RU);
  • Vancosam (LK);
  • Vancosan (BR, FI, IS, LT, LV);
  • Vancotech (LK);
  • Vancotek (AR);
  • Vancotex (MY);
  • Vancotrat (BR);
  • Vancox (MX);
  • Vancozin (EG, KR);
  • Vanlyo (TW);
  • Vanmicira (CZ);
  • Vantocil (ID);
  • Varedet (AR, PE, PY, UY);
  • Vivocin (MY);
  • Voncon (GR);
  • Vondem (GR);
  • Voxin (GR)


For country abbreviations used in Lexicomp (show table)

REFERENCES

  1. Adane ED, Herald M, Koura F. Pharmacokinetics of vancomycin in extremely obese patients with suspected or confirmed Staphylococcus aureus infections. Pharmacotherapy. 2015;35(2):127-139. doi:10.1002/phar.1531 [PubMed 25644478]
  2. Al-Jafar H, Al-Yousef A, Al-Shatti S, Al-Banwan K. Drug-immune thrombocytopenia with thrombosis versus heparin-induced thrombocytopenia: a critical clinical controversy. Case Rep Nephrol Dial. 2015;5(2):152‐159. doi:10.1159/000435806 [PubMed 26266247]
  3. Aljefri DM, Avedissian SN, Rhodes NJ, Postelnick MJ, Nguyen K, Scheetz MH. Vancomycin area under the curve and acute kidney injury: a meta-analysis. Clin Infect Dis. 2019;69(11):1881-1887. doi:10.1093/cid/ciz051 [PubMed 30715208]
  4. Al-Jeraisy M, Phelps SJ, Christensen ML, Einhaus S. Intraventricular vancomycin in pediatric patients with cerebrospinal fluid shunt infections. J Pediatr Pharmacol Ther. 2004;9(1):36-42.
  5. Álvarez R, López Cortés LE, Molina J, Cisneros JM, Pachón J. Optimizing the clinical use of vancomycin. Antimicrob Agents Chemother. 2016;60(5):2601-2609. doi: 10.1128/AAC.03147-14. [PubMed 26856841]
  6. Alvarez-Arango S, Ogunwole SM, Sequist TD, Burk CM, Blumenthal KG. Vancomycin infusion reaction - moving beyond "Red Man Syndrome". N Engl J Med. 2021;384(14):1283-1286. doi:10.1056/NEJMp2031891 [PubMed 33830710]
  7. Amaker RD, DiPiro JT, Bhatia J. Pharmacokinetics of Vancomycin in Critically Ill Infants Undergoing Extracorporeal Membrane Oxygenation. Antimicrob Agents Chemother. 1996;40(5):1139-1142. [PubMed 8723454]
  8. American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett E, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
  9. American Academy of Pediatrics Committee on Infectious Diseases. Treatment of bacterial meningitis. Pediatrics. 1988;81(6):904-907. [PubMed 3368290]
  10. American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin no. 199: use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2018;132(3):e103-e119. [PubMed 30134425]
  11. American College of Obstetricians and Gynecologists (ACOG). Prevention of group B streptococcal early-onset disease in newborns: ACOG committee opinion, number 797 [published correction appears in Obstet Gynecol. 2020;135(4):978-979]. Obstet Gynecol. 2020;135(2):e51-e72. doi:10.1097/AOG.0000000000003668 [PubMed 31977795]
  12. American Thoracic Society and Infectious Diseases Society of America, "Guidelines for the Management of Adults With Hospital-Acquired, Ventilator-Associated, and Healthcare-Associated Pneumonia," Am J Respir Crit Care Med, 2005, 171(4):388-416. [PubMed 15699079]
  13. An SY, Hwang EK, Kim JH, et al. Vancomycin-associated spontaneous cutaneous adverse drug reactions. Allergy Asthma Immunol Res. 2011;3(3):194‐198. doi:10.4168/aair.2011.3.3.194 [PubMed 21738885]
  14. Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(6):605-627. doi: 10.1086/676022. [PubMed 24799638]
  15. Anderson DJ, Sexton DJ. Antimicrobial prophylaxis for prevention of surgical site infection in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed June 4, 2020.
  16. Anne S, Middleton E Jr, Reisman RE. Vancomycin anaphylaxis and successful desensitization. Ann Allergy. 1994;73(5):402‐404. [PubMed 7978531]
  17. Apisarnthanarak A, Razavi B, Mundy LM. Adjunctive intracolonic vancomycin for severe Clostridium difficile colitis: case series and review of the literature. Clin Infect Dis. 2002;35(6):690-696. doi:10.1086/342334 [PubMed 12203166]
  18. Arnaud FCS, Libório AB. Attributable nephrotoxicity of vancomycin in critically ill patients: a marginal structural model study. J Antimicrob Chemother. 2020;75(4):1031‐1037. doi:10.1093/jac/dkz520 [PubMed 31904834]
  19. Arnold DM, Nazi I, Warkentin TE, et al. Approach to the diagnosis and management of drug-induced immune thrombocytopenia. Transfus Med Rev. 2013;27(3):137‐145. doi:10.1016/j.tmrv.2013.05.005 [PubMed 23845922]
  20. Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults and Children. 5th ed. Philadelphia, PA: American College of Physicians; 2007.
  21. Arroyo-Mercado F, Khudyakov A, Chawla GS, Cantres-Fonseca O, McFarlane IM. Red man syndrome with oral vancomycin: a case report. Am J Med Case Rep. 2019;7(1):16‐17. doi:10.12691/ajmcr-7-1-5 [PubMed 31123702]
  22. Aster RH, Bougie DW. Drug-induced immune thrombocytopenia. N Engl J Med. 2007;357(6):580‐587. doi:10.1056/NEJMra066469 [PubMed 17687133]
  23. Austin JP, Foster BA, Empey A. Replace red man syndrome with vancomycin flushing reaction. Hosp Pediatr. 2020;10(7):623-624. doi:10.1542/hpeds.2020-0125 [PubMed 32571794]
  24. Baddour LM, Flynn PM, Fekete T. Infections of cerebrospinal fluid shunts and other devices. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 21, 2019.
  25. Baddour LM, Wilson WR, Bayer AS, et al; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association [published correction appears in Circulation. 2015;132(17):e215]. Circulation. 2015;132(15):1435-1486. doi: 10.1161/CIR.0000000000000296. [PubMed 26373316]
  26. Baddour LM, Wilson WR, Bayer AS, et al, “Infective Endocarditis. Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association - Executive Summary: Endorsed by the Infectious Diseases Society of America,” Circulation, 2005, 111(23):3167-184. [PubMed 15956145]
  27. Bailey P, Gray H. An elderly woman with 'red man syndrome' in association with oral vancomycin therapy: a case report. Cases J. 2008;1(1):111. doi:10.1186/1757-1626-1-111 [PubMed 18710566]
  28. Bailie GR, Neal D. Vancomycin ototoxicity and nephrotoxicity. A review. Med Toxicol Adverse Drug Exp. 1988;3(5):376‐386. doi:10.1007/BF03259891 [PubMed 3057327]
  29. Baker CJ. Neonatal Group B streptococcal disease: prevention. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 8, 2020.
  30. Baltimore RS, Gewitz M, Baddour LM, et al; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young and the Council on Cardiovascular and Stroke Nursing. Infective endocarditis in childhood: 2015 update: a scientific statement from the American Heart Association. Circulation. 2015;132(15):1487-1515. doi:10.1161/CIR.0000000000000298 [PubMed 26373317]
  31. Baptista JP, Roberts JA, Sousa E, Freitas R, Deveza N, Pimentel J. Decreasing the time to achieve therapeutic vancomycin concentrations in critically ill patients: developing and testing of a dosing nomogram. Crit Care. 2014;18(6):654. doi:10.1186/s13054-014-0654-2 [PubMed 25475123]
  32. Barshak MB. Antimicrobial approach to intra-abdominal infections in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed June 8, 2021.
  33. Bateman DA, Thomas W, Parravicini E, Polesana E, Locatelli C, Lorenz JM. Serum creatinine concentration in very-low-birth-weight infants from birth to 34-36 wk postmenstrual age. Pediatr Res. 2015;77(5):696-702. [PubMed 25675426]
  34. Bauer LA, Black DJ, Lill JS. Vancomycin dosing in morbidly obese patients. Eur J Clin Pharmacol. 1998;54(8):621-625. doi:10.1007/s002280050524 [PubMed 9860149]
  35. Bellón T. Mechanisms of severe cutaneous adverse reactions: recent advances. Drug Saf. 2019;42(8):973‐992. doi:10.1007/s40264-019-00825-2 [PubMed 31020549]
  36. Benner KW, Worthington MA, Kimberlin DW, et al, "Correlation of Vancomycin Dosing to Serum Concentrations in Pediatric Patients: A Retrospective Database Review," J Pediatr Pharmacol Ther, 2009, 14:86-93.
  37. Benner KW, Worthington MA, Kimberlin DW, Hill K, Buckley K, Tofil NM. Correlation of vancomycin dosing to serum concentrations in pediatric patients: a retrospective database review. J Pediatr Pharmacol Ther. 2009;14(2):86-93. doi: 10.5863/1551-6776-14.2.86. [PubMed 23055895]
  38. Berbari E, Baddour LM. Prosthetic joint infection: treatment. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 29, 2019.
