vancomycin hydrochloride

vancomycin hydrochloride

Vancocin

Pharmacologic class: Tricyclic glycopeptide

Therapeutic class: Anti-infective

Pregnancy risk category C

Action

Binds to bacterial cell wall, inhibiting cell-wall synthesis and causing secondary damage to bacterial membrane

Availability

Capsules: 125 mg, 250 mg

Powder for injection: 500-mg vial, 1-g vial, 5-g vial, 10 g-vial

Powder for oral solution: 1-g and 10-g bottles

⊘Indications and dosages

➣ Severe, life-threatening infections caused by susceptible strains of methicillin-resistant staphylococci, Staphylococcus epidermidis, Streptococcus viridans or Streptococcus bovis (alone or combined with an aminoglycoside), or Enterococcus faecalis (combined with an aminoglycoside)

Adults: 500 mg I.V. q 6 hours or 1 g I.V. q 12 hours

Children: 10 mg/kg I.V. q 6 hours

Infants and neonates: Initially, 15 mg/kg I.V., followed by 10 mg/kg I.V. q 8 hours in infants 8 days to 1 month old, or 10 mg/kg I.V. q 12 hours in infants less than 8 days old

➣ Endocarditis prophylaxis in penicillin-allergic patients at moderate risk who are scheduled for dental and other invasive procedures

Adults: 1 g I.V. slowly over 1 to 2 hours, with infusion completed 30 minutes before invasive procedure begins

Children: 20 mg/kg I.V. over 1 to 2 hours, with infusion completed 30 minutes before invasive procedure begins

➣ Enterocolitis caused by Streptococcus aureus; antibiotic-related pseudomembranous diarrhea caused by Clostridium difficile

Adults: 500 mg to 2 g P.O. daily in three or four divided doses for 7 to 10 days

Children: 40 mg/kg P.O. daily in three or four divided doses for 7 to 10 days, up to a maximum of 2 g/day

Dosage adjustment

• Renal impairment
• Elderly patients

Off-label uses

• Peritonitis
• Meningitis
• Intraocular infections
• Febrile neutropenia

Contraindications

• Hypersensitivity to drug

Precautions

Use cautiously in:
• renal impairment, preexisting hearing loss
• concurrent use of anesthetics, immunosuppressants, or nephrotoxic or ototoxic drugs
• elderly patients
• pregnant or breastfeeding patients
• neonates.

Administration

☞ Know that I.V. therapy is ineffective against enterocolitis and pseudomembranous diarrhea.
• For intermittent I.V. infusion, dilute by adding 10 or 20 ml of sterile water for injection to vial containing 500 mg or 1 g of drug, respectively, to yield a concentration of 50 mg/ml. Dilute further by adding at least 100 ml or 200 ml, respectively, of dextrose 5% in water or normal saline solution; infuse over at least 1 hour.
• Don't give by I.M. route.
☞ Keep emergency equipment and epinephrine on hand in case of anaphylaxis.

Route	Onset	Peak	Duration
P.O.	Unknown	Unknown	Unknown
I.V.	Immediate	Immediate	Unknown

Adverse reactions

CV: hypotension, cardiac arrest, vascular collapse

EENT: permanent hearing loss, ototoxicity, tinnitus

GI: nausea, vomiting, pseudomembranous colitis

GU: nephrotoxicity, severe uremia

Hematologic: eosinophilia, leukopenia, neutropenia

Respiratory: wheezing, dyspnea

Skin: "red man" syndrome (nonallergic histamine reaction with rapid I.V. infusion), rash, urticaria, pruritus, necrosis

Other: chills, fever, thrombophlebitis at injection site, anaphylaxis

Interactions

Drug-drug. Aminoglycosides, amphotericin B, bacitracin, cephalosporins, cisplatin, colistin, nondepolarizing neuromuscular blockers, pentamidine: increased risk of nephrotoxicity and ototoxicity

Warfarin: increased risk of bleeding

Drug-diagnostic tests. Albumin, blood urea nitrogen (BUN), creatinine: increased levels

Eosinophils, neutrophils: decreased counts

Patient monitoring

☞ Monitor closely for signs and symptoms of hypersensitivity reactions, including anaphylaxis.
• Check drug blood level weekly. Therapeutic peak ranges from 30 to 40 g/L; therapeutic trough, 5 to 10 mg/L.
• Assess BUN and creatinine levels every 2 days, or daily in patients with unstable renal function.
• Monitor urine output daily. Weigh patient at least weekly.
• Assess hearing before and during therapy; stay alert for hearing loss. Patient may require baseline and weekly audiograms.
• Check I.V. site often for phlebitis.
• Watch for "red-man" syndrome, which can result from rapid infusion. Signs and symptoms include hypotension, pruritus, and maculopapular rash on face, neck, trunk, and limbs.
• Monitor CBC. Watch for signs and symptoms of blood dyscrasias.
• Closely monitor respiratory status. Stay alert for wheezing and dyspnea.
☞ Monitor vital signs and cardiovascular status, especially for vascular collapse and other signs of impending cardiac arrest.

Patient teaching

• Tell patient he may take with or without food.
• Instruct patient to take oral drug exactly as prescribed for as long as prescribed, even if symptoms improve.
• Explain importance of prophylactic I.V. therapy to patients at risk for endocarditis who are scheduled for invasive procedures.
☞ Advise patient to promptly report rash, hearing loss, breathing problems, and signs and symptoms of "red-man" syndrome, nephrotoxicity, and blood dyscrasias.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.