Vancomycin (Vancocin) is a glycopeptide antibiotic that is used in the treatment of serious life-threatening infections including infections of the brain, heart, lungs, bones, bloodstream infections, and complicated skin infections.

Vancomycin (Vancocin) Uses:

• Clostridioides(formerly Clostridium) difficile infection (oral): 

  • It is indicated for treatment of clostridium  difficile infection (CDI)

• Endocarditis (injection):

  • Corynebacteria (diphtheroids): 

    • It is indicated for diphtheroid endocarditis treatment in combination with either rifampin (aminoglycoside), or both in prosthetic valve endocarditis (early onset) caused by diphtheroids

  • Enterococcal: 

    • It is used to treat endocarditis due to enterococci (eg, Enterococcus faecalis) combined with an aminoglycoside.

  • Staphylococcal:

    • it is indicated for Staphylococcal endocarditis treatment.

  • Streptococcal:

    • It is used to treat endocarditis due to streptococcus viridans or Streptococcus bovis, as a monotherapy or with an aminoglycoside combination.

  • Enterocolitis (oral): 

    • It is indicated for Staphylococcus aureus enterocolitis treatment (including methicillin-resistant strains).

Note: Staphylococcal enterocolitis is  not common; the disease and treatment are not well described in the literature

• Staphylococcal infections (injection): 

  • Treatment of serious or severe infections brought on by susceptible strains of methicillin-resistant (beta-lactam-resistant) staphylococci, such as septicemia, bone infections, lower respiratory tract infections, skin, and skin structure infections;
  • empiric therapy of infections when methicillin-resistant staphylococci are suspected

• Off Label Use of Vancomycin in Adults:

  • Catheter-related infections;
  • Cerebrospinal fluid (CSF) shunt infection;
  • Clostridioides (formerly Clostridium) difficile infection (rectal administration);
  • Endophthalmitis
  • Group B streptococcus, maternal use (neonatal prophylaxis);
  • Intra-abdominal infections;
  • Meningitis, bacterial;
  • Perioperative prophylaxis;
  • Peritonitis, treatment (continuous ambulatory peritoneal dialysis [CAPD] patients);
  • Prosthetic joint infection; Surgical site infections

Vancomycin (Vancocin) Dose in Adults

Vancomycin (Vancocin) Usual dosage range: 

Note:

• Initial IV dose:  according to body weight (in obese patients):
• subsequent dose: Adjustment should be done on basis of serum trough vancomycin concentrations and renal function.
• For dosing in patients with altered pharmacokinetics (morbidly obese, burns, critical illness, altered renal function, pregnancy, cystic fibrosis) calculations may be needed to determine the appropriate dose and interval
• For treating uncomplicated skin and soft tissue infections (non-obese) and have a normal renal function, serum trough monitoring is generally not required

Oral: 

• Note: Ineffective for systemic infections: 125 - 500 mg 4 times a day

Intravenous: 

• Note: Ineffective for treating C. difficile infections (CDIs):
  • 15 - 20 mg/kg/dose (rounded to the nearest 250 mg;
  • The usual maximum dose: 2 g/dose initially) every 8 -12 hours.

Note: 15 mg/kg/dose (usual maximum: 2 g/dose initially) 12 hourly is a usual starting dose in most nonobese patients with normal renal function Loading dose: Complicated infections in seriously ill patients:

• 25 - 30 mg/kg (based on actual body weight) may be used to rapidly achieve target concentrations.

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Vancomycin Indication-specific dosing:

Vancomycin (Vancocin) Dose in the treatment of Bacteremia (off-label):

• Empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus:

  • 15–20 mg/kg per dosage injected every 8 to 12 hours
  • 2 g/dose is the maximum first dose.
  • Adjust to maintain trough concentration of 15 - 20 mcg/mL.
  • Loading dose can be considered in seriously ill patients.
  • If patient has catheter-related blood stream infection, antibiotic lock therapy can be given for catheter salvage, in addition to systemic therapy

• Empiric therapy or pathogen-specific therapy for methicillin-resistant coagulase-negative staphylococci:

  • 15–20 mg/kg per dosage injected every 8 to 12 hours
  • 2 g/dose, as a maximum initial dose, every 8 to 12 hours
  • Adjust the dose to obtain a trough concentration of 15 - 20 mcg/mL.
  • If the patient has a catheter-related blood stream infection, antibiotic lock therapy can be given for catheter salvage, in addition to systemic therapy

• Antibiotic lock technique(catheter-salvage strategy) (off-label use):

  • The solution is made with vancomycin 5mg/ml (Heparin 5000 units/mL can be combined) for antibiotic lock technique
  • Put the solution in each lumen of the catheter in sufficient volume to fill the catheter (2-5 mL) with dwell time of  48-72 hours
  • This technique is used with systemic antibiotics in patient with a catheter-related blood infection
  • The duration of lock therapy should be 10 - 14 days. Dwell times depends on the frequency of catheter use
  • After catheter use, replace the lock solution with fresh solution.

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Vancomycin (Vancocin) Dose for treating Brain abscess, intracranial epidural abscess, or spinal epidural abscess (off-label):

• As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant  aureus: 

  • 15 - 20 mg/kg/dose IV: every 8-12 hours
  • Maximum initial dose: 2 g/dose
  • Adjust the dose to maintain a trough concentration of 15 - 20 mcg/mL.
  • Loading dose may be considered in seriously ill patients

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Vancomycin (Vancocin) Dose for treating Cerebrospinal fluid (CSF) shunt infection (off-label): 

• As a part of empiric therapy or therapy targeted against a particular pathogen (such as methicillin-resistant aureus or coagulase-negative staphylococci):

  • 15–20 mg/kg/dose IV, spaced 8–12 hours apart.
  • 2 g/dose is the maximum first dose.
  • Adjust the dose to get a trough concentration of 15 - 20 mcg/mL.
  • Loading dose may be considered in seriously ill patients.

