Vancomycin

Indications

Oral Administration

Intravenous Administration

  • Enterococcus (see Enterococcus, [[Enterococcus]])
    • Vancomycin and gentamicin (see Gentamicin, [[Gentamicin]]) demonstrate synergism against most Enterococcus species
  • Methicillin-Resistant Staphylococcus Aureus (MRSA) (see Staphylococcus Aureus, [[Staphylococcus Aureus]])
    • Synergism: vancomycin and gentamicin (see Gentamicin, [[Gentamicin]]) demonstrate synergism against most Staphylococcus species
    • Vancomycin is the first line agent: its use has paralleled the increasing emergence of MRSA
    • Vancomycin does not inhibit production of PVL cytotoxin and may result in some clinical failures
    • Continuous Vancomycin infusion is not associated with an improved outcome in the treatment of MRSA infection
  • Methicillin-Sensitive Staphylococcus Aureus (MSSA) (see Staphylococcus Aureus, [[Staphylococcus Aureus]])
    • Synergism: vancomycin and gentamicin (see Gentamicin, [[Gentamicin]]) demonstrate synergism against most Staphylococcus species
  • Streptococcus Pneumoniae (Pneumococcus) (see Streptococcus Pneumoniae, [[Streptococcus Pneumoniae]])
    • Effective against penicillin-resistant Streptococcus Pneumoniae

Contraindications

  • Hypersensitivity Reaction to Glycopeptides: excluding red man syndrome
  • Problem with Dosing Frequency in Adjustment for Creatinine Clearance
  • Strains with Higher MIC to Vancomycin: MIC >2 mg/L
  • Situations Where IV Administration is Difficult or Undesirable
    • Situations Where Vancomycin Infusion Would Result in an Unnecessary Prolongation of Hospital Stay
    • Situations Where Vancomycin Infusion Would Be Complicated By Problematic IV Access

Pharmacology

  • Glycopeptide Antibiotic Which Inhibits Cell Wall Synthesis in Gram-Positive Bacteria
    • Inhibits the Bacterial Cell Wall Polymer at a Site of Peptidoglycan Synthesis Earlier Than β-Lactam Antibiotics (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]])
    • Inhibition of Bacterial RNA Synthesis and Permeability of Cytoplasmic Membranes
    • Bactericidal Against Almost All Gram-Positive Bacteria, Except Enterococcus
    • Does Not Cross the Outer Cell Wall of Gram-Negative Organisms: ineffective for these organisms

Tissue Penetration

  • Central Nervous System/Cerebrospinal Fluid: poor, except when meninges are inflammed
  • Lung Penetration: poor

Pharmacokinectics

  • High Concentrations of Heparin (see Heparin, [[Heparin]]): may inactivate vancomycin, leading to antibiotic failure

Administration

  • IV (For All Indications, Except Clostridium Difficile Colitis): xxx
    • Desired Trough Level: 15 mg/L
  • PO (For Clostridium Difficile Colitis): xxx

Adverse Effects

Dermatologic Adverse Effects

Red Man Syndrome

  • Mechanism: rapid administration of vancomycin with histamine release
  • Onset: may occur during or immediately after vancomycin infusion
  • Clinical
    • Hypotension (see Hypotension, [[Hypotension]])
    • Pruritic Erythematous Rash (see Erythroderma, [[Erythroderma]]): over body, face, and neck
    • Fever (see Fever, [[Fever]])
  • Treatment
    • Slow Down Intravenous Vancomycin Infusion Rate to <15 mg/min
    • Pre-Treat with H1-Histamine Receptor Antagonists (see H1-Histamine Receptor Antagonists, [[H1-Histamine Receptor Antagonists]]): may be useful
    • Pre-Treat with H2-Histamine Receptor Antagonists (see H2-Histamine Receptor Antagonists, [[H2-Histamine Receptor Antagonists]]): may be useful
      • Famotidine (Pepcid) (see Famotidine, [[Famotidine]])
    • Corticosteroids (see Corticosteroids, [[Corticosteroids]]): not useful

Hematologic Adverse Effects

Neutropenia (see Neutropenia, [[Neutropenia]])

  • Epidemiology: occurs in 2% of cases

Renal Adverse Effects

Acute Interstitial Nephritis (see Acute Interstitial Nephritis, [[Acute Interstitial Nephritis]])

  • xxxx

Other Adverse Effects

Thrombophlebitis

  • Epidemiology: occurs in 5-15% of cases

References

  • Therapy for pneumococcal infection at the millennium: doubts and certainties. Am J Med 1999; 107:77S-85S
  • The threat of vancomycin resistance. Am J Med 1999; 106:26S-37S
  • Nosocomial infections in the ICU: the growing importance of antibiotic-resistant pathogens. Chest 1999; 115(suppl): 34S-41S
  • Symposium on antimicrobial agents—part XII. Vancomycin. Mayo Clin Proc 1999; 74:928-935
  • Antihistamine prophylaxis permits rapid vancomycin infusion. Crit Care Med 1999; 27:1732-1737