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Paul A. Pham, Pharm.D. and John G. Bartlett, M.D.
08-28-2009
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Available formulation in Zambia: Powder for injection: 250 mg (as hydrochloride) vial.
- Generally reserved for treatment of severe infections due to cloxacillin-resistant staphylococci and ampicillin-resistant enterococci; also as an alternative agent for prophylaxis and treatment of endocarditis in penicillin-allergic patients.
- Empiric treatment of S. aureus in pts with PCN allergy or known high rate of cloxacillin resistance: vancomycin 15 mg/kg q12h.
- Bacterial meningitis due to PCN-resistant pneumococcus: vancomycin 20mg/kg IV q12h plus rifampin 600 mg PO q12h.
- Alternative to metronidazole for the treatment ofC. difficilecolitis. IV vancomycin can be given orally at 125 mg q6h x 10 days.
Zambia Information Author: Paul A. Pham, Pharm. D.
- Bone and joint infections
- Pneumonia
- Septicemia
- Endocarditis treatment and prophylaxis (in PCN allergic pts)
- Oral vancomycin: antibiotic-associated pseudomembranous colitis caused by C. difficileand enterocolitis caused by S. aureus(including MRSA)
- Hardware-associated infections
brand
name
| generic
| Mfg
| brand
forms
| cost*
|
| Vancocin, Lyphocin | Vancomycin HCl | Generic manufacturers | IV
vial
500mg; 1000mg | $4.70 ; $9.65 |
| Vancocin Pulvule | Vancomycin HCl | Viropharma | oral
pulvule
125mg; 250mg | $17.70 ; $35.66 |
*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP).
AWP Prices were obtained and gathered by Lakshmi Vasist Pharm D using the Red Book, manufacturer's
information, and the McKesson database.
^Dosage is indicated in mg unless otherwise noted.
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Systemic infections caused by MRSA and other resistant Gram-positive organisms: 15mg/kg IV q12h (dose based on actual body weight). Typical dose 1gm IV q12h for 70kg pt with normal renal function. Higher dose (15 mg/kg IV q8h or 22.5 mg/kg IV q12h ) recommended for CNS infections.
- Target trough: 15-20 mcg/mL (endocarditis and pneumonia); 20 mcg/mL (CNS infections); 10-15 mcg/mL (bacteremia with MRSA MIC<2).
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C. difficilecolitis: 125mg PO q6h x 7-10 d.Higher doses 250-500mg PO q6h (+/- IV metrondiazole) may be given with ileus or severe disease
- Oral preparation not systemically absorbed and ineffective for any infections other than C. difficilecolitis and S. aureusenterocolitis.Parenteral formulation not effective for treatment of staphylococcal enterocolitis and pseudomembranous colitis caused by C. difficile.
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Staphylococcal enterocolitis: 500-2000 mg POper day in 3-4 divided doses x 7-10 d.
- IV vancomycin can be given orally for C. difficilecolitisto decrease cost ($5 vs. $80 per day).
- Intraventricular or intrathecal dose: vancomycin 20 mg/d (up to 30 mg). Use preservative free vancomycin 1gm vial for reconstitution.
GFR >60 ml/min: 15 mg/kg IV q12 (monitor serum concentrations , Target Cmin: 10-20 mcg/ml.
GFR 30-59 ml/min: 15mg/kg q24h. GFR 15-29 ml/min: 15mg/kg IV q48h (monitor serum concentrations, Target Cmin :10-20 mcg/ml.
15 mg/kg IV, then redose based on serum concentrations, redose with Cmin <10-20 mcg/ml)
15 mg/kg, then redose based on on serum concentrations, redose with Cmin <10-20 mcg/ml) IV. Generally twice a week administration required.
0.5-1.0 gm IV/wk (monitor serum concentrations, redose when Cmin <10-20 mcg/ml)
CVVH 15 mg/kg q48h. CVVHD: 15 mg/kg IV q24h (monitor serum concentrations, redose when Cmin <10-20 mcg/ml).
Generally well tolerated.
- Red man syndrome:flushing over chest/face +/- hypotension & pruritis (infusion over > 60 min may reverse or prevent; pretreatment w/antihistamine may alleviate symptoms). Red man syndrome should not be construed as a true allergy.
- Phlebitis
- Renal function impairment (most often in combination with aminoglycosides).Uncommon with modern formulations of drug but controversial.
- Neutropenia
- Eosinophilia
- Drug fever
- Allergic reactions w/rash
- Tissue irritation
- Ototoxicity (controversial)
- Thrombocytopenia
- Non-depolarizing muscle relaxants (succinylcholine, atracurium, vecuronium, pancuronium, tubocurarine): case reports of enhanced neuromuscular blockade. Monitor closely with co-administration.
- Cholestyramine:binds to oral vancomycin. Do not co-administer; consider oral metronidazole with cholestyramineco-administration.
- Aminoglycoside: controversial but higher incidence of nephrotoxicity associated with vancomycin and aminoglycoside co-administration.
- Vancomycin-resistant S. aureus (VRSA): MIC = 16 mcg/mL (7 isolates reported to date). Vancomycin-intermediate S. aureus (VISA): MIC range 4-8 mcg/mL. Heteroresistant S. aureus (hetero VISA): MIC=4 mcg/mL (but contain subpopulation of organisms that have MICs of 4-8 mcg/mL). Vancomycin-sensitive S. aureus: MIC = 2 mcg/mL or lower (former breakpoint was 4 mcg/mL).
- MIC breakpoint of 4 mcg/mL for Enterococci.
Vancomycin appropriate in following conditions: 1) For treatment of serious infections caused by beta-lactam resistant gram-positive microorganisms, 2) Treatment of infections caused by gram-positive microorganisms in pts who have serious allergies to beta-lactam antimicrobials, 3) When antibiotic-associated colitis fails to respond to metronidazole therapy or is moderate to severe and potentially life-threatening, 4) Prophylaxis, as recommended by American Heart Association, for endocarditis following certain procedures in pts at high risk for endocarditis, 5) Prophylaxis for major surgical procedures involving implantation of prosthetic materials or devices (e.g., cardiac and vascular procedures and total hip replacement) at institutions that have high rate of infections caused by MRSA or methicillin-resistant S. epidermidis. Single dose of vancomycin administered immediately before surgery is sufficient unless procedure lasts > 6 hrs, in which case dose should be repeated. Prophylaxis should be discontinued after maximum of 2 doses.
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