Supportive care is advised, with maintenance of glomerular filtration. Vancomycin is poorly removed by dialysis. Hemofiltration and hemoperfusion with polysulfone resin have been reported to result in increased vancomycin clearance. To obtain up-to-date information about the treatment of overdose, a good resource is your certified Regional Poison Control Center. In managing overdosage, consider the possibility of multiple drug overdoses, interaction among drugs, and unusual drug kinetics in your patient.
Infusion-related events are related to both the concentration and the rate of administration of vancomycin. Infusion-related events may occur, however, at any rate or concentration. The usual daily intravenous dose is 2 g divided either as mg every 6 hours or 1 g every 12 hours. Other patient factors, such as age or obesity, may call for modification of the usual intravenous daily dose. Each dose should be administered over a period of at least 60 minutes.
Close monitoring of serum concentrations of vancomycin may be warranted in these patients. In pediatric patients up to the age of 1 month, the total daily intravenous dosage may be lower. Each dose should be administered over 60 minutes. In premature infants, vancomycin clearance decreases as postconceptional age decreases. Therefore, longer dosing intervals may be necessary in premature infants. Close monitoring of serum concentrations of vancomycin is recommended in these patients.
Dosage adjustment must be made in patients with impaired renal function. In premature infants and the elderly, greater dosage reductions than expected may be necessary because of decreased renal function. Measurement of vancomycin serum concentrations can be helpful in optimizing therapy, especially in seriously ill patients with changing renal function. Vancomycin serum concentrations can be determined by use of microbiologic assay, radioimmunoassay, fluorescence polarization immunoassay, fluorescence immunoassay, or high-pressure liquid chromatography.
If creatinine clearance can be measured or estimated accurately, the dosage for most patients with renal impairment can be calculated using the following table. The table is not valid for functionally anephric patients.
The dose required to maintain stable concentrations is 1. In patients with marked renal impairment, it may be more convenient to give maintenance doses of to 1, mg once every several days rather than administering the drug on a daily basis. In anuria, a dose of 1, mg every 7 to 10 days has been recommended. When only serum creatinine is known, the following formula based on sex, weight, and age of the patient may be used to calculate creatinine clearance. The creatinine clearance should be measured promptly.
The serum creatinine must represent a steady state of renal function. Otherwise, the estimated value for creatinine clearance is not valid. Such a calculated clearance is an overestimate of actual clearance in patients with conditions: 1 characterized by decreasing renal function, such as shock, severe heart failure, or oliguria; 2 in which a normal relationship between muscle mass and total body weight is not present, such as in obese patients or those with liver disease, edema, or ascites; and 3 accompanied by debilitation, malnutrition, or inactivity.
The safety and efficacy of vancomycin administration by the intrathecal intralumbar or intraventricular routes have not been established. Intermittent infusion is the recommended method of administration.
Good professional practice suggests that compounded admixtures should be administered as soon after preparation as is feasible. After reconstitution, the vials may be stored in a refrigerator for 14 days without significant loss of potency. For doses of mg 15 mL , at least mL of solution must be used. For doses of 1 gram 20 mL , at least mL of solution must be used. For doses of 1.
The desired dose diluted in this manner should be administered by intermittent IV infusion over a period of at least 60 minutes. Solutions that are diluted with the following infusion fluids may be stored in a refrigerator for 96 hours:.
Vancomycin solution has a low pH and may cause chemical or physical instability when it is mixed with other compounds. Mixtures of solutions of vancomycin and beta-lactam antibiotics have been shown to be physically incompatible.
The likelihood of precipitation increases with higher concentrations of vancomycin. It is recommended to adequately flush the intravenous lines between the administration of these antibiotics.
Although intravitreal injection is not an approved route of administration for vancomycin, precipitation has been reported after intravitreal injection of vancomycin and ceftazidime for endophthalmitis using different syringes and needles.
The precipitates dissolved gradually, with complete clearing of the vitreous cavity over two months and with improvement of visual acuity. Parenteral drug products should be visually inspected for particulate matter and discoloration prior to administration, whenever solution and container permit. Oral vancomycin is used in treating antibiotic-associated pseudomembranous colitis caused by C. The usual adult total daily dosage is mg to 2 g given in 3 or 4 divided doses for 7 to 10 days.
The total daily dosage should not exceed 2 g. The appropriate dose may be diluted in 1 oz of water and given to the patients to drink. Common flavoring syrups may be added to the solution to improve the taste for oral administration. The diluted solution may be administered via a nasogastric tube. Vancomycin Hydrochloride for Injection, USP is supplied as a sterile powder in single-dose fliptop vials that contain the vancomycin equivalent of either mg, mg, 1 g or 1.
Rx only To reduce the development of drug-resistant bacteria and maintain the effectiveness of vancomycin hydrochloride for injection and other antibacterial drugs, vancomycin hydrochloride for injection should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.
Synergy The combination of vancomycin and an aminoglycoside acts synergistically in vitro against many strains of Staphylococcus aureus , Streptococcus bovis , enterococci, and the viridans group streptococci.
Aerobic gram-positive microorganisms Diphtheroids Enterococci e. Aerobic gram-positive microorganisms Listeria monocytogenes Streptococcus pyogenes Streptococcus pneumoniae including penicillin-resistant strains Streptococcus agalactiae. Anaerobic gram-positive microorganisms Actinomyces species Lactobacillus species. Nephrotoxicity Systemic vancomycin exposure may result in acute kidney injury AKI.