  39. Berbari EF, Kanj SS, Kowalski TJ, et al; Infectious Diseases Society of America. 2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clin Infect Dis. 2015;61(6):e26-e46. doi: 10.1093/cid/civ482. [PubMed 26229122]
  40. Bergman MM, Glew RH, Ebert TH. Acute interstitial nephritis associated with vancomycin therapy. Arch Intern Med. 1988;148(10):2139‐2140. [PubMed 3178372]
  41. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784-791. doi: 10.1001/jamasurg.2017.0904. [PubMed 28467526]
  42. Berthaud R, Benaboud S, Hirt D, et al. Early Bayesian dose adjustment of vancomycin continuous infusion in children: a randomized controlled trial. Antimicrob Agents Chemother. Published online October 7, 2019. doi:10.1128/AAC.01102-19 [PubMed 31591117]
  43. Bilbao-Meseguer I, Rodríguez-Gascón A, Barrasa H, Isla A, Solinís MÁ. Augmented renal clearance in critically ill patients: a systematic review. Clin Pharmacokinet. 2018;57(9):1107-1121. doi:10.1007/s40262-018-0636-7 [PubMed 29441476]
  44. Black E, Lau TT, Ensom MH. Vancomycin-induced neutropenia: is it dose- or duration-related? Ann Pharmacother. 2011;45(5):629‐638. doi:10.1345/aph.1P583 [PubMed 21521866]
  45. Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. Lancet. 2019;393(10167):183‐198. doi:10.1016/S0140-6736(18)32218-9 [PubMed 30558872]
  46. Bodilsen J, Brouwer MC, Nielsen H, Van De Beek D. Anti-infective treatment of brain abscess. Expert Rev Anti Infect Ther. 2018;16(7):565-578. doi: 10.1080/14787210.2018.1489722. [PubMed 29909695]
  47. Bose S, Wurm E, Popovich MJ, Silver BJ. Drug-induced immune-mediated thrombocytopenia in the intensive care unit. J Clin Anesth. 2015;27(7):602‐605. doi:10.1016/j.jclinane.2015.06.021 [PubMed 26260647]
  48. Bourget P, Fernandez H, Delouis C, et al, "Transplacental Passage of Vancomycin During the Second Trimester of Pregnancy," Obstet Gynecol, 1991, 78(5 Pt 2):908-11. [PubMed 1923224]
  49. Bradley JS, Byington CL, Shah SS, et al; Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25-e76. [PubMed 21880587]
  50. Bradley JS, Nelson JD, Barnett ED, et al, eds. Nelson's Pediatric Antimicrobial Therapy. 27th ed. American Academy of Pediatrics; 2021.
  51. Bratzler DW, Dellinger EP, Olsen KM, et al; American Society of Health-System Pharmacists; Infectious Diseases Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. [PubMed 23327981]
  52. Britton RA, Young VB. Role of the intestinal microbiota in resistance to colonization by Clostridium difficile. Gastroenterology. 2014;146(6):1547‐1553. doi:10.1053/j.gastro.2014.01.059 [PubMed 24503131]
  53. Brockow K, Przybilla B, Aberer W, et al. Guideline for the diagnosis of drug hypersensitivity reactions: S2K-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI) and the German Dermatological Society (DDG) in collaboration with the Association of German Allergologists (AeDA), the German Society for Pediatric Allergology and Environmental Medicine (GPA), the German Contact Dermatitis Research Group (DKG), the Swiss Society for Allergy and Immunology (SGAI), the Austrian Society for Allergology and Immunology (ÖGAI), the German Academy of Allergology and Environmental Medicine (DAAU), the German Center for Documentation of Severe Skin Reactions and the German Federal Institute for Drugs and Medical Products (BfArM). Allergo J Int. 2015;24(3):94‐105. doi:10.1007/s40629-015-0052-6 [PubMed 26120552]
  54. Brown KA, Khanafer N, Daneman N, Fisman DN. Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother. 2013;57(5):2326‐2332. doi:10.1128/AAC.02176-12 [PubMed 23478961]
  55. Brummett RE, Fox KE. Vancomycin- and erythromycin-induced hearing loss in humans. Antimicrob Agents Chemother. 1989;33(6):791‐796. doi:10.1128/aac.33.6.791 [PubMed 2669623]
  56. Brummett RE, Fox KE, Jacobs F, Kempton JB, Stokes Z, Richmond AB. Augmented gentamicin ototoxicity induced by vancomycin in guinea pigs. Arch Otolaryngol Head Neck Surg. 1990;116(1):61‐64. doi:10.1001/archotol.1990.01870010065019 [PubMed 2294943]
  57. Bruniera FR, Ferreira FM, Saviolli LR, et al. The use of vancomycin with its therapeutic and adverse effects: a review. Eur Rev Med Pharmacol Sci. 2015;19(4):694‐700. [PubMed 25753888]
  58. Buck ML, "Pharmacokinetic Changes During Extracorporeal Membrane Oxygenation: Implications for Drug Therapy of Neonates," Clin Pharmacokinet, 2003, 42(5):403-17. [PubMed 12739981]
  59. Buck ML, "Vancomycin Pharmacokinetics in Neonates Receiving Extracorporeal Membrane Oxygenation," Pharmacotherapy, 1998, 18(5):1082-6. [PubMed 9758319]
  60. Bunke CM, Aronoff GR, Brier ME, Sloan RS, Luft FC. Vancomycin kinetics during continuous ambulatory peritoneal dialysis. Clin Pharmacol Ther. 1983;34(5):631-637. [PubMed 6627823]
  61. Butler M, Olson A, Drekonja D, et al; Agency for Healthcare Research and Quality (US). Early diagnosis, prevention, and treatment of Clostridium difficile: update. Comparative effectiveness review No. 172. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0087162/. Published March 2016. [PubMed 27148613]
  62. Cacoub P, Musette P, Descamps V, et al. The DRESS syndrome: a literature review. Am J Med. 2011;124(7):588‐597. doi:10.1016/j.amjmed.2011.01.017 [PubMed 21592453]
  63. Capparelli EV, Lane JR, Romanowski GL, et al, "The Influences of Renal Function and Maturation on Vancomycin Elimination in Newborns and Infants," J Clin Pharmacol, 2001, 41(9):927-34. [PubMed 11549096]
  64. Carmichael AJ, Al-Zahawi MF. Pancytopenia associated with vancomycin. Br Med J. 1986;293:1103.
  65. Carreno JJ, Kenney RM, Lomaestro B. Vancomycin-associated renal dysfunction: where are we now?. Pharmacotherapy. 2014;34(12):1259‐1268. doi:10.1002/phar.1488 [PubMed 25220436]
  66. Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease, revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010; 59(RR-10):1-32. [PubMed 21088663]
  67. Centers for Disease Control and Prevention (CDC). FAQs for clinicians about C. diff. https://www.cdc.gov/cdiff/clinicians/faq.html. March 27, 2020. Accessed May 6, 2020.
  68. Chang D, "Influence of Malignancy on the Pharmacokinetics of Vancomycin in Infants and Children," Pediatr Infect Dis J, 1995, 14(8):667-73. [PubMed 8532423 ]
  69. Chang D, Liem L, and Malogolowkin M, "A Prospective Study of Vancomycin Pharmacokinetics and Dosage Requirements in Pediatric Cancer Patients," Pediatr Infect Dis J, 1994, 13(11):969-74. [PubMed 7845750]
  70. Changela A, Javaiya H, Rickenback K, Elnawawi A, Changela K. Toxic epidermal necrolyis after vancomycin use: a case report and discussion of management. Am J Ther. 2013;20(2):223‐225. doi:10.1097/MJT.0b013e3181f94c27 [PubMed 21273948]
  71. Chopra N, Oppenheimer J, Derimanov GS, Fine PL. Vancomycin anaphylaxis and successful desensitization in a patient with end stage renal disease on hemodialysis by maintaining steady antibiotic levels. Ann Allergy Asthma Immunol. 2000;84(6):633‐635. doi:10.1016/S1081-1206(10)62416-7 [PubMed 10875494]
