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Pharmacologic class: Tricyclic glycopeptide
Therapeutic class: Anti-infective
Pregnancy risk category C (with parenteral use); B (with oral use)
Binds to bacterial cell wall, inhibiting cell-wall synthesis and causing secondary damage to bacterial membrane
Capsules: 125 mg, 250 mg
Powder for injection: 500-mg vial, 1-g vial, 5-g vial, 10 g-vial
⊘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 Staphylococcus aureus
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; total daily dose shouldn't exceed 2 g.
➣Clostridium difficile-associated diarrhea
Adults: 125 mg P.O. q.i.d. for 10 days
Children: 40 mg/kg P. O. in three or four divided doses for 7 to 10 days; total daily dose shouldn't exceed 2 g.
• Renal impairment
• Elderly patients
• Intraocular infections
• Febrile neutropenia
• Hypersensitivity to drug
Use cautiously in:
• renal impairment, preexisting hearing loss
• concurrent use of anesthetics, immunosuppressants, or nephrotoxic or ototoxic drugs
• elderly patients
• pregnant or breastfeeding patients
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.
• Be aware that capsules aren't systemically absorbed; therefore, oral therapy is ineffective in infections other than C. difficile-associated diarrhea and enterocolitis caused by S. aureus.
Keep emergency equipment and epinephrine on hand in case of anaphylaxis.
CV: hypotension, cardiac arrest, vascular collapse
EENT: permanent hearing loss, ototoxicity, tinnitus
GI: nausea, vomiting, abdominal pain, 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
Drug-drug.Aminoglycosides, amphotericin B, bacitracin, cephalosporins, cisplatin, colistin, nondepolarizing neuromuscular blockers, pentamidine (with parenteral use): increased risk of nephrotoxicity and ototoxicity
Anesthetic agents (with parenteral use): erythema and histamine-like flushing
Drug-diagnostic tests.Albumin, blood urea nitrogen (BUN), creatinine: increased levels
Eosinophils, neutrophils: decreased counts
Potassium: decreased level
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.
• 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.
ClassificationTherapeutic: anti infectives
- Soft-tissue infections in patients who have allergies to penicillin or its derivatives or when sensitivity testing demonstrates resistance to methicillin.
- Staphylococci (including methicillin-resistant strains of Staphylococcus aureus),
- Group A beta-hemolytic streptococci,
- Streptococcus pneumoniae,
- Clostridium difficile,
- Enterococcus faecalis,
- Enterococcus faecium.
Time/action profile (blood levels)
|IV||rapid||end of infusion||12–24 hr|
Adverse Reactions/Side Effects
Ear, Eye, Nose, Throat
- nephrotoxicity (most frequent)
- phlebitis (most frequent)
- back and neck pain
- hypersensitivity reactions including anaphylaxis (life-threatening)
- "red man" syndrome (with rapid infusion)
Drug-Drug interactionMay cause additive ototoxicity and nephrotoxicity with other ototoxic and nephrotoxic drugs (aspirin, aminoglycosides, cyclosporine, cisplatin, loopdiuretics ).May enhance neuromuscular blockade from nondepolarizing neuromuscular blocking agents.↑ risk of histamine flush when used with generalanesthetics in children.
Serious Systemic Infections
Endocarditis Prophylaxis in Penicillin-Allergic Patients
Diarrhea Due to C. difficile
Renal ImpairmentIntravenous (Adults) An initial loading dose of 750 mg–1 g (not less than 15 mg/kg); serum level monitoring is optimal for choosing maintenance dose in patients with renal impairment; these guidelines may be helpful. CCr 50–80 mL/min—1 g q 1–3 days; CCr 10–50 mL/min—1 g q 3–7 days; CCr <10 mL/min—1 g q 7–14 days.
Availability (generic available)
- Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.
- Obtain specimens for culture and sensitivity prior to initiating therapy. First dose may be given before receiving results.
- Monitor IV site closely. Vancomycin is irritating to tissues and causes necrosis and severe pain with extravasation. Rotate infusion site.
- Monitor BP throughout IV infusion.
- Evaluate eighth cranial nerve function by audiometry and serum vancomycin levels prior to and throughout therapy in patients with borderline renal function or those >60 yr of age. Prompt recognition and intervention are essential in preventing permanent damage.
- Monitor intake and output ratios and daily weight. Cloudy or pink urine may be a sign of nephrotoxicity.
- Assess patient for signs of superinfection (black, furry overgrowth on tongue; vaginal itching or discharge; loose or foul-smelling stools). Report occurrence.
- Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify health care professional immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction.
- Pseudomembranous Colitis: Assess bowel status (bowel sounds, frequency and consistency of stools, presence of blood in stools) throughout therapy.
- Lab Test Considerations: Monitor for casts, albumin, or cells in the urine or decreased specific gravity, CBC, and renal function periodically during therapy.
