VANCOMYCIN
Clinical safety rating: safe
Other nephrotoxic drugs increase risk of toxicity Monitor levels to minimize risk of nephrotoxicity and ototoxicity (red man syndrome).
Inhibits bacterial cell wall synthesis by binding to the D-alanyl-D-alanine terminus of the peptidoglycan precursor, blocking polymerization and cross-linking.
| Metabolism | Minimal hepatic metabolism; primarily excreted unchanged by glomerular filtration. |
| Excretion | Vancomycin is primarily excreted unchanged via glomerular filtration, with over 90% of a dose recovered in urine within 24 hours. Minor biliary/fecal elimination accounts for <5%. |
| Half-life | Terminal elimination half-life is approximately 4-6 hours in adults with normal renal function (creatinine clearance >90 mL/min). In severe renal impairment (CrCl <30 mL/min), half-life may extend to 24-48 hours or longer, necessitating therapeutic drug monitoring. |
| Protein binding | 30-55% bound to albumin. |
| Volume of Distribution | 0.4-1.0 L/kg, with a mean of approximately 0.7 L/kg. This indicates distribution into extracellular fluid and some tissues, but limited penetration into cerebrospinal fluid (CSF) unless meninges are inflamed. |
| Bioavailability | Intravenous: 100% systemic bioavailability. Oral: <10% (negligible systemic absorption), used only for local gastrointestinal effects. |
| Onset of Action | Intravenous administration: onset occurs within 1 hour, with peak serum concentrations achieved at the end of the infusion. Oral administration: onset is delayed (up to 6 hours) due to poor systemic absorption; systemic effect is negligible. |
| Duration of Action | Bactericidal activity persists for 6-12 hours following an intravenous infusion, supporting a typical dosing interval of 12 hours (or longer in renal impairment). Oral vancomycin acts locally in the gut for Clostridioides difficile infection, with action duration related to bowel transit time. |
| Molecular Weight | 1449.25 |
| Action Class | Glycopeptides |
| Brand Substitutes | Mego 500mg Injection, Vanacin CP 500mg Injection, Vancoray 500mg Injection, G Vanc 500mg Injection, Vantox-CP 500mg Injection |
15-20 mg/kg IV every 8-12 hours (maximum single dose 2 g, maximum daily dose 4 g) with target trough concentrations of 15-20 mg/L for serious infections.
| Dosage form | SOLUTION |
| Renal impairment | CrCl 30-50 mL/min: 15-20 mg/kg IV every 24 hours. CrCl 10-29 mL/min: 15-20 mg/kg IV every 48 hours. CrCl <10 mL/min: 15-20 mg/kg IV every 96 hours or based on serum concentrations. |
| Liver impairment | No dosage adjustment required for hepatic impairment alone; monitor serum concentrations in severe hepatic dysfunction with concomitant renal impairment. |
| Pediatric use | Neonates: 10-15 mg/kg IV every 12-48 hours based on gestational and postnatal age. Infants and children >1 month: 15-20 mg/kg IV every 6-12 hours, maximum single dose 2 g. |
| Geriatric use | Lower initial doses (10-15 mg/kg IV) and extended intervals (e.g., every 12-24 hours) due to age-related decline in renal function; monitor renal function and trough concentrations closely. |
| 1st trimester | Vancomycin crosses the placenta; limited human data suggest no major teratogenic risk. Use only if clearly needed. |
| 2nd trimester | No evidence of harm in animal studies; human data limited. Use if benefit outweighs risk. |
| 3rd trimester | Considered safe for maternal infections; avoid prolonged high doses to reduce risk of neonatal renal toxicity or ototoxicity. |
Clinical note
Other nephrotoxic drugs increase risk of toxicity Monitor levels to minimize risk of nephrotoxicity and ototoxicity (red man syndrome).
| FDA category | Human |
| Placental transfer | Crosses placenta; fetal serum levels may reach 60-80% of maternal levels. Distributed to amniotic fluid. |
| Breastfeeding |
■ FDA Black Box Warning
Rapid bolus administration may cause hypotension, arrhythmias, and cardiac arrest. Administer as a diluted solution over at least 60 minutes.
| Serious Effects |
Hypersensitivity to vancomycin
| Precautions | Nephrotoxicity: Monitor renal function and adjust dosing in renal impairment., Ototoxicity: Monitor for hearing loss or tinnitus, especially in elderly or those with renal impairment., Red Man Syndrome: Infusion-related histamine release causing flushing, pruritus, and hypotension; prevent by slow infusion and premedication., Superinfection: Prolonged use may result in overgrowth of nonsusceptible organisms., Thrombocytopenia: Has been reported; monitor platelet counts. |
| Food/Dietary | No significant food interactions reported. Absorption unaffected by food. Oral vancomycin is not absorbed systemically; used for C. difficile colitis. |
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| Vancomycin is poorly absorbed orally, so infant exposure via breast milk is minimal. However, monitor infant for diarrhea or allergic reactions. Compatible with breastfeeding. |
| Lactation Rating | L2 (Safe) |
| Teratogenic Risk | Vancomycin is classified as FDA Pregnancy Category B. Animal studies have not shown teratogenic effects. In humans, vancomycin crosses the placenta but has not been associated with congenital malformations or fetal toxicity. However, data in pregnant women are limited; use only if clearly needed. Maternal IV vancomycin may cause transient fetal serum levels; no evidence of teratogenicity in first trimester. |
| Fetal Monitoring | Monitor maternal serum vancomycin trough concentrations (target 10-20 mg/L for most indications) to ensure therapeutic efficacy and avoid toxicity. Assess renal function (serum creatinine, BUN) and urine output frequently due to nephrotoxicity risk. Monitor for ototoxicity (hearing loss, tinnitus) especially with prolonged therapy or high doses. Fetal monitoring: assess fetal heart rate and growth if clinically indicated; no specific fetal monitoring required. |
| Fertility Effects | Vancomycin has no known direct effects on human fertility based on available data. Animal studies have not reported impairment of fertility. Use during pregnancy is not expected to affect fertility in offspring, but data are limited. |
| Clinical Pearls | Monitor trough concentrations (target 10-20 mcg/mL for most infections; 15-20 mcg/mL for serious MRSA infections). AUC-guided dosing may improve efficacy and reduce nephrotoxicity. Infuse over at least 1 hour to avoid red man syndrome. Renal function monitoring is essential; adjust dose in renal impairment. Vancomycin has poor lung penetration; consider alternative for pneumonia if MIC > 1. |
| Patient Advice | Take exactly as prescribed; do not miss doses. · Report any rash, itching, or difficulty breathing immediately. · You may experience flushing or redness during infusion (red man syndrome); inform your nurse. · Drink plenty of fluids unless instructed otherwise. · Tell your doctor if you have hearing loss, ringing in ears, or kidney problems. |