  72. Chu VH. Staphylococcal toxic shock syndrome. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed March 23, 2021.
  73. Cies JJ, Moore WS 2nd, Nichols K, Knoderer CA, Carella DM, Chopra A. Population pharmacokinetics and pharmacodynamic target attainment of vancomycin in neonates on extracorporeal life support. Pediatr Crit Care Med. 2017;18(10):977-985. [PubMed 28650363]
  74. Collins CE, Ayturk MD, Flahive JM, Emhoff TA, Anderson FA Jr, Santry HP. Epidemiology and outcomes of community-acquired Clostridium difficile infections in Medicare beneficiaries. J Am Coll Surg. 2014;218(6):1141‐1147.e1. doi:10.1016/j.jamcollsurg.2014.01.053 [PubMed 24755188]
  75. Cook AM, Mieure KD, Owen RD, Pesaturo AB, Hatton J. Intracerebroventricular administration of drugs. Pharmacotherapy. 2009;29(7):832-845. [PubMed 19558257]
  76. Covvey JR, Erickson O, Fiumara D, et al. Comparison of vancomycin area-under-the-curve dosing versus trough target-based dosing in obese and nonobese patients with methicillin-resistant Staphylococcus aureus bacteremia. Ann Pharmacother. 2020;54(7):644-651. doi:10.1177/1060028019897100 [PubMed 31888350]
  77. Crass RL, Dunn R, Hong J, Krop LC, Pai MP. Dosing vancomycin in the super obese: less is more. J Antimicrob Chemother. 2018;73(11):3081-3086. doi:10.1093/jac/dky310 [PubMed 30203073]
  78. Craycraft ME, Arunakul VL, Humeniuk JM. Probable vancomycin-associated toxic epidermal necrolysis. Pharmacotherapy. 2005;25(2):308‐312. doi:10.1592/phco.25.2.308.56953 [PubMed 15767246]
  79. Crew P, Heintz SJ, Heintz BH. Vancomycin dosing and monitoring for patients with end-stage renal disease receiving intermittent hemodialysis. Am J Health Syst Pharm. 2015;72(21):1856-1864. doi:10.2146/ajhp150051 [PubMed 26490819]
  80. Cristallini S, Hites M, Kabtouri H, et al. New regimen for continuous infusion of vancomycin in critically ill patients. Antimicrob Agents Chemother. 2016;60(8):4750-4756. doi:10.1128/AAC.00330-16 [PubMed 27216073]
  81. de Hoog M, Mouton JW, van den Anker JN. Vancomycin: pharmacokinetics and administration regimens in neonates. Clin Pharmacokinet. 2004;43(7):417-440. [PubMed 15139793]
  82. Debast SB, Bauer MP, Kuijper EJ; European Society of Clinical Microbiology and Infectious Diseases. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2014;20(suppl 2):1-26. doi: 10.1111/1469-0691.12418. [PubMed 24118601]
  83. Denaburg M, Patel S. Salvage antibiotic-lock therapy in critically ill pediatric patients: a pharmacological review for pediatric intensive care unit nurses. AACN Adv Crit Care. 2013;24(3):233-240. [PubMed 23880743]
  84. Deshpande A, Pasupuleti V, Thota P, et al. Community-associated Clostridium difficile infection and antibiotics: a meta-analysis. J Antimicrob Chemother. 2013;68(9):1951‐1961. doi:10.1093/jac/dkt129 [PubMed 23620467]
  85. di Fonzo H, Villegas Gutsch M, Castroagudin A, Cabrera MV, Mazzei ME, Rueda D. Agranulocytosis induced by vancomycin. Case report and literature review. Am J Case Rep. 2018;19:1053‐1056. doi:10.12659/AJCR.909956 [PubMed 30174327]
  86. Domis MJ, Moritz ML. Red man syndrome following intraperitoneal vancomycin in a child with peritonitis. Front Pediatr. 2014;2:55. doi:10.3389/fped.2014.00055 [PubMed 24926475]
  87. Downes KJ, Hayes M, Fitzgerald JC, et al. Mechanisms of antimicrobial-induced nephrotoxicity in children. J Antimicrob Chemother. 2020;75(1):1‐13. doi:10.1093/jac/dkz325 [PubMed 31369087]
  88. Drew RH, Sakoulas G. Vancomycin: Parenteral dosing, monitoring, and adverse effects in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed December 28, 2020.
  89. Duff JM, Moreb JS, Muwalla F. Severe neutropenia following a prolonged course of vancomycin that progressed to agranulocytosis with drug reexposure. Ann Pharmacother. 2012;46(1):e1. doi:10.1345/aph.1Q467 [PubMed 22170976]
  90. Durand M. Bacterial endophthalmitis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed May 7, 2020.
  91. Elyasi S, Khalili H, Dashti-Khavidaki S, Mohammadpour A. Vancomycin-induced nephrotoxicity: mechanism, incidence, risk factors and special populations. A literature review. Eur J Clin Pharmacol. 2012;68(9):1243‐1255. doi:10.1007/s00228-012-1259-9 [PubMed 22411630]
  92. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol. 1995;113(12):1479-1496. [PubMed 7487614]
  93. File TM Jr. Treatment of community-acquired pneumonia in adults who require hospitalization. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 28, 2021.
  94. Filippone EJ, Kraft WK, Farber JL. The nephrotoxicity of vancomycin. Clin Pharmacol Ther. 2017;102(3):459‐469. doi:10.1002/cpt.726 [PubMed 28474732]
  95. Fiorito TM, Luther MK, Dennehy PH, LaPlante KL, Matson KL. Nephrotoxicity with vancomycin in the pediatric population: a systematic review and meta-analysis. Pediatr Infect Dis J. 2018;37(7):654-661. doi:10.1097/INF.0000000000001882 [PubMed 29280786]
  96. Firvanq (vancomycin hydrochloride) [prescribing information]. Wilmington, MA: Azurity Pharmaceuticals; January 2021.
  97. Flume PA, Mogayzel PJ Jr, Robinson KA, et al; Clinical Practice Guidelines for Pulmonary Therapies Committee. Cystic fibrosis pulmonary guidelines: treatment of pulmonary exacerbations. Am J Respir Crit Care Med. 2009;180(9):802-808. doi: 10.1164/rccm.200812-1845PP. [PubMed 19729669]
  98. Forouzesh A, Moise PA, Sakoulas G. Vancomycin ototoxicity: a reevaluation in an era of increasing doses. Antimicrob Agents Chemother. 2009;53(2):483‐486. doi:10.1128/AAC.01088-08 [PubMed 19001107]
  99. Forrence EA, Goldman MP. Vancomycin-associated exfoliative dermatitis. DICP. 1990;24(4):369‐371. doi:10.1177/106002809002400405 [PubMed 2139270]
  100. Freiman JP, Graham DJ, Reed TG, McGoodwin EB. Chemical peritonitis following the intraperitoneal administration of vancomycin. Perit Dial Int. 1992;12(1):57‐60. [PubMed 1543783]
  101. Frymoyer A, Guglielmo BJ, Hersh AL. Desired vancomycin trough serum concentration for treating invasive methicillin-resistant Staphylococcal infections. Pediatr Infect Dis J. 2013;32(10):1077-1079. [PubMed 23652479]
  102. Frymoyer A, Hersh AL, Benet LZ, Guglielmo BJ. Current recommended dosing of vancomycin for children with invasive methicillin-resistant Staphylococcus aureus infections is inadequate. Pediatr Infect Dis J. 2009;28(5):398-402. doi: 10.1097/INF.0b013e3181906e40. [PubMed 19295465]
  103. Frymoyer A, Hersh AL, El-Komy MH, et al. Association between vancomycin trough concentration and area under the concentration-time curve in neonates. Antimicrob Agents Chemother. 2014;58(11):6454-6461. [PubMed 25136027]
  104. Frymoyer A, Stockmann C, Hersh AL, Goswami S, Keizer RJ. Individualized empiric vancomycin dosing in neonates using a model-based approach. J Pediatric Infect Dis Soc. 2019;8(2):97-104. [PubMed 29294072]
  105. Gan IM, van Dissel JT, Beekhuis H, Swart W, van Meurs JC. Intravitreal vancomycin and gentamicin concentrations in patients with postoperative endophthalmitis. Br J Ophthalmol. 2001;85(11):1289-1293. [PubMed 11673290]
  106. Genuini M, Oualha M, Bouazza N, et al. Achievement of therapeutic vancomycin exposure with continuous infusion in critically ill children. Pediatr Crit Care Med. 2018;19(6):e263-e269. doi:10.1097/PCC.0000000000001474 [PubMed 29394210]
  107. Gilmore ES, Friedman JS, Morrell DS. Extensive fixed drug eruption secondary to vancomycin. Pediatr Dermatol. 2004;21(5):600‐602. doi:10.1111/j.0736-8046.2004.21516.x [PubMed 15461771]
  108. Girand HL. Antibiotic lock therapy for treatment of catheter-related bloodstream infections. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 9, 2019.
  109. Girand HL. Continuous infusion vancomycin in pediatric patients: a critical review of the evidence. J Pediatr Pharmacol Ther. 2020;25(3):198-214. doi:10.5863/1551-6776-25.3.198 [PubMed 32265603]