• Intraventricular (adjunct to systemic therapy; use a preservative-free preparation):

  • 5 - 20 mg; According to some experts dose interval should be adjusted according to CSF vancomycin concentrations (goal: 10 to 20 times MIC of the causative organism), size of ventricles, and daily output from the ventricular drain. The data available is limited.
  • Intraventricular vancomycin is administered through the ventricular drain, clamp drain for 15 - 60 minutes after administration.

Note: Intraventricular administration is usually given in patients who does not respond to parenteral therapy even after removal of CSF shunt or when CSF shunt cannot be removed.

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Vancomycin (Vancocin) Dose in the treatment of Clostridioides (formerly Clostridium) difficile infection (CDI):

Note: Criteria for disease severity is based on expert opinion and should not replace clinical judgment.

• Non-severe CDI (supportive clinical data: WBC ≤15,000 cells/mm3and serum creatinine <1.5 mg/dL): oral

  • Initial episode: 125 mg 4 times a day for 10 days.

  • First recurrence:

    • Pulsed-tapered regimen for the initial episode: 125 mg four times daily for 10–14 days, then 125 mg twice daily for 7 days, then 125 mg once daily for 7 days, and finally 125 mg every 2–3 days for 2–8 weeks.
    • 125 mg four times a day for ten days if metronidazole or fidaxomicin were used to treat the initial episode.

  • Second or subsequent recurrence:

    • Pulsed-tapered regimen as above or 125 mg 4 times a day for 10 days followed by rifaximin.
    • Severe CDI: 125 mg 4 times a day. According to supported clinical data, severe CDI is if the patient has WBC >15,000 cells/mm3 and/or serum creatinine ≥1.5 mg/dL

  • Fulminant CDI:

    • 500mg 4 times a day orally or via nasogastric tube.
    • According to supported clinical data, patient is with fulminant CDI if the patient has: ileus, megacolon, and/or hypotension/shock:
      • Oral or via nasogastric tube: 500 mg 4 times a day with IV metronidazole;
      • In the case of ileus, vancomycin retention enema may be considered

Rectal:

• Fulminant CDI with ileus:

  • Retention enema (off-label route):

    • 500 mg in 100 mL normal saline;  use very 6 hourly and retain as long as possible
    • It can be used with oral vancomycin in case of partial ileus is partial)
    • In patients with complete ileus retention enema is used plus Intravenous metronidazole.

Note: Optimal regimen not established. Rectal vancomycin should be used in patients with no response to standard therapy and  should be performed by individuals with expertise in administration, as there is the risk of colonic perforation.

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Vancomycin (Vancocin) Dose in the treatment of Endocarditis (off-label):

• Enterococcus (native or prosthetic valve) (penicillin-resistant strains or patients unable to tolerate beta-lactams):

  • IV: 15 mg/kg/dose every 12 hours combined with gentamicin
  • Maximum initial dose: 2 g/dose
  • Adjust the dose to maintain a trough concentration of 10 - 20 mcg/mL,  some experts suggest a trough of 15 - 20 mcg/mL
  • Duration of therapy: 6 weeks

• aureus, methicillin-resistant or methicillin-susceptible (severe-beta lactam hypersensitivity) (alternative agent):Intravenous:

  • Native valve endocarditis:

    • 15 mg/kg/dose every 12 ours
    • Maximum initial dose: 2 g/dose
    • Adjust dose to maintain  serum trough concentration of 10 - 20 mcg/mL some experts suggests obtaining trough concentration of 15 - 20 mg/kg/dose and dose every 8 - 12 hours
    • Duration of therapy: 6 weeks

  • Prosthetic valve endocarditis:

    • 15 mg/kg/dose every 12 hours
    • Maximum initial dose: 2 g/dose
    • Adjust the dose to maintain trough concentration of 10 - 20 mcg/mL while some experts suggest to maintain a trough concentration of 15 - 20 mcg/mL and dose every 8-12 hours
    • Duration of therapy: At least 6 weeks (combined with rifampin throughout the therapy and gentamicin for the first 2 weeks).

• Viridans group streptococci and S. bovis (native or prosthetic valve) (penicillin or ceftriaxone intolerance):

  • IV: 15 mg/kg/dose Intravenous. every 12 hours for 4 weeks (native valve) or 6 weeks (prosthetic valve)
  • Maximum initial dose: 2 g/dose
  • Adjust the dose to maintain a trough concentration of 10 - 15 mcg/mL.

IDSA Infective Endocarditis Guidelines

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Vancomycin (Vancocin) Dose in the treatment of Endophthalmitis (off-label): 

• Intravitreal: Usual dose: 1 mg per 0.1 mL normal saline or sterile water injected into vitreum, usually in combination with ceftazidime
• Can be repeated after 48 hours if required on basis of culture result.

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Vancomycin (Vancocin) Dose as an alternative agent in the treatment of Group B streptococcus (neonatal prophylaxis) (off-label): 

• IV: 1 g every 12 hours from onset of labor until delivery. Some experts recommends loading dose of 2 grams
• Pharmacokinetic study shows , 20 mg/kg (maximum: 2 g/dose) every 8 hours has better achievement of therapeutic neonatal cord blood concentrations; however, clinical efficacy and safety of this regimen have not been validated.

Note:

• Vancomycin is reserved for penicillin-allergic patients at high risk for anaphylaxis
• If organism is resistant to clindamycin
• When no susceptibility data are available.

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Vancomycin (Vancocin) Dose for treating Intra-abdominal infection (off-label):

• As a part of empiric therapy or a treatment for a specific infection (like methicillin-resistant aureus): 

  • IV: Every 8 to 12 hours, 15 to 20 mg/kg.
  • 2 g/dose is the maximum first dose.
  • Adjust dose to maintain a trough concentration of 15 - 20 mcg/mL.

