Antibiotic · Glycopeptide
Vancomycin (Vancocin)
Also called Vancocin, vanc
Indications
- Serious infections from methicillin-resistant staphylococci: septicemia, endocarditis, bone, lower respiratory tract and skin infections (label)
- Serious staphylococcal infection in penicillin-allergic patients or when other drugs fail (label)
- Empiric MRSA coverage in sepsis, pneumonia, meningitis and line infection, with a beta-lactam, stopped when cultures exclude it
- C. difficile colitis and staphylococcal enterocolitis, by mouth (label)
Dosing
| Where | Dose |
|---|---|
| Antimicrobials | Vancomycin: Load by weight; maintenance by AUC or levels |
On the quick cards
Mechanism of action
Vancomycin is a glycopeptide whose bactericidal action comes mainly from blocking cell-wall synthesis; it also alters membrane permeability and RNA synthesis (label). It binds the D-alanyl-D-alanine end of peptidoglycan precursors, which stops their transfer and cross-linking. It is inactive against gram-negative bacilli (label), because the large molecule cannot cross their outer membrane. Enterococci with vanA or vanB genes build D-Ala-D-lactate ends instead, the basis of VRE.
Pharmacology
- Infectious: staphylococci including MRSA, streptococci and enterococci (enterococcal endocarditis only with an aminoglycoside); inactive against gram-negative bacilli, mycobacteria and fungi (label)
- Skin and cardiovascular: rapid infusion can cause flushing, itching and exaggerated hypotension, including shock and rarely cardiac arrest (label); histamine-mediated, formerly red man syndrome
- Renal: AKI rises with exposure, and trough-guided dosing caused more nephrotoxicity than AUC dosing (IDSA/ASHP 2020)
- Ear and blood: ototoxicity, mostly with excessive doses, prior hearing loss or other ototoxic drugs; reversible neutropenia, usually after a week or more (label)
Pharmacokinetics
| Half-life | 4–6 h with normal kidneys; about 7.5 days if anephric (label) |
|---|---|
| Distribution | 0.3–0.43 L/kg (label) |
| Protein binding | About 55% (label) |
| Metabolism | None apparent (label) |
| Elimination | About 75% in urine within 24 h by glomerular filtration (label) |
| Target | AUC 400–600 mg·h/L assuming an MIC of 1, best by Bayesian software; trough-only 15–20 mg/L no longer recommended (IDSA/ASHP 2020) |
| Loading | 20–35 mg/kg actual weight in critical illness, at most 3,000 mg (IDSA/ASHP 2020) |
| Dialysis | Poorly removed by standard dialysis (label); keep pre-dialysis levels 15–20 mg/L (IDSA/ASHP 2020) |
| CRRT | Load 20–25 mg/kg, then 7.5–10 mg/kg every 12 h at 20–25 mL/kg/h effluent (IDSA/ASHP 2020) |
Chemistry
- Tricyclic glycopeptide from Amycolatopsis orientalis; C₆₆H₇₅Cl₂N₉O₂₄·HCl, MW 1485.74 (label)
- Large and polar: no metabolism, renal elimination and no gram-negative penetration
- Reconstituted pH 2.5–4.5 (label); acidic, so dilute to no more than 5 mg/mL and infuse over at least 60 min, no faster than 10 mg/min (label)
- Physically incompatible with beta-lactam solutions (label)
Adverse effects and cautions
In the one-pagers
- Lab Values to KnowTherapeutic drug levels: Vancomycin: AUC 400–600 mg·h/L (MIC 1) for serious MRSA: Kidney injury: rising creatinine, low urine output
- Pharmacology by Class and SuffixTraps and look-alikes: -mycin is not one class: aminoglycosides, macrolides, vancomycin, clindamycin.
- Sepsis and Septic Shock BundleHour-1 bundle element by element: Underfilled bottles are the commonest cause of false-negative cultures. Give the beta-lactam first: cefepime and meropenem can be pushed over 3–5 min where policy allows, while vancomycin runs 1–2 h. Loading doses are full regardless of renal function because sepsis expands the volume of distribution. Epinephrine, metformin, liver failure and seizures raise lactat
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Sources
- FDA label: Vancomycin HCl for Injection (Xellia, 2022)
- FDA label: Vancomycin HCl for Injection (Hospira, 2021)
- Rybak 2020 (IDSA/ASHP/PIDS/SIDP vancomycin guideline)
For education and exam preparation only. Follow your institution’s protocols. Typical adult values for study. Follow the order, the label and your institution's protocols.