  110. Goldenberg DL, Sexton DJ. Septic arthritis in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed June 11, 2020.
  111. Golightly LK, Teitelbaum I, Kiser TH, et al, eds. Renal Pharmacotherapy. Springer Science; 2013.
  112. Goodpasture HC, Dolan PJ Jr, Jacobs ER, Meredith WT. Pseudomembranous colitis & antibiotics. Kans Med. 1986;87(5):133-146. [PubMed 3712916]
  113. Goss CH, Heltshe SL, West NE, et al; STOP2 Investigators. A randomized clinical trial of antimicrobial duration for cystic fibrosis pulmonary exacerbation treatment. Am J Respir Crit Care Med. 2021;204(11):1295-1305. doi:10.1164/rccm.202102-0461OC [PubMed 34469706]
  114. Gottlieb M, Long B, Koyfman A. The evaluation and management of toxic shock syndrome in the emergency department: a review of the literature. J Emerg Med. 2018;54(6):807-814. doi: 10.1016/j.jemermed.2017.12.048. [PubMed 29366615]
  115. Gould FK, Denning DW, Elliott TS, et al; Working Party of the British Society for Antimicrobial Chemotherapy. Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy [published correction appears in J Antimicrob Chemother. 2012;67(5)1304]. J Antimicrob Chemother. 2012;67(2):269-289. [PubMed 22086858]
  116. Guilhaumou R, Marsot A, Dupouey J, et al. Pediatric patients with solid or hematological tumor disease: vancomycin population pharmacokinetics and dosage optimization. Ther Drug Monit. 2016;38(5):559-566. doi:10.1097/FTD.0000000000000318 [PubMed 27631462]
  117. Gupta S, Sharma S, Menon N, Ahuja S, Dahdouh M. Case report of vancomycin-induced pancytopenia. Rev Soc Bras Med Trop. 2016;49(2):258‐259. doi:10.1590/0037-8682-0263-2015 [PubMed 27192600]
  118. Habib G, Lancellotti P, Antunes MJ, et al; ESC Scientific Document Group. 2015 ESC guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36(44):3075-3128. doi: 10.1093/eurheartj/ehv319. [PubMed 26320109]
  119. Hanberger H, Nilsson LE, Maller R, Isaksson B. Pharmacodynamics of daptomycin and vancomycin on Enterococcus faecalis and Staphylococcus aureus demonstrated by studies of initial killing and postantibiotic effect and influence of Ca2+ and albumin on these drugs. Antimicrob Agents Chemother. 1991;35(9):1710-1716. doi:10.1128/aac.35.9.1710 [PubMed 1659305]
  120. Hassaballa H, Mallick N, Orlowski J. Vancomycin anaphylaxis in a patient with vancomycin-induced red man syndrome. Am J Ther. 2000;7(5):319‐320. doi:10.1097/00045391-200007050-00010 [PubMed 11317179]
  121. Healy DP, Sahai JV, Fuller SH, Polk RE. Vancomycin-induced histamine release and "red man syndrome": comparison of 1- and 2-hour infusions. Antimicrob Agents Chemother. 1990;34(4):550-554. [PubMed 1693055]
  122. Hecht SM, Ardura MI, Yildiz VO, Ouellette CP. Central venous catheter management in high-risk children with bloodstream infections. Pediatr Infect Dis J. 2020;39(1):17-22. [PubMed 31725118]
  123. Hecht JR, Olinger EJ. Clostridium difficile colitis secondary to intravenous vancomycin. Dig Dis Sci. 1989;34(1):148‐149. doi:10.1007/BF01536172 [PubMed 2910675]
  124. Hedge DD, Strain JD, Heins JR, Farver DK. New advances in the treatment of Clostridium difficile infection (CDI). Ther Clin Risk Manag. 2008;4(5):949‐964. doi:10.2147/tcrm.s3145 [PubMed 19209277]
  125. Heil EL, Claeys KC, Mynatt RP, et al. Making the change to area under the curve-based vancomycin dosing. Am J Health Syst Pharm. 2018;75(24):1986-1995. doi: 10.2146/ajhp180034. [PubMed 30333114]
  126. Heintz BH, Matzke GR, Dager WE. Antimicrobial dosing concepts and recommendations for critically ill adult patients receiving continuous renal replacement therapy or intermittent hemodialysis. Pharmacotherapy. 2009;29(5):562-577. [PubMed 19397464]
  127. Hensgens MP, Goorhuis A, Dekkers OM, Kuijper EJ. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother. 2012;67(3):742‐748. doi:10.1093/jac/dkr508 [PubMed 22146873]
  128. Hepner DL, Castells MC. Anaphylaxis during the perioperative period. Anesth Analg. 2003;97(5):1381‐1395. doi:10.1213/01.ane.0000082993.84883.7d [PubMed 14570656]
  129. Hoie EB, Swigart SA, Leuschen MP, et al. Vancomycin pharmacokinetics in infants undergoing extracorporeal membrane oxygenation. Clin Pharm. 1990;9(9):711-715. [PubMed 2225752]
  130. Holmes NE, Turnidge JD, Munckhof WJ, et al. Vancomycin AUC/MIC ratio and 30-day mortality in patients with staphylococcus aureus bacteremia. Antimicrob Agents Chemother. 2013;57(4):1654-1663. doi:10.1128/AAC.01485-12 [PubMed 23335735]
  131. Hong J, Krop LC, Johns T, Pai MP. Individualized vancomycin dosing in obese patients: a two-sample measurement approach improves target attainment. Pharmacotherapy. 2015;35(5):455-463. doi:10.1002/phar.1588 [PubMed 26011138]
  132. Hsiao SH, Chou CH, Lin WL, et al. High risk of cross-reactivity between vancomycin and sequential teicoplanin therapy. J Clin Pharm Ther. 2012;37(3):296‐300. doi:10.1111/j.1365-2710.2011.01291.x [PubMed 22017186]
  133. Hung YP, Lee NY, Chang CM, et al. Tolerability of teicoplanin in 117 hospitalized adults with previous vancomycin-induced fever, rash, or neutropenia: a retrospective chart review. Clin Ther. 2009;31(9):1977‐1986. doi:10.1016/j.clinthera.2009.09.010 [PubMed 19843487]
  134. Hurst AL, Baumgartner C, MacBrayne CE, Child J. Experience with continuous infusion vancomycin dosing in a large pediatric hospital. J Pediatric Infect Dis Soc. 2019;8(2):174-179. doi:10.1093/jpids/piy032 [PubMed 29718415]
  135. Hurst S, McMillan M. Innovative solutions in critical care units: extravasation guidelines. Dimens Crit Care Nurs. 2004;23(3):125-128. [PubMed 15192356]
  136. Iwata K, Doi A, Fukuchi T, et al. A systematic review for pursuing the presence of antibiotic associated enterocolitis caused by methicillin resistant Staphylococcus aureus. BMC Infect Dis. 2014;14:247-259. [PubMed 24884581]
  137. Jha P, Swanson K, Stromich J, Michalski BM, Olasz E. A rare case of vancomycin-induced linear immunoglobulin a bullous dermatosis. Case Rep Dermatol Med. 2017;2017:7318305. doi:10.1155/2017/7318305 [PubMed 28168063]
  138. Johnson S, Lavergne V, Skinner AM, et al. Clinical practice guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 focused update guidelines on management of Clostridioides difficile infection in adults. Clin Infect Dis. 2021;73(5):e1029-e1044. doi:10.1093/cid/ciab549 [PubMed 34164674]
  139. Jumah MTB, Vasoo S, Menon SR, De PP, Neely M, Teng CB. Pharmacokinetic/pharmacodynamic determinants of vancomycin efficacy in Enterococcal bacteremia. Antimicrob Agents Chemother. 2018;62(3). doi:10.1128/AAC.01602-17 [PubMed 29263057]
  140. Justo JA, Bookstaver PB. Antibiotic lock therapy: review of technique and logistical challenges. Infect Drug Resist. 2014;7:343-363. [PubMed 25548523]
  141. Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society [published online July 14, 2016]. Clin Infect Dis. doi: 10.1093/cid/ciw353. [PubMed 27418577]
  142. Kelly CP, Lamont JT, Bakken JS. Clostridioides difficile in adults: treatment and prevention. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 25, 2021a.