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Vancomycin (Vancocin) Dose in the treatment of bacterial Meningitis (off-label): 

• As part of empiric therapy or pathogen-specific therapy (for instance, methicillin-resistant aureus or penicillin- and cephalosporin-resistant S. pneumoniae): 

  • IV: Every 8 to 12 hours, 15 to 20 mg/kg.
  • 2 g/dose is the maximum first dose.
  • Adjust dose to maintain trough concentration of 15 - 20 mcg/mL
  • Loading dose may be given in seriously ill patients.

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Vancomycin (Vancocin) Dose in the treatment of Osteomyelitis (off-label): 

• As a part of empiric therapy or a treatment for a specific infection (like methicillin-resistant aureus): 

  • IV: Every 8 to 12 hours, 15 to 20 mg/kg.
  • 2 g/dos is the maximum beginning dose.
  • Adjust dose to maintain a trough concentration of 15 - 20 mcg/mL.
  • Loading dose can be given in seriously ill patients.

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Vancomycin (Vancocin) Dose in the Perioperative 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): 

• Intravenous: 15 mg/kg, should be given within 60-120 minutes before surgical incision
• Maximum initial dose: 2 g/dose
• If procedure is lengthy or in case of extensive blood loss dose of vancomycin may be repeated during surgery in 2 half-lives (with normal renal functions)
• In cases where an extension of prophylaxis required postoperatively, total duration should be ≤24 hours.
• Postoperative prophylaxis is not recommended in clean and clean-contaminated surgeries.

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Vancomycin (Vancocin) Dose in the treatment of treatment of Peritonitis, (continuous ambulatory dialysis [CAPD] patients) (off-label): Intraperitoneal:

Note: Intraperitoneal administration is preferred to Intravenous administration. Adjust dose to obtain a trough concentration between 15 - 20 mcg/mL.

• Intermittent (preferred):
  • 15 - 30 mg/kg added to one exchange of CAPD solution 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 or with significant residual renal function.
• Continuous (all exchanges):
  • Loading dose: 30 mg/kg added to first exchange of CAPD solution;
  • maintenance dose: 1.5 mg/kg/bag for each subsequent exchange of CAPD solution.

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Vancomycin (Vancocin) Dose in the treatment of Pneumonia, S. aureus (methicillin-resistant): Intravenous:

• Community-acquired pneumonia (CAP): As part of empiric therapy or pathogen-specific therapy for methicillin-resistant S. aureus that has been acquired locally.: 

  • Every 8 to 12 hours, 15 to 20 mg/kg.
  • 2 g/dose is the maximum first dose.
  • Adjust dose to get a trough concentration of 15 - 20 mcg/mL .
  • When treating very unwell individuals, a loading dose may be appropriate.

Note: Minimum duration of therapy is 7 days and depends on disease severity and response to therapy; patients should be afebrile for ≥48 hours and clinically stable before discontinuation.

• Pneumonia contracted in a hospital (HAP) or pneumonia brought on by a ventilator (VAP): as a part of pathogen-specific or empiric therapy for methicillin-resistant S. aureus:
  • Every 8 to 12 hours, 15 to 20 mg/kg.
  • 2 g/dose, as a maximum initial dose, every 8 to 12 hours
  • Adjust dose to get a trough concentration of 15 - 20 mcg/mL.
  • Patients who are critically unwell may want to consider a loading dosage.

Note: Duration is for a minimum of 7 days and varies based on disease severity and response to therapy.

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Vancomycin (Vancocin) Dose in the treatment of Prosthetic joint infection: Intravenous:

• Treatment for methicillin-resistant or susceptible S. aureus that is pathogen-specific (alternative agent in beta-lactam intolerance):

  • every 8 to 12 hours, 15 to 20 mg/kg.
  • 2 g/dose is the maximum first dose.
  • Adjust dose to get a trough concentration of 15 - 20 mcg/mL.

Note: Can be used in combination of oral rifampin in selected cases (eg, debridement and retention of prosthesis or one-stage arthroplasty).

• Pathogen-specific therapy for Enterococcusspp (penicillin susceptible [alternative agent] or penicillin resistant):

  • 12 hourly doses of 15 mg/kg
  • 2 g/dose is the maximum first dose.

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Vancomycin (Vancocin) Dose in the treatment of Sepsis/septic shock (off-label): 

• As a part of pathogen-specific or empiric therapy for methicillin-resistant aureus:

  • IV: Every 8 to 12 hours, 15 to 20 mg/kg.
  • 2 g/dose, as a maximum initial dose, every 8 to 12 hours
  • Adjust dose to get a trough concentration of 15 - 20 mcg/mL
  • Administer within 1 hour of identifying sepsis.
  • A loading dose can be given in seriously ill patients
  • Duration: 7 - 10 days usually adequate for serious infections
  • Different factors play a role in determining optimal duration of therapy

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Vancomycin (Vancocin) Dose in the treatment of Septic arthritis, without prosthetic material (off-label): 

• As a component of empiric therapy or pathogen-specific therapy for coagulase-negative staphylococci or methicillin-resistant aureus: 

  • IV: every 8 to 12 hours, 15 to 20 mg/kg.
  • 2 g/dose is the maximum first dose.
  • Adjust dose to get a trough concentration of 15 - 20 mcg/mL
  • In the absence of osteomyelitis, the total treatment time is 3 to 4 weeks, which includes oral step-down therapy.
  • Other recommends 4 weeks of parenteral therapy for patients with concomitant bacteremia (in the absence of endocarditis)

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Vancomycin (Vancocin) Dose for treating Skin and soft tissue infections (hospitalized patient) (off-label):

• As a part of pathogen-specific or empiric therapy for methicillin-resistant aureus:

  • IV: 12 hourly doses of 15 mg/kg
  • 2 g/dose is the maximum first dose.
  • Adjust dose to get a trough concentration of 10 - 15 mcg/mL in uncomplicated infection or 15 - 20 mcg/mL in complicated infection or seriously ill.

Note: In necrotizing infection, must be used in combination with other agents as empirical therapy.

