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Drug dosage identifier

Vancomycin Hydrochloride

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Dose and administration

Postmenstrual age (weeks) Dose (mg/kg/dose) Dosing interval (hours)
≤28 15 24
29 to 35 15 12
≥36 15 8
  • Administer each dose over 1 to 2 hours.
  • Take serum trough level before 3rd dose. Adjust dose interval if necessary and continue to monitor trough levels : See Special Considerations below.

Contraindications

  • Intramuscular injection - must not be given by this route
  • Known hypersensitivity to vancomycin

Precautions

  • Infusion rate - must be given over 1 to 2 hours. See Possible adverse effects
  • Renal impairment - use with caution.
  • Concurrent therapy with nephrotoxic/ototoxic drugs. See Drug interactions
  • Preterm infants, especially those with extreme immaturity.
  • Hearing loss - avoid or use cautiously. Monitor levels.

Clinical pharmacology

Vancomycin is an glycopeptide antimicrobial, chemically unrelated to any other antimicrobial agent. Acting at a site different from other penicillins, vancomycin inhibits bacterial cell wall synthesis and may also cause secondary damage to the cytoplasmic membrane and inhibition of bacterial RNA synthesis.

It is bactericidal against many gram-positive organisms. In vitro susceptibility includes Listeria monocytogenes, and species of Lactobacillus, Actinomyces, Clostridium, and Bacillus.

Gram-negative bacteria, mycobacteria and fungi are resistant.

There are increasing reports of high-level acquired vancomycin resistance amongst enterococci with apparent resistance transfer to other Gram-positive organisms notably Staph. aureus.8 Organisms with high-level resistance to vancomycin demonstrate cross-resistance to teicoplanin. Low-level resistance in enterococci to vancomycin does not appear to be transferable to teicoplanin; however low-level resistance to staphylococcus strains shows cross-resistance to teicoplanin.

Vancomycin is administered intravenously and is poorly absorbed when given orally. There is no apparent metabolism and it is excreted unchanged by glomerular filtration. The mean elimination half-life from plasma is 4 to 6 hours in adults with normal renal function. Protein binding is approximately 55%. It does not readily diffuse across the meninges into the cerebrospinal fluid.

Possible adverse effects

  • Anaphylactoid reactions during or after infusion. Severe reactions may require treatment with adrenaline, corticosteroids & oxygen.
  • "Red man Syndrome" - flushing of upper body (red neck), or pain and muscle spasm of the chest & back. Associated with too rapid infusion.
  • Deafness
  • Hypotension, palpitations, tachycardia (associated with too rapid infusion)
  • Rash
  • Pain and thrombophlebitis as vancomycin is extremely irritant to the tissues. Dilute appropriately and rotate infusion sites.
  • Neutropenia (reversible on discontinuation), thrombocytopenia (rarely)
  • Renal failure

Drug interactions

The following are possible interactions with drugs commonly used in NICU:

  • Amikacin, amphotericin B, gentamicin, other aminoglycosides: nephrotoxicity
  • Dobutamine, dopamine, frusemide: decrease in vancomycin clearance due to increase in cardiac output.
  • Frusemide: ototoxicity.
  • Indomethacin: decrease in vancomycin clearance. May require a 50% reduction in vancomycin dose. Monitor vancomycin levels.
  • Suxamethonium: increase in neuromuscular blockade. This may be associated with too rapid administration of vancomycin. Use cautiously with other NMBAs.
  • Zidovudine: neutropenia. Use vancomycin cautiously with all drugs which may cause neutropenia. Monitor FBC.

Special considerations

  • Not to be administered intramuscularly. Vancomycin is irritant to tissues and can cause pain and possible necrosis.
  • Monitoring: (results are available within 3 hours)7
    Trough levels only are required.
    Take trough (within one hour prior to next dose): 10 - 15 mg/L.
    Peak levels are not required in patients with normal renal function. 

Management of Vancomycin administration

Description5

  • Vancomycin vials available as 500mg or 1000mg.
  • The vials contain vancomycin as a white powder for reconstitution. The solution is pH 2.5 - 4.5 when reconstituted with water, and has an osmolality at 5mg/ml of 249 mOsmol/kg (in glucose 5%) and 291 mOsmol/kg (in sodium chloride 0.9%).

Prescription

The maintenance dose is charted on the drug chart as mg/dose.

Administration3,5,8,9

  Vancomycin DBL  Vancomycin other brands
Powder space 0.5 ml 0.0ml
Water to be added 9.5 ml 10.0ml
  500 mg in 10.0 ml 500 mg in 10.0ml
  1. Use appropriate powder space and reconstitute vial with Water for Injection to give a solution of 50mg/ml.
  2. Then further dilute this solution to 5 mg/ml with sodium chloride 0.9% or glucose 5%.
  3. For fluid restricted patients a solution of 10mg/ml can be used, but this must be infused via a central line. The higher concentration increases the risk of infusion-related adverse events
  4. Each dose must be administered over at least one hour, preferably 2 hours. Can be infused through a 0.2 micron filter.
  5. As vancomycin is irritant to the tissues, avoid intramuscular injection and extravasation when given intravenously.
  6. Flush line with sodium chloride 0.9% before and after infusion.
  7. Incompatible with: blood or blood products, cefotaxime, cefoxitin, ceftazidime, cefuroxime, heparin.

Observation and documentation

  • Monitor renal output. Take serum trough levels as advised (see Special Considerations).
  • Monitor for adverse effects.
  • Notify medical staff of potential drug interactions.

Storage

  • Unopened - store at room temperature <25°C
  • After reconstitution: discard remaining contents immediately after use. Do not store reconstituted vials.

References

  1. Neonatal Formulary 6: drug use in pregnancy and first year of life, Compiled by Edmund Hey, BMJ publishing, Wiley-Blackwell 2007.
  2. Vancomycin Data sheet. Auckland: Pacific Pharmaceuticals Ltd; 2005.
  3. Paediatric Formulary. (5th ed.) Guy's, St. Thomas' and Lewisham Hospitals.
  4. Baxter K(ed). Stockley's Drug Interactions (7th ed.). London: Pharmaceutical Press, 2006.
  5. Trissel LA (ed). Handbook on Injectable Drugs (14th ed.). Bethesda: American Society
  6. Sweetman SC, (ed.).Martindale The Complete Drug Reference (35th ed.).London: Pharmaceutical Press, 2007.
  7. Auckland District Health Board. LabPlus Laboratory Handbook. Updated 6 December 2007.
  8. Fary R, Smith R, (eds.). Neonatal Pharmacopoeia (2nd ed.). Melbourne: Pharmacy Department, The Royal Women's Hospital, 2005.
  9. Kemp C, McDowell J (ed). Paediatric Pharmacopoeia (13th ed). Parkville, Melbourne: Pharmacy Department, Royal Children's Hospital, 2002.

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Document Control

  • Date last published: 30 March 2011
  • Document type: Drug Dosage Guideline
  • Services responsible: ADHB Pharmacy, Neonatology
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years