  143. Kelly CR, Fischer M, Allegretti JR, et al. ACG clinical guidelines: prevention, diagnosis, and treatment of Clostridioides difficile infections. Am J Gastroenterol. 2021b;116(6):1124-1147. doi:10.14309/ajg.0000000000001278 [PubMed 34003176]
  144. Khicher S, Weinberger JJ. Vancomycin-associated erythema multiforme. Am J Ther. 2019. doi:10.1097/MJT.0000000000001038 [PubMed 31356340]
  145. Kim AJ, Lee JY, Choi SA, Shin WG. Comparison of the pharmacokinetics of vancomycin in neurosurgical and non-neurosurgical patients. Int J Antimicrob Agents. 2016;48(4):381-387. doi:10.1016/j.ijantimicag.2016.06.022 [PubMed 27546217]
  146. Kim BK, Kim JH, Sohn KH, Kim JY, Chang YS, Kim SH. Incidence of teicoplanin adverse drug reactions among patients with vancomycin-associated adverse drug reactions and its risk factors. Korean J Intern Med. 2020;35(3):714‐722. doi:10.3904/kjim.2018.404 [PubMed 31722513]
  147. Klibanov OM, Filicko JE, DeSimone JA Jr, Tice DS. Sensorineural hearing loss associated with intrathecal vancomycin. Ann Pharmacother. 2003;37(1):61‐65. doi:10.1345/aph.1C145 [PubMed 12503934]
  148. Konvinse KC, Trubiano JA, Pavlos R, et al. HLA-A*32:01 is strongly associated with vancomycin-induced drug reaction with eosinophilia and systemic symptoms. J Allergy Clin Immunol. 2019;144(1):183‐192. doi:10.1016/j.jaci.2019.01.045 [PubMed 30776417]
  149. Kullar R, Davis SL, Levine DP, Rybak MJ. Impact of vancomycin exposure on outcomes in patients with methicillin-resistant Staphylococcus aureus bacteremia: support for consensus guidelines suggested targets. Clin Infect Dis. 2011;52(8):975-981. doi:10.1093/cid/cir124 [PubMed 21460309]
  150. Kupstaite R, Baranauskaite A, Pileckyte M, Sveikata A, Kadusevicius E, Muckiene G. Severe vancomycin-induced anaphylactic reaction. Medicina (Kaunas). 2010;46(1):30‐33. [PubMed 20234160]
  151. Langton MM, Ahern JW, MacDougall J. An AUC target simulation for vancomycin in patients with class III obesity. J Pharm Pract. Published online November 10, 2019. doi:10.1177/0897190019885241 [PubMed 31709893]
  152. LaPlante KL, Mermel LA. In vitro activity of daptomycin and vancomycin lock solutions on staphylococcal biofilms in a central venous catheter model. Nephrol Dial Transplant. 2007;22(8):2239-2246. [PubMed 17403700]
  153. Launay-Vacher V, Izzedine H, Mercadal L, Deray G. Clinical review: use of vancomycin in haemodialysis patients. Crit Care. 2002;6(4):313-316. [PubMed 12225605]
  154. Le J, Bradley JS, Murray W, et al. Improved vancomycin dosing in children using area under the curve exposure. Pediatr Infect Dis J. 2013;32(4):e155-163. [PubMed 23340565]
  155. Le J, Ny P, Capparelli E, et al. Pharmacodynamic characteristics of nephrotoxicity associated with vancomycin use in children. J Pediatric Infect Dis Soc. 2015;4(4):e109-e116. doi:10.1093/jpids/piu110 [PubMed 26582878]
  156. Lee JY, Ko KS, Peck KR, Oh WS, Song JH. In vitro evaluation of the antibiotic lock technique (ALT) for the treatment of catheter-related infections caused by staphylococci. J Antimicrob Chemother. 2006;57(6):1110-1115. [PubMed 16556639]
  157. Leonard MB, Koren G, Stevenson DK, et al, "Vancomycin Pharmacokinetics in Very Low Birth Weight Neonates," Pediatr Infect Dis J, 1989, 8(5):282-6. [PubMed 2657617]
  158. Levy JH, Marty AT. Vancomycin and adverse drug reactions. Crit Care Med. 1993;21(8):1107‐1108. doi:10.1097/00003246-199308000-00002 [PubMed 7687945]
  159. Lin Wu FL, Liu SS, Yang TY, et al. A larger dose of vancomycin is required in adult neurosurgical intensive care unit patients due to augmented clearance. Ther Drug Monit. 2015;37(5):609-618. doi:10.1097/FTD.0000000000000187 [PubMed 25627406]
  160. Li PK, Szeto CC, Piraino B, et al. International Society for Peritoneal Dialysis. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int. 2010;30(4):393-423. doi: 10.3747/pdi.2010.00049. [PubMed 20628102]
  161. Li PK, Szeto CC, Piraino B, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int. 2016;36(5):481-508. [PubMed 27282851]
  162. Lin YF, Yang CH, Sindy H, et al. Severe cutaneous adverse reactions related to systemic antibiotics. Clin Infect Dis. 2014;58(10):1377‐1385. doi:10.1093/cid/ciu126 [PubMed 24599767]
  163. Lin Z, Kotler DP, Schlievert PM, Sordillo EM. Staphylococcal enterocolitis: forgotten but not gone? Dig Dis Sci. 2010;55(5):1200-1207. [PubMed 19609675]
  164. Lipsky BA, Berendt AR, Cornia PB, et al; Infectious Diseases Society of America. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-73. doi: 10.1093/cid/cis346. [PubMed 22619242]
  165. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis. 2011;52(3):285-292. doi: 10.1093/cid/cir034. [PubMed 21217178]
  166. Lodise TP, Drusano GL, Zasowski E, et al. Vancomycin exposure in patients with methicillin-resistant Staphylococcus aureus bloodstream infections: how much is enough? Clin Infect Dis. 2014;59(5):666-675. doi:10.1093/cid/ciu398 [PubMed 24867791]
  167. Lodise TP, Lomaestro B, Graves J, Drusano GL. Larger vancomycin doses (at least four grams per day) are associated with an increased incidence of nephrotoxicity. Antimicrob Agents Chemother. 2008;52(4):1330-1336. doi: 10.1128/AAC.01602-07. [PubMed 18227177]
  168. 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;49(4):507‐514. doi:10.1086/600884 [PubMed 19586413]
  169. Lodise TP, Rosenkranz SL, Finnemeyer M, et al. The emperor's new clothes: prospective observational evaluation of the association between initial vancomycin exposure and failure rates among adult hospitalized patients with methicillin-resistant Staphylococcus aureus bloodstream infections (PROVIDE). Clin Infect Dis. 2020;70(8):1536-1545. doi:10.1093/cid/ciz460 [PubMed 31157370]
  170. Löwdin E, Odenholt I, Cars O. In vitro studies of pharmacodynamic properties of vancomycin against Staphylococcus aureus and Staphylococcus epidermidis. Antimicrob Agents Chemother. 1998;42(10):2739-2744. doi:10.1128/AAC.42.10.2739 [PubMed 9756787]
  171. Lucksiri A, Scott MK, Mueller BA, Hamburger RJ, Sowinski KM. CAHP-210 dialyzer influence on intra-dialytic vancomycin removal. Nephrol Dial Transplant. 2002;17(9):1649-1654. doi:10.1093/ndt/17.9.1649 [PubMed 12198218]
  172. Mancini A, Todd L. Inconsistencies in ISPD peritonitis recommendations: 2016 update on prevention and treatment and the ISPD catheter-related infection recommendations: 2017 update. Perit Dial Int. 2018;38(4):309-310. doi: 10.3747/pdi.2018.00026. [PubMed 29987068]
  173. Mandl DL, Garrison MW, Palpant SD. Agranulocytosis induced by vancomycin or ticarcillin/clavulanate. Ann Pharmacother. 1997;31(11):1321‐1324. doi:10.1177/106002809703101109 [PubMed 9391687]
  174. Marik PE, Ferris N. Delayed hypersensitivity reaction to vancomycin. Pharmacotherapy. 1997;17(6):1341‐1344. [PubMed 9399623]
  175. Marsot A, Boulamery A, Bruguerolle B, et al. Vancomycin: a review of population pharmacokinetic analyses. Clin Pharmacokinet. 2012;51(1):1-13. [PubMed 22149255]
  176. Martí R, Rosell M, Pou L, Garcia L, Pascual C. Influence of biochemical parameters of liver function on vancomycin pharmacokinetics. Pharmacol Toxicol. 1996;79(2):55-59. [PubMed 8878246]
  177. Matsunaga N, Hisata K, Shimizu T. An investigation into the vancomycin concentration in the cerebrospinal fluid due to vancomycin intraventricular administration in newborns: a study of 13 cases. Medicine (Baltimore). 2015;94(22):e922. [PubMed 26039127]
  178. Matzke GR, McGory RW, Halstenson CE, Keane WF. Pharmacokinetics of vancomycin in patients with various degrees of renal function. Antimicrob Agents Chemother. 1984;25(4):433-437. doi:10.1128/aac.25.4.433 [PubMed 6732213]
  179. Matzke GR, Zhanel GG, and Guay DRP, "Clinical Pharmacokinetics of Vancomycin," Clin Pharmacokinet, 1986, 11(4):257-82. [PubMed 3530582]
  180. Mawri S, Jain T, Shah J, Hurst G, Swiderek J. Vancomycin-induced acute generalized exanthematous pustulosis (AGEP) masquerading septic shock-an unusual presentation of a rare disease. J Intensive Care. 2015;3:47. doi:10.1186/s40560-015-0114-3 [PubMed 26561525]
  181. Mayhew JF, Deutsch S. Cardiac arrest following administration of vancomycin. Can Anaesth Soc J. 1985;32(1):65‐66. doi:10.1007/BF03008541 [PubMed 3971208]
  182. Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society revised guidelines on the management of intra-abdominal infection. Surg Infect (Larchmt). 2017;18(1):1-76. doi:10.1089/sur.2016.261 [PubMed 28085573]
  183. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):987‐994. doi:10.1093/cid/ciy149 [PubMed 29562266]
  184. McKamy S, Chen T, Lee M, Ambrose PJ. Evaluation of a pediatric continuous-infusion vancomycin therapy guideline. Am J Health Syst Pharm. 2012;69(23):2066-2071. doi:10.2146/ajhp120072 [PubMed 23172265]
  185. Men P, Li HB, Zhai SD, Zhao RS. Association between the AUC0-24/MIC ratio of vancomycin and its clinical effectiveness: a systematic review and meta-analysis. PLoS One. 2016;11(1):e0146224. doi: 10.1371/journal.pone.0146224. [PubMed 26731739]
  186. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49(1):1-45. doi:10.1086/599376 [PubMed 19489710]
  187. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST. [PubMed 31573350]
  188. Middleton PG, Gade EJ, Aguilera C, et al. ERS/TSANZ Task Force Statement on the management of reproduction and pregnancy in women with airways diseases. Eur Respir J. 2020;55(2):1901208. doi:10.1183/13993003.01208-2019 [PubMed 31699837]
  189. Min Z, Garcia RR, Murillo M, Uchin JM, Bhanot N. Vancomycin-associated Henoch-Schönlein purpura. J Infect Chemother. 2017;23(3):180‐184. doi:10.1016/j.jiac.2016.08.012 [PubMed 27681233]
  190. Minhas JS, Wickner PG, Long AA, Banerji A, Blumenthal KG. Immune-mediated reactions to vancomycin: A systematic case review and analysis. Ann Allergy Asthma Immunol. 2016;116(6):544‐553. doi:10.1016/j.anai.2016.03.030 [PubMed 27156746]
  191. Miyazu D, Kodama N, Yamashita D, et al. DRESS syndrome caused by cross-reactivity between vancomycin and subsequent teicoplanin administration: a case report. Am J Case Rep. 2016;17:625‐631. doi:10.12659/ajcr.899149 [PubMed 27572807]
  192. Moffett BS, Morris J, Galati M, Munoz F, Arikan AA. Population pharmacokinetics of vancomycin in pediatric extracorporeal membrane oxygenation. Pediatr Crit Care Med. 2018;19(10):973-980. [PubMed 30063652]
  193. Mohammadi M, Jahangard-Rafsanjani Z, Sarayani A, Hadjibabaei M, Taghizadeh-Ghehi M. Vancomycin-induced thrombocytopenia: a narrative review. Drug Saf. 2017;40(1):49‐59. doi:10.1007/s40264-016-0469-y [PubMed 27848200]
  194. Moise-Broder PA, Forrest A, Birmingham MC, Schentag JJ. Pharmacodynamics of vancomycin and other antimicrobials in patients with Staphylococcus aureus lower respiratory tract infections. Clin Pharmacokinet. 2004;43(13):925-942. doi:10.2165/00003088-200443130-00005 [PubMed 15509186]
  195. Mulla H, Pooboni S. Population pharmacokinetics of vancomycin in patients receiving extracorporeal membrane oxygenation. Br J Clin Pharmacol. 2005;60(3):265-275. [PubMed 16120065]
  196. Murray BE, Arias CA, Nannini EC. Glycopeptides (vancomycin and teicoplanin), streptogramins (quinupristin-dalfopristin), lipopeptides (daptomycin), and lipoglycopeptides (telavancin). In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, PA: Elsevier Saunders;2015:377.