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Vancomycin (Vancocin) Dose in the treatment of Surgical site infections (off-label): 

• As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant aureus: 

  • IV: 15 mg/kg/dose: every 12 hours
  • Maximum initial dose : 2 g/dose
  • Adjust dose to get trough concentrations of 10 - 15 mcg/mL (uncomplicated infection) or 15 - 20 mcg/mL (complicated infections or seriously ill).

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Vancomycin (Vancocin) Dose in the treatment of staphylococcal Toxic shock syndrome (off-label): 

• As a component of empiric therapy or pathogen-specific therapy for methicillin-resistant  aureus:
  • IV: 15 - 20 mg/kg/dose: every 8 - 12 hours
  • Maximum initial dose: 2 g/dose initially)
  • Adjust dose to get a trough concentration of 15 - 20 mcg/mL
  • Duration depends on underlying etiology; 10 - 14 days of treatment is recommended in the absence of bacteremia or other distinct focus of infection.

Vancomycin (Vancocin) Dose in Children:

Initial dosage recommendations presented, serum concentrations should be monitored and adjusted accordingly. Note: Dose adjustment in renal impairment.

• Consider single-dose administration with serum concentration monitoring in patients with urine output <1 mL/kg/hour or if serum creatinine significantly increases from baseline (eg, doubles).
• Optimal dose and frequency not established in patients receiving ECMO; available data is very limited and primarily from neonatal experience. 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.

Dose for susceptible infection:

• Infants, Children, and Adolescents:

  • IV: every 6 to 8 hours, 45 to 60 mg/kg each day;
  • Further doses and frequency should base on serum concentrations.

Note: Every 6 hour dosing recommended as initial dosage regimen if targeting trough serum concentrations >10 mcg/mL in patients with normal renal function. Close monitoring of serum concentrations and assurance of adequate hydration status is recommended. Utilize local antibiogram and protocols for further guidance.

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Vancomycin (Vancocin) Dose in the treatment of Bacteremia [S. aureus (methicillin-resistant)]: 

• Infants, Children, and Adolescents:

  • IV: Depending on the severity, 15 mg/kg/dose given every 6 hours for 2 to 6 weeks

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Vancomycin (Vancocin) Dose in the treatment of Bone and joint infection:

• Osteomyelitis ( aureus[methicillin-resistant]):

  • Infants, Children, and Adolescents:
    • IV: Every six hours for at least four to six weeks, 15 mg/kg.

• Septic arthritis ( aureus[methicillin-resistant]):

  • Infants, Children, and Adolescents:
    • IV: Every six hours for at least three to four weeks, 15 mg/kg.

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Vancomycin (Vancocin) Dose in the treatment of C. difficile infection:

• Manufacturer's labeling:

  • Infants, Children, and Adolescents:
    • Oral: 40 mg/kg/day divided into 6–8 hour intervals for 7–10 days.
    • The daily maximum is 2,000 mg.

• Guideline recommendations:

  • Non-severe infection, initial or first recurrence: 
    • Children and Adolescents: Oral: 10 mg/kg per dosage 10 days, 4 times per day; maximum dose: 125 mg/dose
  • Severe/fulminant infection, initial:
    • Children and Adolescents:
      • Oral: 10 mg/kg per dosage four times each day for ten days.
      • 500 mg maximum per dose
      • IV metronidazole can be considered in addition to vancomycin in critically ill patients
      • If patient is unable to tolerate oral therapy, can be given through NG tube
      • Rectal: Note: May be given if patient is suffering from ileus . Limited data available
      • Rectal enema: 500 mg in 100 mL NS; dose volume should be given according to age of patient. there is no established optimal doses for pediatric patients; suggested volumes for children: 1 - 3 years: 50 mL; 4 - 9 years: 75 mL; >10 years: 100 mL . Administer 4 times a day with or without IV metronidazole.

  • Second or subsequent recurrence:

    • Children and Adolescents:
      • Regimen with a pulsed-taper: Orally: 10 mg/kg/dose given four times daily for 10–14 days; then 10 mg/kg/dose given twice daily for 7 days; then 10 mg/kg/dose given once daily for 7 days; and finally 10 mg/kg/dose given every two–three days for 2–8 weeks.
      • Maximum dose: 125 mg/dose.

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Vancomycin (Vancocin) Dose in the treatment of CNS infection:

• Brain abscess, subdural empyema, spinal epidural abscess [ aureus(methicillin-resistant)]:

  • Infants, Children, and Adolescents:

    • IV: 15 mg/kg/dose given every six hours for four to six weeks (some experts combine with rifampin).

• Meningitis:

  • Infants, Children, and Adolescents:

    • IV: dose of 15 mg/kg every 6 hours;
    • Note: Maintain trough serum concentrations of 15 - 20 mcg/mL.

• aureus(methicillin-resistant):

  • Infants, Children, and Adolescents:

    • IV: Every six hours for two weeks, at a dosage of 15 mg/kg (some experts combine with rifampin).

• VP-shunt infection, ventriculitis: Limited data available:

  • Infants, Children, and Adolescents:

    • Intrathecal/intraventricular (use a preservative-free preparation):
      • 5 - 20 mg/day;
      • The usual dose: 10 or 20 mg/day.
      • Infants have smaller CSF volume, some guidelines recommend decreasing the infant dose

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Vancomycin (Vancocin) Dose in the treatment of treatment of Endocarditis:

• Empiric therapy/ culture-negative:

  • Children and Adolescents:

    • IV 60 mg/kg split into six doses each day
    • The daily maximum is 2,000 mg.
    • Use for a minimum of 4 weeks while utilising additional antibiotics (longer duration for prosthetic material required)
    • Target trough serum concentrations of 10 - 15 mcg/mL are required, adjust dose accordingly. Higher trough concentrations (15 - 20 mcg/mL) may be needed if there is no response or if a resistant organism (MIC >1 mcg/mL) is identified

• Streptococcus (including enterococcus):

