Parenteral Manual

Vancomycin

Disclaimer: Official controlled document is the CHEO online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Alternate Name(s): 
VANCOCIN®
Classification: 
Antibiotic
Original Date: 
August 2005
Revised Date: 
December 2019
Indications: 
  • Serious infections due to gram positive organisms that are resistant, or suspected to be resistant, to other antibiotics (e.g. MRSA)
  • May be indicated in certain patients allergic to beta-lactam antibiotics
Reconstitution and Stability: 

VIAL SIZE

STERILE WATER for INJECTION  REQUIRED

FINAL CONCENTRATION

500 mg

10 mL

50 mg/mL

1,000 mg

20 mL

50 mg/mL

5,000 mg

100 mL

50 mg/mL

  • Reconstituted vial stable 24 hours at room temperature (8 hours after initial entry) and 4 days refrigerated
  • Reconstituted solutions may vary from a light yellow to light brown, and yellowish pink and pinkish - does not interfere with potency and purity
  • Stable for 24 days at room temperature and 30 days refrigerated at concentrations of 4-5 mg/mL in 0.9% NaCl
  • Stable for 17 days at room temperature and 30 days in the fridge at concentrations of 4-5 mg/mL in D5W
  • It is recommended to have a double check for calculations of reconstitution, and further dilution, to prevent medication errors leading to adverse drug effects.
Compatibility: 

- Solutions Compatible: dextrose up to D10W, 0.9% NaCl, dextrose-saline combinations, ringer's lactate

- Additive/Above Cassette Compatible: KCl

- Y-site Compatible: amiodarone, fluconazole, heparin (0.5 - 1 unit/mL), meropenem, morphine, TPN (amino acids/dextrose)

- Incompatible: heparin (greater than 1 unit/mL), many incompatibilities

Administration: 

(For approved routes of administration by nursing personnel, refer to Policy for the Administration of Intravenous Medications.)

SC NO
IM NO
IV Direct NO
IV Intermittent Infusion

YES

Syringe pump dilution: 5 mg/mL only

 

Large volume pump:
Usual dilution: 5 mg/mL

Fluid restricted patients: 10 mg/mL

Infusion time: doses less than or equal to 600 mg  - infuse over 60 min
                          doses greater than 600 mg -  infuse over 10 mg/min

IV Continuous Infusion YES

 

Dosage: 

(For neonatal dosages, refer to Neonatal IV Drug Manual.)

Pediatric:

  • 15 mg/kg/dose IV  Q6H
    -Adjust interval in renal impairment as chart below
  • Maximum: 4 g/day prior to therapeutic drug monitoring
     

Adult:

  • 15 - 20 mg/kg/dose IV q 8 -12 hours
  • Maximum: 4 g/day prior to therapeutic drug monitoring
     

DOSING INTERVAL ADJUSTMENT IN RENAL IMPAIRMENT:

Cr Cl Dosing Interval           
> 90 mL/minute Q6H
70-89 mL/minute Q8H
46-69 mL/minute Q12H
30-45 mL/minute Q18H
15-29 mL/minute Q24H
end-stage or dialysis 10-20 mg/kg.  Subsequent doses and frequency based on vancomycin levels
Potential hazards of parenteral administration: 
  • "Red-man" syndrome (pruritus, tachycardia, hypotension, rash involving face, neck, upper trunk, back and upper arms)  -less likely to occur with longer infusion time (>1 hour)
  • Thrombophlebitis with repeated or prolonged therapy
  • Extravasation causes pain and necrosis. If extravasation occurs, click HERE for treatment guidelines.   
  • Anaphylaxis and hypersensitivity reactions
  • Ototoxicity with prolonged elevated peak concentrations (>40 mg/L)
  • Nephrotoxicity (higher incidence with trough concentrations >10 mg/L and in combination with other nephrotoxic drugs)

 

Notes: 
  • Monitor periodic renal function tests, urinalysis, serum drug levels, WBC, audiogram
  • "Red-man" syndrome usually develops with rapid infusion of vancomycin - slow the infusion rate to over 1½ - 2 hours.  Pretreatment with an antihistamine may prevent the reaction
  • Caution in patients using other nephrotoxic or ototoxic drugs

 

 

Therapeutic Drug Monitoring:   
   
  - Therapeutic serum concentration:

  • PRE (Trough) levels :
    6 - 10 mg/L  -Infections (eg. bacteremia) with coagulase negative staphylococci (eg. S. epidermidis) including line infections
    10 - 15 mg/L - Skin and soft tissue infections caused by methicillin resistant Staphylococcus aureus (MRSA)
                        - Empiric treatment of bacterial meningitis - limited to 48 hours unless there is isolation of an organism that is resistant to beta-lactams -an ID consultation would be required
    15 - 20 mg/L - Infections with invasive or persistent MRSA such as infective endocarditis, osteomyelitis, meningitis, pneumonia or deep, severe soft tissue infections
  • POST (Peak) :   Not routine - restricted to patients requiring phamacokinetic calculations: consult pharmacy
     

  - Sampling time:

  • When checking trough level, administer next dose as scheduled.  Do not wait for levels to be reported unless otherwise advised
  • Initial sample : before fifth dose
  • Consider trough level prior to second dose for patients with a low CrCl
  • Pre: 0-30 min prior to next dose
  • Post: not routine - 60 - 90  minutes following 60 minute infusion -post levels are difficult to interpret for infusion times greater than 1 hour

    - Routine Monitoring:

  •  Baseline serum creatinine and PRE level .  Repeat both ONCE weekly.  For trough levels greater than or equal to 15 mg/L repeat TWICE weekly
  •  Patients receiving greater than 7 days of therapy should have a weekly CBC to asses for neutropenia
     

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