  197. Nagahama Y, VanBeek MJ, Greenlee JDW. Red man syndrome caused by vancomycin powder. J Clin Neurosci. 2018;50:149‐150. doi:10.1016/j.jocn.2018.01.044 [PubMed 29398192]
  198. Nathanson DR, Sheahan M, Chao L, Wallack MK. Intracolonic use of vancomycin for treatment of Clostridium difficile colitis in a patient with a diverted colon: report of a case. Dis Colon Rectum. 2001;44(12):1871-1872. doi:10.1007/BF02234471 [PubMed 11742178]
  199. National Institute for Health and Care Excellence (NICE). Drug allergy: diagnosis and management. https://www.nice.org.uk/guidance/cg183. September 3, 2014. Accessed May 6, 2020.
  200. Navinés-Ferrer A, Serrano-Candelas E, Lafuente A, Muñoz-Cano R, Martín M, Gastaminza G. MRGPRX2-mediated mast cell response to drugs used in perioperative procedures and anaesthesia. Sci Rep. 2018;8(1):11628. doi:10.1038/s41598-018-29965-8 [PubMed 30072729]
  201. Neely MN, Kato L, Youn G, et al. Prospective trial on the use of trough concentration versus area under the curve to determine therapeutic vancomycin dosing. Antimicrob Agents Chemother. 2018;62(2):e02042-17. doi: 10.1128/AAC.02042-17. [PubMed 29203493]
  202. Ng K, Mabasa VH, Chow I, Ensom MH. Systematic review of efficacy, pharmacokinetics, and administration of intraventricular vancomycin in adults. Neurocrit Care. 2014;20(1):158-171. doi: 10.1007/s12028-012-9784-z. [PubMed 23090839]
  203. Nielsen HE, Sorensen I, and Hansen HE, “Peritoneal Transport of Vancomycin During Peritoneal Dialysis,” Nephron, 1979, 24(6):274-7. [PubMed 514426]
  204. Nousari HC, Costarangos C, Anhalt GJ. Vancomycin-associated linear IgA bullous dermatosis. Ann Intern Med. 1998;129(6):507‐508. doi:10.7326/0003-4819-129-6-199809150-00021 [PubMed 9735094]
  205. Nyman HA, Agarwal A, Senekjian HO, Leypoldt JK, Cheung AK. Removal of vancomycin administered during dialysis by a high-flux dialyzer. Hemodial Int. 2018;22(3):383-387. doi:10.1111/hdi.12637 [PubMed 29380499]
  206. Ocampos-Martinez E, Penaccini L, Scolletta S, et al. Determinants of early inadequate vancomycin concentrations during continuous infusion in septic patients. Int J Antimicrob Agents. 2012;39(4):332-337. doi:10.1016/j.ijantimicag.2011.12.008 [PubMed 22333933]
  207. O'Donnell E, Shepherd C, Neff A. Immune thrombocytopenia from vancomycin in orthopedic cement. Am J Hematol. 2007;82(12):1122. doi:10.1002/ajh.20916 [PubMed 17665503]
  208. Onwuchuruba CN, Towers CV, Howard BC, Hennessy MD, Wolfe L, Brown MS. Transplacental passage of vancomycin from mother to neonate. Am J Obstet Gynecol. 2014;210(4):352.e1-352.e4. doi: 10.1016/j.ajog.2014.01.019. [PubMed 24679944]
  209. Osler T, Lott D, Bordley J 4th, Lynch F, Ellsworth C, Kozak A. Cefazolin-induced pseudomembranous colitis resulting in perforation of the sigmoid colon. Dis Colon Rectum. 1986;29(2):140-143. doi:10.1007/BF02555402 [PubMed 3510836]
  210. Osmon DR, Berbari EF, Berendt AR, et al; Infectious Diseases Society of America. Diagnosis and management of prosthetic joint infection: clinical practice guideline by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):e1-e25. [PubMed 23223583]
  211. Osmon DR, Tande AJ. Osteomyelitis in adults: Treatment. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed July 8, 2019.
  212. Otani IM, Kuhlen JL Jr, Blumenthal KG, Guyer A, Banerji A. A role for vancomycin epicutaneous skin testing in the evaluation of perioperative anaphylaxis. J Allergy Clin Immunol Pract. 2015;3(6):984‐985. doi:10.1016/j.jaip.2015.06.017 [PubMed 26246124]
  213. Packer M, Chang DF, Dewey SH, et al; ASCRS Cataract Clinical Committee. Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis. J Cataract Refract Surg. 2011;37(9):1699-1714. [PubMed 21782382]
  214. Parasuraman JM, Albur M, Fellows G, Heep A. Monitoring intraventricular vancomycin for ventriculostomy access device infection in preterm infants. Childs Nerv Syst. 2018;34(3):473-479. [PubMed 29067501]
  215. Pasic M, Jost R, Carrel T, Von Segesser L, Turina M. Intracolonic vancomycin for pseudomembranous colitis. N Engl J Med. 1993;329(8):583. doi:10.1056/NEJM199308193290819 [PubMed 8336766]
  216. Pea F, Furlanut M, Negri C, et al. Prospectively validated dosing nomograms for maximizing the pharmacodynamics of vancomycin administered by continuous infusion in critically ill patients. Antimicrob Agents Chemother. 2009;53(5):1863-1867. doi:10.1128/AAC.01149-08 [PubMed 19223642]
  217. Pediatric Infectious Diseases Society (PIDS). Pediatric Infectious Diseases Society endorses new terminology: vancomycin flushing syndrome. https://pids.org/wp-content/uploads/2021/04/PIDS-Endorses-New-Terminology_Vanc-Flushing-Syn_Final_4.27.21-1.pdf. April 27, 2021. Accessed May 5, 2021.
  218. Pettit NN, DePestel DD, Fohl AL, et al. Risk factors for systemic vancomycin exposure following administration of oral vancomycin for the treatment of Clostridium difficile infection. Pharmacotherapy. 2015;35(2):119-126. doi: 10.1002/phar.1538. [PubMed 25689243]
  219. Pettit RS, Peters SJ, McDade EJ, et al. Vancomycin dosing and monitoring in the treatment of cystic fibrosis: results of a National Practice Survey. J Pediatr Pharmacol Ther. 2017;22(6):406-411. doi: 10.5863/1551-6776-22.6.406. [PubMed 29290740]
  220. Pfausler B, Haring HP, Kampfl A, Wissel J, Schober M, Schmutzhard E. Cerebrospinal fluid (CSF) pharmacokinetics of intraventricular vancomycin in patients with staphylococcal ventriculitis associated with external CSF drainage. Clin Infect Dis. 1997;25(3):733-735. [PubMed 9314470]
  221. Pingili CS, Okon EE. Vancomycin-induced leukocytoclastic vasculitis and acute renal failure due to tubulointerstitial nephritis. Am J Case Rep. 2017;18:1024‐1027. doi:10.12659/ajcr.905214 [PubMed 28943633]
  222. Pogue JM, DePestel DD, Kaul DR, Khaled Y, Frame DG. Systemic absorption of oral vancomycin in a peripheral blood stem cell transplant patient with severe graft-versus-host disease of the gastrointestinal tract. Transpl Infect Dis. 2009;11(5):467-470. doi:10.1111/j.1399-3062.2009.00426.x [PubMed 19638004]
  223. Radu L, Bengry T, Akierman A, Alshaikh B, Yusuf K, Dersch-Mills D. Evolution of empiric vancomycin dosing in a neonatal population. J Perinatol. 2018;38(12):1702-1707. [PubMed 30341404]
  224. Rainkie D, Ensom MH, Carr R. Pediatric assessment of vancomycin empiric dosing (PAVED): a retrospective review. Paediatr Drugs. 2015;17(3):245-253. [PubMed 25813682]
  225. Reardon J, Lau TT, Ensom MH. Vancomycin loading doses: a systematic review. Ann Pharmacother. 2015;49(5):557-565. doi: 10.1177/1060028015571163. [PubMed 25712445]
  226. Reyes MP and Ostrea EM Jr, "Toxicity of Vancomycin Given During Pregnancy (Reply)," Am J Obstet Gynecol, 1990, 163(4 Pt 1):1376.