  • Children and Adolescents:

    • IV: 40 mg/kg/day divided every 8–12 hours for a minimum of 4–6 weeks; a patient using prosthetic material may require longer time and extra antibiotics depending on the organism found.
    • Adjust dose accordingly to achieve the target trough serum concentrations of 10 -15 mcg/mL ; higher trough concentrations (15 to 20 mcg/mL) may be needed for resistant organisms (MIC >1 mcg/mL) or if there is a lack of response

• aureus:

  • Non-methicillin resistant:

    • Children and Adolescents: IV: 40 mg/kg/day divided into 8–12 hour intervals for a minimum of 4–6 weeks;
    • Depending on the organism found and a patient wearing prosthetic material, a longer course of treatment and more antibiotics may be required.
    • Higher trough concentrations (15 to 20 mcg/mL) may be required for resistant organisms (MIC >1 mcg/mL) or if there is a lack of response. Adjust dose accordingly to attain the target trough serum concentrations of 10 mcg/mL to 15 mcg/mL.

  • Methicillin-resistant:

    • AHA Guidelines:
      • Children and Adolescents:
        • IV: 40 mg/kg/day divided into 8–12 hour intervals for a minimum of 6 weeks;
        • The daily maximum is 2,000 mg.
        • If the patient has prosthetic material, a longer period may be required.
        • Dose should be adjusted to target trough serum concentrations of 15 - 20 mcg/mL.
    • IDSA Guidelines:
      • Infants, Children, and Adolescents: IV: 60 mg/kg split into six doses each day

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Vancomycin (Vancocin) Dose in the treatment of Enterocolitis (S. aureus): 

• Infants, Children, and Adolescents:

  • Oral: 40 mg/kg/day divided into 6–8 hour intervals for 7–10 days.
  • The daily maximum is 2,000 mg.

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Vancomycin (Vancocin) Dose in the treatment of complicated Intra-abdominal infection, (MRSA): 

• Infants, Children, and Adolescents:

  • IV: Divided every 6 to 8 hours, 40 mg/kg/day.

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Vancomycin (Vancocin) Dose in the treatment of Peritonitis (peritoneal dialysis).

• Prophylaxis:

  • Infants, Children, and Adolescents:

    • Touch contamination of PD line (if known MRSA colonization): Intraperitoneal: 25 mg/L

High-risk gastrointestinal procedures: 

Note: Use should be reserved for patients at high risk for MRSA:

• IV: 10 mg/kg administered 60 - 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 - 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 - 4 days after the previous dose; repeat doses if patient has serum concentration <15 mcg/mL.

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

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Vancomycin (Vancocin) Dose for Pneumonia:

• Community-acquired pneumonia (CAP):

  • Infants >3 months, Children, and Adolescents:

    • every 6 to 8 hours, IV, 40 to 60 mg/kg/day
    • Dosing to achieve AUC/MIC >400 has been recommended for treating moderate to severe MRSA infections

• Alternate dosing: 

  • aureus(methicillin-resistant):

    • Depending on severity, administer 60 mg/kg/day IV divided every 6 hours to infants, children, and adolescents for 7–21 days.

  • Health care-associated pneumonia (HAP), S. aureus (methicillin-resistant):

    • Infants, Children, and Adolescents:
      • Depending on the severity, 60 mg/kg/day IV divided every 6 hours for 7 to 21 days.

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Vancomycin (Vancocin) Dose in the treatment of Septic thrombosis of cavernous or dural venous sinus [S. aureus (methicillin-resistant)]: 

• Infants, Children, and Adolescents:

  • .15 mg/kg IV every six hours for four to six weeks (some experts combine with rifampin)

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Vancomycin (Vancocin) Dose for Complicated Skin and skin structure infections: [MRSA or S. aureus (methicillin-sensitive) in penicillin-allergic patients]: 

• Infants, Children, and Adolescents:

  • Non-necrotizing infection: 10 mg/kg IV every six hours
  • Necrotizing infection: every six hours, an IV dose of 15 mg/kg. Continue until no longer necessary, patient has shown clinical improvement, and has been afebrile for 48–72 hours.

  • Alternate dosing: aureus (methicillin-resistant):

    • Infants, Children, and Adolescents: For 7 to 14 days, provide 60 mg/kg/day IV split every 6 hours.

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Vancomycin (Vancocin) Dose in the prophylaxis of Surgical (perioperative): 

• Infants, Children, and Adolescents:
  • Intravenous: 120 minutes before the surgical incision, 15 mg/kg/dose.
  • Can be administered in combination with other antibiotics depending upon the surgical procedure.

Pregnancy Risk Category: B

• Vancomycin crosses into the placenta. It can be detected in fetal blood, amniotic fluid and cord blood.
• Negative fetal effects include nephrotoxicity and sensorineural hearing loss. These effects were not reported in the second and third trimesters.
• Due to altered pharmacokinetics, pregnant patients may require higher doses. While the maternal half-life remains unchanged, volume distribution and plasma clearance can be increased.
• You should adjust the dose according to serum concentration monitoring.
• Vancomycin is recommended to treat Clostridium difficile (formerly Clostridium difficile) infections in pregnant women.
• Vancomycin is recommended to be used as an alternative agent in order to prevent the transmission from mothers to babies of group B streptococcal disease (GBS).
• Vancomycin is recommended for patients with MRSA colonization. It can be used prophylactically prior to Cesarean delivery.
• [US Boxed Warning]Animal reproductive studies have shown that polyethylene glycol (PEG400) and N-acetyl D'alanine (NADA), may cause fetal malformations. 
• PEG 400, NADA are both excipients of vancomycin preparations. Vancomycin should not be administered during pregnancy. You can use other forms of vancomycin. 
• Before using any formulation containing PEG 400 or NADA, it is important to determine if the woman is pregnant.