Ototoxicity Ototoxicity has occurred in patients receiving vancomycin hydrochloride for injection. Clostridioides difficile Associated Diarrhea CDAD Clostridioides difficile associated diarrhea CDAD has been reported with use of nearly all antibacterial agents, including vancomycin hydrochloride for injection, and may range in severity from mild diarrhea to fatal colitis. Hemorrhagic Occlusive Retinal Vasculitis HORV Hemorrhagic occlusive retinal vasculitis, including permanent loss of vision, occurred in patients receiving intracameral or intravitreal administration of vancomycin during or after cataract surgery.
Serial tests of auditory function may be helpful in order to minimize the risk of ototoxicity. Carcinogenesis, Mutagenesis, Impairment of Fertility Although no long-term studies in animals have been performed to evaluate carcinogenic potential, no mutagenic potential of vancomycin hydrochloride for injection was found in standard laboratory tests. Pregnancy Teratogenic Effects Animal reproduction studies have not been conducted with vancomycin.
It is the drug of choice for the treatment of infections due to methicillin-resistant staphylococci, Corynebacterium jeikeium , and resistant strains of Streptococcus pneumoniae. Vancomycin is an alternative drug for serious staphylococcal and streptococcal infections, including endocarditis, when allergy precludes the use of penicillins and cephalosporins.
Vancomycin can cause two types of hypersensitivity reactions, the red man syndrome and anaphylaxis [ 2 ]. Red man syndrome is an infusion-related reaction peculiar to vancomycin [ 3 ].
It typically consists of pruritus, an erythematous rash that involves the face, neck, and upper torso. Less frequently, hypotension and angioedema can occur. Patients commonly complain of diffuse burning and itching and of generalized discomfort.
They can rapidly become dizzy and agitated, and can develop headache, chills, fever, and paresthesia around the mouth.
In severe cases, patients complain of chest pain and dyspnea. In many patients, the syndrome is a mild, evanescent pruritus at the end of the infusion that goes unreported. Signs of red man syndrome would appear about 4—10 min after an infusion started or may begin soon after its completion.
The reaction may not be of the same severity with successive exposures, but it can occur for the first time after several doses or with a slow infusion [ 4 ]. Delayed reactions at or near the end of a 90 or min infusion have been seen in patients who had been on vancomycin therapy for longer than 7 days without prior incident [ 5 ].
Most of the hospital protocols require vancomycin to be infused over 60 min, as a minimum [ 5 , 6 ]. Sporadic reports of red man syndrome following the administration of vancomycin via routes other than intravenously are also on the increase. Red man syndrome has been linked to intraperitoneal and oral administration of vancomycin [ 7 ].
Red man syndrome was in the past attributed to impurities found in vancomycin preparations, earning the drug the nickname 'Mississippi mud'. But reports of the syndrome persisted even after improvements in the compound's purity [ 5 ].
Studies have shown that an unknown percentage of the population may be prone to releasing a large amount of histamine in response to vancomycin [ 6 ].
The hypersensitivity reactions that can arise due to vancomycin are due to its effect on the mast cells. In tissue culture, vancomycin causes degranulation of peritoneal mast cells in rats [ 8 ]. The anaphylactic reaction is mediated by IgE.
Red man syndrome, an anaphylactoid reaction, is caused by the degranulation of mast cells and basophils, resulting in the release of histamine independent of preformed IgE or complement. The extent of histamine release is related partly to the amount and rate of the vancomycin infusion.
Clinical studies have shown that the plasma tryptase levels were not significantly elevated in confirmed anaphylactoid reactions, so they can be used to distinguish chemical reactions from immunologic reactions [ 9 ]. The most common hypersensitivity reaction associated with vancomycin is red man syndrome.
The incidence varies between 3. Studies of vancomycin also show that the most severe reactions occur in patients younger than the age of 40, particularly in children [ 6 ]. One explanation for these results is that an infection induces some histamine release as part of the natural immune response.
Having a higher histamine level to begin with is thought to downregulate vancomycin's effect on mast cells and basophils. No reaction occurred with a mg dose. Total histamine release was greater with the faster infusion. Antibiotics such as ciprofloxacin, amphotericinB, rifampcin and teicoplanin [ 14 ] can potentially cause red man syndrome.
Consider continuous infusion in critically ill patients or when unable to achieve therapeutic vancomycin levels with intermittent dosing — seek specialist advice. Switching from intermittent vancomycin dosing to a continuous infusion:.
Commence at the dose equivalent to the total daily dose administered in the previous 24 hour period. Dose adjustment If the steady state level is outside of the therapeutic range, adjust the dose according to the following formula:. The next dose is then given 6 hours after the loading dose.
Use actual body weight for dose calculations, including obese patients, up to the maximum recommended doses.
Take a trough level before the 2nd dose is due and with hold the dose until the result is known. Seek specialist advice for subsequent dosing. Vancomycin levels should be repeated until there are two consecutive levels within target range. After this, vancomycin levels can be repeated every 3 days or whenever there is a significant change in bodyweight, serum creatinine or if the dose has been adjusted. Vancomycin is potentially nephrotoxic and ototoxic especially when used in combination with other nephrotoxic or ototoxic agents eg aminoglycosides and in renal impairment.
These features develop quickly and usually subside within an hour but may persist for several hours in some cases. The Royal Children's Hospital Melbourne. Rapid infusion may cause red man syndrome see Adverse Effects section below Vancomycin levels are required to ensure that the target therapeutic range is achieved see Therapeutic Drug Monitoring section below Continuous infusions of vancomycin in infants aged 0 to 90 days are associated with earlier and improved attainment of target concentrations compared with intermittent dosing Dose Patient age Dosing regimen 0—90 days Continuous infusion recommended.
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