  227. Reyes MP, Ostrea EM Jr, Cabinian AE, et al. Vancomycin during pregnancy: does it cause hearing loss or nephrotoxicity in the infant? Am J Obstet Gynecol. 1989;161(4):977-981. [PubMed 2801848]
  228. Reynolds PM, MacLaren R, Mueller SW, Fish DN, Kiser TH. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34(6):617-632. doi: 10.1002/phar.1396. [PubMed 24420913]
  229. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43(3):304-377. doi: 10.1007/s00134-017-4683-6. [PubMed 28101605]
  230. Rocha JL, Kondo W, Baptista MI, Da Cunha CA, Martins LT. Uncommon vancomycin-induced side effects. Braz J Infect Dis. 2002;6(4):196‐200. doi:10.1590/s1413-86702002000400007 [PubMed 12204187]
  231. Rodvold KA, Everett JA, Pryka RD, and Kraus DM, "Pharmacokinetics and Administration Regimens of Vancomycin in Neonates, Infants and Children," Clin Pharmacokinet, 1997, 33(1):32-51. [PubMed 9250422]
  232. Rokas KE, Johnson JW, Beardsley JR, Ohl CA, Luther VP, Williamson JC. The addition of intravenous metronidazole to oral vancomycin is associated with improved mortality in critically ill patients with Clostridium difficile infection. Clin Infect Dis. 2015;61(6):934-941. doi: 10.1093/cid/civ409. [PubMed 26024909]
  233. Rybak MJ, Albrecht LM, Boike SC, et al, "Nephrotoxicity of Vancomycin, Alone and With an Aminoglycoside," J Antimicrob Chemother, 1990, 25(4):679-87. [PubMed 2351627]
  234. Rybak MJ, Boike SC. Monitoring vancomycin therapy. Drug Intell Clin Pharm. 1986;20(10):757-761. [PubMed 3769763]
  235. Rybak MJ, Le J, Lodise TP, et al. 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 (ASHP/IDSA/SIDP). Am J Health Syst Pharm. 2020;77(11):835‐864. doi:10.1093/ajhp/zxaa036 [PubMed 32191793]
  236. Rybak M, Lomaestro B, Rotschafer JC, 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 (ASHP/IDSA/SIDP). Am J Health Syst Pharm. 2009;66(1):82‐98. doi:10.2146/ajhp080434 [PubMed 19106348]
  237. Saffouri G, Khanna S, Estes L, Pardi D. Outcomes from rectal vancomycin therapy in patients with Clostridium difficile infection. Am J Gastroenterol. 2014;109(6):924-925. doi:10.1038/ajg.2014.80 [PubMed 24896763]
  238. Sawada A, Kawanishi K, Morikawa S, et al. Biopsy-proven vancomycin-induced acute kidney injury: a case report and literature review. BMC Nephrol. 2018;19(1):72. doi:10.1186/s12882-018-0845-1 [PubMed 29587650]
  239. Sawyer RG, Claridge JA, Nathens AB, et al; STOP-IT Trial Investigators. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015;372(21):1996-2005. doi:10.1056/NEJMoa1411162 [PubMed 25992746]
  240. Schaad UB, McCracken GH Jr, Nelson JD. Clinical pharmacology and efficacy of vancomycin in pediatric patients. J Pediatr. 1980;96(1):119-126. [PubMed 7350291]
  241. Schmelzer TM, Christmas AB, Norton HJ, Heniford BT, Sing RF. Vancomycin intermittent dosing versus continuous infusion for treatment of ventilator-associated pneumonia in trauma patients. Am Surg. 2013;79(11):1185-1190. doi:10.1177/000313481307901123 [PubMed 24165255]
  242. Schutze GE, Willoughby RE, Committee on Infectious Diseases, American Academy of Pediatrics. Clostridium difficile infection in infants and children. Pediatrics. 2013;131(1):196-200. [PubMed 23277317]
  243. Scott MK, Macias WL, Kraus MA, Clark WR, Carfagna MA, Mueller BA. Effects of dialysis membrane on intradialytic vancomycin administration. Pharmacotherapy. 1997;17(2):256-262. [PubMed 9085316]
  244. Sexton DJ, Sampson JH. Intracranial epidural abscess. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 16, 2021.
  245. Sexton DJ, Sampson JH. Spinal epidural abscess. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 30, 2019b.
  246. Shah-Khan F, Scheetz MH, Ghossein C. Biopsy-proven acute tubular necrosis due to vancomycin toxicity. Int J Nephrol. 2011;2011:436856. doi:10.4061/2011/436856 [PubMed 21716699]
  247. Shaker MS, Wallace DV, Golden DBK, et al. Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol. 2020;145(4):1082‐1123. doi:10.1016/j.jaci.2020.01.017 [PubMed 32001253]
  248. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017;65(12):e45‐e80. doi:10.1093/cid/cix669 [PubMed 29053792]
  249. Shokouhi S, Alavi Darazam I. Determination of vancomycin trough level in serum and cerebrospinal fluid of patients with acute community-acquired meningitis: a prospective study. J Infect. 2014;69(5):424-429. doi: 10.1016/j.jinf.2014.06.010 [PubMed 24973553]
  250. Simon RH. Cystic fibrosis: treatment of acute pulmonary exacerbations. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed January 20, 2022.
  251. Sivagnanam S, Deleu D. Red man syndrome. Crit Care. 2003;7(2):119‐120. doi:10.1186/cc1871 [PubMed 12720556]
  252. Smetana KS, Cook AM. Cerebrospinal fluid vancomycin dosing and monitoring: the quandary posed by guideline recommendations. Clin Infect Dis. 2018;67(6):980-981. doi: 10.1093/cid/ciy189. [PubMed 29518176]
  253. Smith PF, Taylor CT. Vancomycin-induced neutropenia associated with fever: similarities between two immune-mediated drug reactions. Pharmacotherapy. 1999;19(2):240‐244. doi:10.1592/phco.19.3.240.30912 [PubMed 10030777]
  254. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infections in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2010;50(12):1695]. Clin Infect Dis. 2010;50(2):133-164. [PubMed 20034345]
  255. Southwick FS. Treatment and prognosis of bacterial brain abscess. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed February 11, 2020.
  256. Spadaro S, Berselli A, Fogagnolo A, et al. Evaluation of a protocol for vancomycin administration in critically patients with and without kidney dysfunction. BMC Anesthesiol. 2015;15:95. doi:10.1186/s12871-015-0065-1 [PubMed 26116239]
  257. Spitzer PG, Eliopoulos GM. Systemic absorption of enteral vancomycin in a patient with pseudomembranous colitis. Ann Intern Med. 1984;100(4):533-534. doi:10.7326/0003-4819-100-4-533 [PubMed 6703548]
  258. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published online ahead of print June 18, 2014]. Clin Infect Dis. 2014;59(2):147-159. doi: 10.1093/cid/ciu296. [PubMed 24947530]
  259. Stockmann C, Hersh AL, Roberts JK, et al. Predictive performance of a vancomycin population pharmacokinetic model in neonates. Infect Dis Ther. 2015;4(2):187-198. [PubMed 25998107]
  260. Surawicz CM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478-498. doi:10.1093/cid/cix1085 [PubMed 23439232]
  261. Suzuki Y, Kawasaki K, Sato Y, et al. Is peak concentration needed in therapeutic drug monitoring of vancomycin? A pharmacokinetic-pharmacodynamic analysis in patients with methicillin-resistant staphylococcus aureus pneumonia. Chemotherapy. 2012;58(4):308-312. doi:10.1159/000343162 [PubMed 23147106]
  262. Symons NL, Hobbes AF, Leaver HK. Anaphylactoid reactions to vancomycin during anaesthesia: two clinical reports. Can Anaesth Soc J. 1985;32(2):178‐181. doi:10.1007/BF03010047 [PubMed 3986655]
  263. Szeto CC, Li PK. Concerns regarding inconsistencies within and between ISPD recommendations for peritonitis and catheter-related infections-in reply. Perit Dial Int. 2018;38(4):311-312. doi: 10.3747/pdi.2018.00046. [PubMed 29987069]
  264. Szymusiak-Mutnick BA, Ross MB. Minimizing the occurrence of red-man syndrome. Am J Health Syst Pharm. 1996;53(17):2098. [PubMed 8870903]
  265. Tashima S, Konishi K, Koga H, Hashimoto T. A case of vancomycin-induced linear IgA bullous dermatosis with circulating IgA antibodies to the NC16a domain of BP180. Int J Dermatol. 2014;53(3):e207‐e209. doi:10.1111/ijd.12047 [PubMed 23829415]
  266. Traber PG, Levine DP. Vancomycin Ototoxicity in patient with normal renal function. Ann Intern Med. 1981;95(4):458‐460. doi:10.7326/0003-4819-95-4-458 [PubMed 7283300]
  267. Trotman RL, Williamson JC, Shoemaker DM, Salzer WL. Antibiotic dosing in critically ill adult patients receiving continuous renal replacement therapy. Clin Infect Dis. 2005;41(8):1159-1166. [PubMed 16163635]
  268. Trubiano JA, Cheng AC, Korman TM, et al. Australasian Society of Infectious Diseases updated guidelines for the management of Clostridium difficile infection in adults and children in Australia and New Zealand. Intern Med J. 2016;46(4):479-493. [PubMed 27062204]
  269. Tsai HC, Huang LM, Chang LY, et al. Central venous catheter-associated bloodstream infections in pediatric hematology-oncology patients and effectiveness of antimicrobial lock therapy. J Microbiol Immunol Infect. 2015;48(6):639-646. [PubMed 25311403]
  270. Tufariello JM, Lowy FD. Infection due to coagulase-negative staphylococci: treatment. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed December 17, 2020.