Use during breastfeeding:

• Vancomycin is excreted in breast milk after IV administration.
• Vancomycin's relative infant dose (RID), is 4.8%. This figure was calculated using the highest concentration of breast milk and compared with an infant therapeutic oral dose at 40 mg/kg/day.
• The highest possible milk concentration (12.7 mg/mL) is used to calculate the infant's daily dose of breast milk. It is estimated that the average infant intake via breastmilk is 1.9 mg/kg/day.
• Breast milk has very low excretion because of its minimal absorption after oral consumption
• Breast milk may contain antibiotics, which can cause non-dose-related changes in the bowel flora. Monitor infants for GI disorders such as thrush and diarrhea.
• Vancomycin is recommended to treat Clostridium difficile (formerly Clostridium difficile) infections in nursing mothers
• Breastfeeding with maternal vancomycin should be done after considering the risk to infants vs the mother's benefit

Vancomycin (Vancocin) Dose in Kidney Disease:

Oral: Manufacturer has not provided nay dose adjustment in labelling. The oral dose has no significant systemic absorptions IV:

Note: Vancomycin levels in patients with any type of renal impairment should be tracked. Although the initial dosage adjustment is not necessary, further dosage changes should be done in accordance with renal function and trough serum concentrations.

Vancomycin Initial Dosage Regimens for Patients With Impaired Renal Function

eGFR (mL/minute per 1.73 m2)	Actual Body Weight
	<60 kg	60 to 80 kg	81 to 100 kg	>100 kg
>90	750 mg every 8 hours	1,000 mg every 8 hours	1,250 mg every 8 hours	1,500 mg every 8 hours
50 to 90	750 mg every 12 hours	1,000 mg every 12 hours	1,250 mg every 12 hours	1,000 mg every 8 hours
15 to 49	750 mg every 24 hours	1,000 mg every 24 hours	1,250 mg every 24 hours	1,500 mg every 24 hours
<15	750 mg	1,000 mg	1,250 mg	1,500 mg
aCheck a random vancomycin level 24 hours after the dose. If random level is ≤20 mcg/mL, repeat the dose. If random level is >20 mcg/mL, do not re-dose; repeat random level in 12 hours.

• Dialysis:

  • Poorly dialyzable by intermittent hemodialysis; however, use of high-flux membranes and continuous renal replacement therapy (CRRT) increases vancomycin clearance, and generally requires replacement dosing.

• End-stage renal disease (ESRD) on intermittent hemodialysis (IHD) (administer after hemodialysis on dialysis days):

  • Initial loading dose: 15 - 25 mg/kg
  • After each dialysis session: 500 - 1,000 mg or 5 - 10 mg/kg.

Note: Dosing dependent on the assumption of 3 times/week, complete IHD sessions.

• Redosing based on pre-HD concentrations:

  • <10 mg/L: Administer 1,000 mg after HD
  • 10 - 25 mg/L: Administer 500 - 750 mg after HD
  • >25 mg/L: Hold vancomycin

• Redosing based on post-HD concentrations:

  • <10 - 15 mg/L: Administer 500 - 1,000 mg

• Peritoneal dialysis (PD):

  • 1 g every 4 - 7 days.

• Continuous renal replacement therapy (CRRT):

  • Renal replacement method, filter type and flow rate determines the drug clearance. Appropriate dosing requires close monitoring of pharmacologic response, signs of adverse reactions due to drug accumulation, as well as drug concentrations in relation to target trough (if appropriate).
  • The following broad recommendations should not replace clinical judgement and are only based on dialysate flow/ultrafiltration rates of 1 to 2 L/hour and limited residual renal function.:
    • CVVH: Loading dose: 15 - 25 mg/kg, Maintenance dose 1,000 mg every 48 hours or 10 - 15 mg/kg every 24 - 48 hours
    • CVVHD: Loading dose: 15 - 25 mg/kg, maintenance dose 1,000 mg every 24 hours or 10 - 15 mg/kg every 24 hours
    • CVVHDF: Loading dose: 15 to 25 mg/kg, 1,000 mg per 24 hours for the maintenance dose, or 5 to 10 mg/kg every 12 hours

Note: Redosing should be done, while the patient receiving CRRT for vancomycin concentrations <10 - 15 mg/L. 

Dose in Liver Disease:

Oral: Manufacturer has not provided any dose adjustment in labelling. There is no significant systemic absorption Intravenous: The manufacturer has not provided any dose adjustment in labeling. Pharmacokinetic is not affected by hepatic dysfunction. 

Common Side Effects of Vancomycin (Vancocin):

• Cardiovascular:

  • Hypotension (accompanied by flushing)

Less Common Side Effects of Vancomycin (Vancocin):

• Cardiovascular:

  • Local phlebitis
  • Flushing of face and neck (Red man syndrome; may be infusion related)

• Central nervous system:

  • Chills
  • Drug fever

• Dermatologic:

  • Skin rash

• Hematologic & oncologic:

  • Eosinophilia
  • Neutropenia (reversible)

Contraindications to Vancomycin (Vancocin):

• Vancomycin formulations that cause hypersensitivity

Warnings and precautions

• Extravasation and thrombophlebitis

  • IV formulation can be irritating; Before starting infusion, ensure that the needle or catheter is properly placed. Extravasation can cause pain, tenderness, and even necrosis.
  • Slow infusion rates are recommended for thrombophlebitis. 2.5 to 5 grams/L, and switch infusion sites.

• Nephrotoxicity:

  • Although there isn't enough proof to say it's directly responsible, it might lead to nephrotoxicity.
  • These are the risk factors for nephrotoxicity:
    • Pre-existing renal impairment
    • Concomitant nephrotoxic drugs
    • Ageing in advanced
    • Dehydration
    • Patients who are critically ill
    • Patients with rapidly changing renal function
    • Higher vancomycin serum levels
    • Long-term exposure
    • Concomitant piperacillin/tazobactam administration.
  • In the absence of any other explanation, a patient with vancomycin-induced renaltoxicity should be diagnosed if multiple (>=2) consecutive serum creatinine levels show an increase of 0.5 mg/dL (or >=50%) from baseline.
  • If the patient experiences signs of nephrotoxicity, it is best to discontinue treatment. Renal impairment can usually be reversed.
  • Oral vancomycin can cause nephrotoxicity (usually in patients over 65 years old).