Trough concentrations should not exceed 10 mcg/mL (mild-moderate infections) or 15–20 mcg/mL (for severe infections).
- May cause increased BUN levels.
Potential Nursing DiagnosesRisk for infection (Indications)
Disturbed sensory perception(auditory) (Side Effects)
- Vancomicin must be given orally for treatment of staphylococcal enterocolitis and C. difficile-associated diarrhea. Orally administered vancomycin is not effective for other types of infections.
- Oral: Use calibrated measuring device for liquid preparations. IV dose form may be diluted in 30 mL of water for oral or nasogastric tube administration. Resulting solution has bitter, unpleasant taste. May mix with a flavoring syrup to mask taste. Stable for 14 days if refrigerated.
- pH: 2.5–5.0.
- Intermittent Infusion: Diluent: To reconstitute, add 10 mL of sterile water for injection to 500-mg vial or 20 mL of sterile water for injection to 1-g vial for a concentration of 50 mg/mL. Dilute further with at least 100 mL of 0.9% NaCl, D5W, D5/0.9% NaCl, or LR for every 500 mg of vancomycin being administered. Reconstituted vials stable for 14 days if refrigerated. Infusion is stable for 96 hr if refrigerated.Concentration: ≤5 mg/mL.
- Rate: Infuse over at least 60 min (90 min for doses >1 g). Do not administer rapidly or as a bolus, to minimize risk of thrombophlebitis, hypotension, and "red-man (neck)" syndrome (sudden, severe hypotension; flushing and/or maculopapular rash of face, neck, chest, and upper extremities). May need to slow infusion further to 1.5–2 hr if red-man syndrome occurs.
- Intrathecal: Diluent: Dilute with preservative-free NS.Concentration: 1–5 mg/mL.
- Rate: Directly instill into ventricular cerebrospinal fluid.
- Y-Site Compatibility: acetylcysteine, acyclovir, aldesleukin, alemtuzumab, alfentanil, allopurinol, alprostadil, amifostine, amikacin, amiodarone, amsacrine, anidulafungin, argatroban, ascorbic acid, atracurium, atropine, azithromycin, benztropine, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin, carmustine, caspofungin, chlorpromazine, ciprofloxacin, cisatracurium, cisplatin, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, dexamethasone, dexmedetomidine, dexrazoxane, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dolasetron, dopamine, doripenem, doxacurium, doxapram, doxorubicin hydrochloride, doxorubicin liposome, doxycycline, enalaprilat, ephedrine, epinephrine, epirubicin, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, filgrastim, fluconazole, fludarabine, folic acid, gemcitabine, gentamicin, glycopyrrolate, granisetron, hetastarch, hydromorphone, ifosfamide, insulin, irinotecan, isoproterenol, ketamine, labetalol, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, melphalan, meperidine, meropenem, metaraminol, methyldopate, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, morphine, multivitamins, mycophenolate, nalbuphine, naloxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, papaverine, pemetrexed, penicillin G, pentamidine, pentazocine, pentobarbital, perphenazine, phenobarbital, phentolamine, phenylephrine, phytonadione, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine, propranolol, protamine, pyridoxime, ranitidine, remifentanil, rifampin, sodium acetate, sodium bicarbonate, sodium citrate, succinylcholine, sufentanil, tacrolimus, teniposide, thiamine, thiotepa, tigecycline, tirofiban, tobramycin, tolazoline, trastuzumab, vasopressin, vecuronium, verapamil, vinblastine, vincristine, vinorelbine, voriconazole, zidovudine, zolendronic acid
- Y-Site Incompatibility: albumin, aminophylline, amphotericin B cholesteryl, amphotericin B colloidal, amphotericin lipid complex, amphotericin B liposome, azathioprine, bivalirudin, cefoperazone, chloramphenicol, dantrolene, daptomycin, diazepam, diazoxide, epoetin alfa, fluorouracil, furosemide, ganciclovir, heparin, ibuprofen, idarubicin, indomethacin, ketorolac, leucovorin calcium, methylprednisolone, mitomycin, moxifloxacin, phenytoin, rituximab, streptokinase, trimethoprim/sulfamethoxazole, valproate sodium
- Advise patients on oral vancomycin to take as directed. Take missed doses as soon as remembered unless almost time for next dose; do not double dose.
- Instruct patient to report signs of hypersensitivity, tinnitus, vertigo, or hearing loss.
- Advise patient to notify health care professional if no improvement is seen in a few days.
- Patients with a history of rheumatic heart disease or valve replacement need to be taught importance of using antimicrobial prophylaxis prior to invasive dental or medical procedures.
- Advise female patient to notify health care professional if pregnancy is planned or suspected or if breast feeding.
- Resolution of signs and symptoms of infection. Length of time for complete resolution depends on organism and site of infection.
- Endocarditis prophylaxis.