VANCOMYCIN HYDROCHLORIDE
Clinical safety rating: safe
Other nephrotoxic drugs increase risk of toxicity Monitor levels to minimize risk of nephrotoxicity and ototoxicity (red man syndrome).
Vancomycin inhibits bacterial cell wall synthesis by binding to the D-alanyl-D-alanine terminus of the pentapeptide precursor, preventing transpeptidation and polymerization of peptidoglycan.
| Metabolism | Vancomycin is minimally metabolized; approximately 80-90% of the dose is excreted unchanged in urine via glomerular filtration. No significant hepatic metabolism. |
| Excretion | Renal: 80-90% unchanged via glomerular filtration; minor biliary (up to 5%) and fecal elimination. |
| Half-life | 4-6 hours in adults with normal renal function; prolonged up to 7 days in anuria. Half-life inversely correlates with creatinine clearance. |
| Protein binding | 30-55% bound, primarily to albumin. |
| Volume of Distribution | 0.4-1 L/kg (0.7 L/kg average); distributes widely into tissues, low CNS penetration unless inflamed. |
| Bioavailability | Oral: <5%. IV: 100% (intravenous administration only for systemic use). |
| Onset of Action | IV: Rapid, within 1 hour; oral: not applicable for systemic infections (oral bioavailability <5%, used for C. difficile colitis). |
| Duration of Action | IV: Bactericidal levels maintained for 6-12 hours; duration depends on dose interval (typically q12h in normal renal function). |
| Molecular Weight | 1449.25 |
1-2 g IV every 12 hours; adjust based on trough concentrations (target 10-20 mcg/mL).
| Dosage form | CAPSULE |
| Renal impairment | CrCl >50 mL/min: usual dose; CrCl 20-50 mL/min: 1-2 g IV every 24 hours; CrCl 10-19 mL/min: 1 g IV every 48-72 hours; CrCl <10 mL/min: 1 g IV every 7-10 days. Use trough monitoring. |
| Liver impairment | No specific adjustments for hepatic impairment; dosing based on renal function. |
| Pediatric use | Neonates: 10-15 mg/kg IV every 8-24 hours based on postmenstrual age; Infants and children: 15 mg/kg IV every 6 hours; max 4 g/day. Therapeutic drug monitoring recommended. |
| Geriatric use | Consider age-related decline in renal function; calculate CrCl using Cockcroft-Gault and adjust dose based on renal function; monitor trough levels closely. |
| 1st trimester | Limited human data; animal studies do not indicate fetal harm. Use only if clearly needed. |
| 2nd trimester | Crosses placenta; no known teratogenicity. Monitor maternal renal function and serum levels. |
| 3rd trimester | Crosses placenta; no known adverse fetal effects. Use for serious infections when benefit outweighs risk. |
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; cord blood levels 50-100% of maternal serum levels. No evidence of fetal harm. |
| Breastfeeding |
■ FDA Black Box Warning
No FDA boxed warning exists for vancomycin hydrochloride.
| Common Effects | MRSA) |
| Serious Effects |
Known hypersensitivity to vancomycin
| Precautions | Nephrotoxicity: Monitor renal function; risk increased with concurrent nephrotoxic drugs., Ototoxicity: May cause hearing loss, especially at high doses or with renal impairment., Infusion-related reactions: Red man syndrome (histamine release) can occur with rapid infusion., Thrombocytopenia and neutropenia: Rare but reported with prolonged therapy., Vancomycin should be used with caution in patients with renal impairment; dosage adjustments required., Monitor serum trough concentrations to optimize efficacy and reduce toxicity. |
| Food/Dietary | No significant food interactions. For oral vancomycin, take on an empty stomach with a full glass of water. Avoid alcohol during therapy due to potential disulfiram-like reaction. |
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| Minimal excretion into breast milk; unlikely to cause adverse effects in infant due to poor oral absorption. Consider monitoring infant for diarrhea or rash. |
| Lactation Rating | L2 (Safer) |
| Teratogenic Risk | Vancomycin crosses the placenta, achieving fetal serum concentrations 30-100% of maternal levels. Animal studies show no teratogenicity at clinically relevant doses. Human data are limited but do not indicate increased risk of major congenital malformations following first-trimester exposure. However, theoretical risk of ototoxicity and nephrotoxicity exists for the fetus if maternal toxicity occurs. Use during pregnancy only if clearly needed, considering benefit-risk. |
| Fetal Monitoring | Monitor maternal serum vancomycin trough concentrations (target 15-20 mg/L for serious infections) and renal function (serum creatinine) every 3-5 days, more frequently if renal instability. Assess for ototoxicity if symptoms occur. Fetal monitoring: standard antenatal surveillance for high-risk pregnancies; consider ultrasound for growth if prolonged therapy. |
| Fertility Effects | No known direct effects on human fertility. Animal studies show no impairment of fertility at doses up to 200 mg/kg/day. However, severe infections treated with vancomycin may indirectly impact fertility due to systemic illness. |
| Clinical Pearls | Vancomycin trough levels should be monitored 30 minutes before the fourth dose; target trough 15-20 mcg/mL for serious infections. Red man syndrome is prevented by infusing over at least 1 hour (1g) or 2 hours (2g). Nephrotoxicity risk increases with concurrent aminoglycosides or piperacillin-tazobactam. Oral vancomycin is not absorbed; used only for C. difficile colitis. |
| Patient Advice | Complete the full course even if you feel better. · Report any rash, itching, or difficulty breathing immediately. · You may experience flushing or itching during infusion; this is not an allergy but can be minimized by slower infusion. · Drink plenty of fluids to prevent kidney problems unless told otherwise. · Avoid alcohol while taking this medication. · Use effective contraception if applicable; vancomycin may decrease oral contraceptive efficacy. |