• Neutropenia:

  • It can cause neutropenia.
  • This risk could be increased by prolonged therapy or use of concomitant medications that cause neutropenia.
  • Monitor leukocytes repeatedly.
  • After discontinuing therapy, expect a rapid reversal in neutropenia.

• Ototoxicity:

  • Ototoxicity may occur when it is used (rarely in monotherapy).
  • Ototoxicity can be characterized by tinnitus and hearing loss, dizziness, vertigo, and other symptoms.
  • Ototoxicity risk factors include excessive dosages, hearing loss, and use of concomitant toxic drugs, e.g. aminoglycosides
  • The risk can be reduced by performing periodic auditory function tests. Ototoxicity can be temporary or permanent.
  • If the patient shows signs of ototoxicity, discontinue use.

• Superinfection

  • Prolong use of vancomycin may result in superinfection bacterial or fungal including difficile infection. Clostridium difficile was observed in Clostridium difficile patients who were treated with antibiotics for more than two months.

• 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 difficile-associated diarrhea.
  • Even though use may be justified, there is a greater risk of adverse reactions in this situation. Consider monitoring serum trough levels, particularly in the case of severe colitis or renal insufficiency.

• Pregnancy:[US Boxed Warning]

  • Vancomycin's excipients include PEG 400 (polyethyleneglyl) and NADA (Nacetyl-D-alanine). In animal studies, these excipients have been shown to cause fetal malformations. Vancomycin should not be used during pregnancy unless there is another available form of vancomycin.

• Renal impairment

  • Patients with kidney impairment, or concomitant use of nephrotoxic and ototoxic medications should be cautious.
  • After repeated oral administrations of vancomycin, renal impairment may result in accumulation. Trough concentration monitoring is recommended.

Vancomycin: Drug Interaction

Risk Factor C (Monitor therapy)
Aminoglycosides	Aminoglycosides' nephrotoxic effects may be made worse by vancomycin.
BCG Vaccine (Immunization)	Antibiotics may reduce the BCG vaccine's therapeutic effect (Immunization).
Lactobacillus and Estriol	The therapeutic effects of Lactobacillus and Estriol may be reduced by antibiotics.
Neuromuscular-Blocking Agents	The neuromuscular-blocking effects of neuromuscular-blocking agents may be strengthened by vancomycin.
Nonsteroidal Anti-Inflammatory Agents	Vancomycin serum levels can rise.
Piperacillin	May intensify Vancomycin's nephrotoxic effects.
Risk Factor D (Consider therapy modification)
Bile Acid Sequestrants	May lessen Vancomycin's therapeutic impact. Management: Whenever feasible, avoid giving oral vancomycin and bile acid sequestrants at the same time. If both medications must be used, think about giving the dosages at least two hours apart to lessen the impact of the interaction.
Colistimethate	Colistimethate's nephrotoxic impact may be amplified by vancomycin.
Sodium Picosulfate	Antibiotics may reduce Sodium Picosulfate's therapeutic impact. Management: If a patient previously used or is currently using an antibiotic, think about utilising an alternative product for bowel cleansing prior to a colonoscopy.
Typhoid Vaccine	The Typhoid Vaccine's therapeutic benefits may be reduced by antibiotics. The only strain impacted is the live attenuated Ty21a strain. Treatment: Patients receiving systemic antibacterial drugs should refrain from receiving the live attenuated typhoid vaccination (Ty21a). It is recommended to wait at least 3 days following the last dose of antibacterial medication before administering this vaccine.
Risk Factor X (Avoid combination)
BCG (Intravesical)	Antibiotics may lessen BCG's therapeutic effects (Intravesical).
Cholera Vaccine	The therapeutic benefit of the cholera vaccine may be reduced by antibiotic use. Avoid administering the cholera vaccine to individuals taking systemic antibiotics, and do so within 14 days.

Monitoring parameters:

Intravenous:

• Frequent renal function monitoring
• Complete blood count
• Pregnancy test before use for formulation containing PEG 400 and NADA excipients,
• Serum trough vancomycin concentrations in select patients (eg, aggressive dosing, life-threatening infection, seriously ill, unstable renal function, concurrent nephrotoxins, prolonged courses)

Vancomycin trough concentration should be monitored as follows:

• Hemodynamically stable patients: Trough concentrations at least once a week.
• Hemodynamically unstable patients: More frequently trough concentrations or in some instances daily.

Prolonged courses (>3 - 5 days): Draw at least one steady-state trough concentration; repeat as clinically appropriate. Note:

• Drawing >1 trough concentration before  fourth dose for short course (<3 days) or lower intensity dosing (target trough concentrations <15 mcg/mL) is not recommended.
• For uncomplicated skin and soft tissue infections who are not obese and have normal renal function, serum trough monitoring is generally not needed.

Oral/rectal therapy:

• Serum monitoring is not typically required
• Systemic absorption is only possible with mucosal disruption due to colitis, especially in patients with renal failure
• Monitor serum vancomycin levels may be considered for patients with renal failure who have severe colitis and require a prolonged course of enteral vancomycin.

How to administer Vancomycin (Vancocin)?

IV:

• The final concentration should not exceed 5mg/mL. This can be achieved by IV intermittent infusion for at least 60 minutes.
• Fluid restriction may be performed at a concentration of 10 mg/mL. However, there is a greater risk of complications from infusions.
• This is not for IM.

Red man syndrome is a condition in which a maculopapular eruption (a reddish rash) occurs on the neck, trunk, face, or upper extremities. In this case, slow down the infusion rate to more than 11/2 to 2 hours, and increase the dilution volumes.