  271. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267-1284. [PubMed 15494903]
  272. Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's clinical practice guidelines for healthcare-associated ventriculitis and meningitis [published online ahead of print February 14, 2017]. Clin Infect Dis. doi: 10.1093/cid/ciw861. [PubMed 28203777]
  273. Udy AA, Roberts JA, Boots RJ, Paterson DL, Lipman J. Augmented renal clearance: implications for antibacterial dosing in the critically ill. Clin Pharmacokinet. 2010;49(1):1-16. doi:10.2165/11318140-000000000-00000 [PubMed 20000886]
  274. University of Oklahoma Health Science Center (OUHSC). Thrombotic thrombocytopenic purpura hemolytic uremic syndrome (TTP-HUS). https://www.ouhsc.edu/platelets/ditp.html. May 4, 2015. Accessed May 6, 2020.
  275. van Hal SJ, Paterson DL, Lodise TP. Systematic review and meta-analysis of vancomycin-induced nephrotoxicity associated with dosing schedules that maintain troughs between 15 and 20 milligrams per liter. Antimicrob Agents Chemother. 2013;57(2):734-744. doi:10.1128/AAC.01568-12 [PubMed 23165462]
  276. Vancocin (vancomycin hydrochloride) [prescribing information]. Baudette, MN: ANI Pharmaceuticals; August 2020.
  277. Vancocin (vancomycin hydrochloride) [prescribing information]. Baudette, MN: ANI Pharmaceuticals Inc; December 2021.
  278. Vancocin (vancomycin hydrochloride) [prescribing information]. Deerfield, IL: Baxter Healthcare Corporation; January 2021.
  279. Vancomycin Hydrochloride (fliptop vial) [prescribing information]. Lake Forest, IL: Hospira; October 2021.
  280. Vancomycin hydrochloride injection [prescribing information]. Lake Zurich, IL: Fresenius Kabi; February 2018.
  281. Vancomycin hydrochloride injection [prescribing information]. Lake Zurich, IL: Fresenius Kabi; January 2019.
  282. Vancomycin hydrochloride injection [prescribing information]. Buffalo Grove, IL: Xellia Pharmaceuticals USA, LLC; January 2020.
  283. Vancomycin hydrochloride injection [prescribing information]. Buffalo Grove, IL: Xellia Pharmaceuticals USA, LLC; May 2021.
  284. Vancomycin hydrochloride injection [prescribing information]. Columbus, OH: Slate Run Pharmaceuticals; April 2020.
  285. Vancomycin hydrochloride injection [prescribing information]. Rockford, IL: Myland Institutional LLC; August 2019.
  286. Vancomycin hydrochloride injection [prescribing information]. Schaumburg, IL: Sagent Pharmaceuticals; January 2018.
  287. Vancomycin hydrochloride lyophilized vial [prescribing information]. Morgantown, WV: Mylan Pharmaceuticals; January 2021.
  288. Vardakas KZ, Trigkidis KK, Boukouvala E, Falagas ME. Clostridium difficile infection following systemic antibiotic administration in randomised controlled trials: a systematic review and meta-analysis. Int J Antimicrob Agents. 2016;48(1):1‐10. doi:10.1016/j.ijantimicag.2016.03.008 [PubMed 27216385]
  289. Verrall AJ, Llorin R, Tam VH, et al. Efficacy of continuous infusion of vancomycin for the outpatient treatment of methicillin-resistant Staphylococcus aureus infections. J Antimicrob Chemother. 2012;67(12):2970-2973. doi: 10.1093/jac/dks328. [PubMed 22915464]
  290. Visentainer L, Massuda JY, Cintra ML, Magalhães RF. Vancomycin-induced linear IgA bullous dermatosis (LABD)-an atypical presentation. Clin Case Rep. 2019;7(5):1091‐1093. doi:10.1002/ccr3.2039 [PubMed 31110752]
  291. Von Drygalski A, Curtis BR, Bougie DW, et al. Vancomycin-induced immune thrombocytopenia. N Engl J Med. 2007;356(9):904‐910. doi:10.1056/NEJMoa065066 [PubMed 17329697]
  292. Vu DH, Nguyen DA, Delattre IK, et al. Determination of optimal loading and maintenance doses for continuous infusion of vancomycin in critically ill patients: population pharmacokinetic modelling and simulations for improved dosing schemes. Int J Antimicrob Agents. 2019;54(6):702-708. doi:10.1016/j.ijantimicag.2019.09.018 [PubMed 31600554]
  293. Waineo MF, Kuhn TC, Brown DL. The pharmacokinetic/pharmacodynamic rationale for administering vancomycin via continuous infusion. J Clin Pharm Ther. 2015;40(3):259-265. doi: 10.1111/jcpt.12270. [PubMed 25865426]
  294. Waldman MA, Black DR, Callen JP. Vancomycin-induced linear IgA bullous disease presenting as toxic epidermal necrolysis. Clin Exp Dermatol. 2004;29(6):633‐636. doi:10.1111/j.1365-2230.2004.01649.x [PubMed 15550142]
  295. Wang JT, Fang CT, Chen YC, Chang SC. Necessity of a loading dose when using vancomycin in critically ill patients. J Antimicrob Chemother. 2001;47(2):246. [PubMed 11157921]
  296. Warady BA, Bakkaloglu S, Newland J, et al. Consensus Guidelines for the Prevention and Treatment of Catheter-Related Infections and Peritonitis in Pediatric Patients Receiving Peritoneal Dialysis: 2012 Update. Perit Dial Int. 2012;(32)(suppl 2):S32-S86. [PubMed 22851742]
  297. Watson T, Hickok J, Fraker S, Korwek K, Poland RE, Septimus E. Evaluating the risk factors for hospital-onset Clostridium difficile infections in a large healthcare system. Clin Infect Dis. 2018;66(12):1957‐1959. doi:10.1093/cid/cix1112 [PubMed 29272341]
  298. Wazny LD, Daghigh B. Desensitization protocols for vancomycin hypersensitivity. Ann Pharmacother. 2001;35(11):1458‐1464. doi:10.1345/aph.1A002 [PubMed 11724099]
  299. Weintrob AC, Sexton DJ. Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 30, 2019.
  300. Wilhem MP, Estes L. Symposium on antimicrobial agents--Part XII. Vancomycin. Mayo Clin Proc. 1999;74(9):928-935. [PubMed 10488798]
  301. Wolf J, Allison KJ, Tang L, Sun Y, Hayden RT, Flynn PM. No evidence of benefit from antibiotic lock therapy in pediatric oncology patients with central line-related bloodstream infection: results of a retrospective matched cohort study and review of the literature. Pediatr Blood Cancer. 2014;61(10):1811-1815. [PubMed 24923808]
  302. Wolfson AR, Zhou L, Li Y, Phadke NA, Chow OA, Blumenthal KG. Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome identified in the electronic health record allergy module. J Allergy Clin Immunol Pract. 2019;7(2):633‐640. doi:10.1016/j.jaip.2018.08.013 [PubMed 30176295]
  303. World Health Organization (WHO). Breastfeeding and maternal medication, recommendations for drugs in the Eleventh WHO Model List of Essential Drugs. 2002. Available at http://www.who.int/maternal_child_adolescent/documents/55732/en/ [PubMed 23215911]
  304. Zasowski EJ, Murray KP, Trinh TD, et al. Identification of vancomycin exposure-toxicity thresholds in hospitalized patients receiving intravenous vancomycin. Antimicrob Agents Chemother. 2017;62(1):e01684-17. doi:10.1128/AAC.01684-17 [PubMed 29084753]
  305. Zylbersztajn BL, Izquierdo G, Santana RC, et al. Therapeutic drug monitoring of vancomycin in pediatric patients with extracorporeal membrane oxygenation support. J Pediatr Pharmacol Ther. 2018;23(4):305-310. [PubMed 30181721]
Topic 12874 Version 525.0