Pediatric Residents

Drug Name: Vancomycin

Click on the titles below for drug details

  • Glycopeptide antibiotic that binds to the D-alanyl-D-alanine precursor of cell walls, inhibiting the peptidoglycan polymerase and transpeptidation reactions and thus the crosslinking needed to keep the cell wall strong.
  • Bactericidal
  • Intravenous (intramuscular is painful)
    • Starting doses:
      • Bacteremia, skin and soft tissue infections:
        • <1 month: 15 mg/kg/dose q12hrs
        • 1 month-14 years: 15 mg/kg/dose q6hrs (max 1000 mg)
        • >14 years: 15 mg/kg/dose q8hrs (max 1500 mg)
      • Meningitis, osteomyelitis, endocarditis, pneumonia
        • <1 month: 15 mg/kg/dose q8hrs
        • >1 month: 15 mg/kg/dose q6hrs (max 1000 mg)
      • If abnormal renal function:
        • 15 mg/kg dose x 1 - check concentration at 8 hours
    • Therapeutic drug monitoring and future doses
      • Talk to your friendly pharmacist for more details about dosing and monitoring practices
      • We have moved from trough to area under the curve (AUC) monitoring for some indications due to studies showing reduced nephrotoxicity with the latter.
      • AUC24/MIC monitoring: For patients with confirmed or suspected MRSA and for patients with general infections (bacteremia, sepsis, febrile neutropenia, skin and soft tissue infections, pneumonia)
        • Goal AUC/MIC: 400-600 mg*hr/L
      • Trough only monitoring: For patients with non-MRSA infections or complicated MRSA infections (CNS infections, endocarditis, osteomyelitis, patients with renal dysfunction dosed by level)
        • Goal trough: 15-20 mcg/mL
  • Enteral (only for Clostridium difficile enteral infections)
    • 10 mg/kg/dose, 4 times daily, 7-10 days; Max 125mg/dose if non-severe, 500mg/dose for severe C. difficile
    • Dosage forms:
      • 125mg and 250mg capsule
      • 125mg/5mL and 250mg/5mL oral solution
  • Gram-positive (remember cell wall!) aerobes
    • Methicillin-resistant Staphylococcus aureus
    • Streptococcus pneumoniae
    • Corynebacteria
    • Enterococcus (note, would not cover "Vancomycin-Resistant Enterococcus " which includes some isolates of Enterococcus faecium)
  • Gram-positive anaerobes
    • Clostridium difficile
  • Not true contraindication but special monitoring if patient has acute kidney injury/renal failure: many will opt to change to another antibiotic
  • Acute kidney injury, especially when given with other nephrotoxins (NSAIDs; synergistic effect with piperacillin/tazobactam is controversial)
  • Vancomycin infusion syndrome: non-IgE mediated rate-dependent rash, generalized flushing, and pruritis
    • Usually occurs within first 10 minutes after start of infusion with first dose but may also occur at any time
    • Can mitigate by administering over 2-3 hours and administering diphenhydramine
    • The term "red man syndrome" should no longer be used due to racist connotations and its use leading to its under-labeling in certain populations (e.g., women, people of darker skin tones) leading to inequitable care
  • Does not get absorbed when taken enterally (why it is used for Clostridium difficile)
  • Advise families that if a rash, flushing, or itching is seen, it may not be a true allergy, but an infusion reaction.