Rapid infusion can cause hypotension, shock, or cardiac arrest. This reaction may be prevented or minimized by administering antihistamines before infusion. Extravasation is a problem.

Extravasation management:

• If extravasation occurs immediately stop infusion (leave needle/cannula in place).
• Extravasated solution can be gently aspirated
• DoNOTFlush the line and take out the needle/cannula
• Eevate extremity.
• You can use dry warm compresses to increase the blood flow local to improve drug removal from the extravasation site
• Refractory cases may be treated with intradermal hyaluronidase.

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.

Antibiotic lock technique (off-label use):

• Use vancomycin lock solution to prepare and inject into the catheter access ports using enough volume (2-5 mL). Dependent on how often you use the catheter, dwell time should take between 48 and 72 hours. After catheter use, withdraw the lock solution and replace it with a fresh vancomycin lock solution.

Intraventricular (off-label route):

Use only preparations that are free from preservatives. Use intraventricular concentrations of 2.5-10 mg/mL to treat CSF shunt infections. To allow vancomycin solution in the CSF to equilibrate, clamp drain for between 15 and 60 minutes.

Intravitreal (off-label route):

• Intravitreal administration requires a concentration of 1 mg/0.1mL NS.

Oral: Solution (Firvanq: Before each use, shake well Injection:

• The reconstituted powder for injection (not the premixed solution), may be dilute and used for oral administration.
• Common flavoring syrups are also available to enhance taste.

Rectal (off-label route):

• Retention enema perrectum: 500 mg in 100-500 mL normal saline.
• Volume may vary depending on the length of the segment being treated. Solution with lower sodium chloride concentrations may be used if sodium chloride causes hyperchloremia. 

Mechanism of action of Vancomycin (Vancocin):

• It acts on the bacterial cell walls and blocks glycopeptide polymerization. 
• It binds tightly with the D-alanyl–D-alanine component of the cell wall precursor

Notice:Slowly bacteriocidal; time-dependent antimicrobial kill

Absorption:

• Oral: Poor; Rectal may experience significant absorption from inflamed colonic mucosa.
• Intraperitoneal (IP). 60% of an IP dosage absorbed within 6 hours

Distribution:

• It is distributed widely in tissues and fluids except for CSF.

• CSF: serum level ratio: Normal meninges: Nil; Inflamed meninges: ~80%

Protein binding: ~55%

Metabolism:

• No apparent metabolism

Half-life elimination: Biphasic: Terminal:

• Newborns: 6 - 10 hours
• Neonates receiving ECMO: 6.53 ± 2.1 hours; others have reported longer: 10.4 ± 6.7 hours
• Infants and Children 3 months - 4 years: 4 hours
• Children and Adolescents >3 years: 2.2 - 3 hours
• Adults: 4 - 6 hours; significantly prolonged with renal impairment
• End-stage renal disease (ESRD): 7.5 days

Time to peak, serum:

• IV: Immediately after completion of infusion

Excretion:

• Mainly through kidneys 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 - 1.5 mL/minute/kg; dependent on GA and/or PMA.
• Neonates, receiving ECMO: ~0.79 mL/minute/kg; some resources has reported a slightly slower rate: 0.67 mL/minute/kg
• Pediatric patients: Median: 1.1 mL/minute/kg (range: 0.33 - 1.87 mL/minute/kg)
• Adults: 0.71 to 1.31 mL/minute/kg

International Brand Names of Vancomycin:

• Firvanq
• Vancocin
• Vancocin HCl
• Vancosol Pack
• JAMP-Vancomycin
• PMS-Vancomycin
• Vancocin
• Vancomycin HCl
• Adimicin
• Aekovan
• Alvarcin
• Celovan
• Citerin
• Covan
• Covancin
• Cytovan
• Dhacocin
• Edicin
• Estavam
• Forstaf
• Icoplax
• Kovan
• Levovanox
• Mersa
• Normedia
• Riveran
• Vacsol
• Vagran
• Vamysin
• Vanauras
• Vanaurus
• Vancard
• Vancep
• Vancin
• Vancin-S
• Vanco-SAAR
• Vanco-Teva
• Vancoavenir
• Vancobac
• Vancobact
• Vancocid
• Vancocin
• Vancocin CP
• Vancocin HCl
• Vancocina
• Vancocine
• Vancodex
• Vancoled
• Vancolon
• Vancomax
• Vancomet
• Vanconix
• Vancorin
• Vancorus
• Vancosam
• Vancosan
• Vancotech
• Vancotek
• Vancotex
• Vancotrat
• Vancox
• Vancozin
• Vanlyo
• Vanmicira
• Vantocil
• Varedet
• Vivocin
• Voncon
• Vondem
• Voxin

Vancomycin Brand Names in Pakistan:

Vancomycin Hcl Injection 1 gm in Pakistan
Hisun	Biocare Pharmaceutical
Vanbact	Nabiqasim Industries (Pvt) Ltd.
Vancolon	Julphar Pakistan
Vancorin	Hoffman Health Pakistan Ltd.
Vancotic	English Pharmaceuticals Industries
Varedet	Medinet Pharmaceuticals
Vinjec	Bosch Pharmaceuticals (Pvt) Ltd.
Zengac	Rotex Medica Pakistan (Pvt) Ltd

Vancomycin Injection 500 Mg in Pakistan
Hisun	Biocare Pharmaceutical
Vanbact	Nabiqasim Industries (Pvt) Ltd.
Vancocin	Eli Lilly Pakistan (Pvt) Ltd.
Vancolon	Julphar Pakistan
Vancorin	Hoffman Health Pakistan Ltd.
Vancotic	English Pharmaceuticals Industries
Varedet	Medinet Pharmaceuticals
Vinjec	Bosch Pharmaceuticals (Pvt) Ltd.
Zengac	Rotex Medica Pakistan (Pvt) Ltd

Vancomycin Infusion 500 Mg in Pakistan
Lyphocin	Mediceena Pharma (Pvt) Ltd.