VANCOMYCIN HYDROCHLORIDE

VANCOMYCIN HYDROCHLORIDE (van-koe-mye'sin) Vancocin Classifications: antibiotic; glycopeptide; Therapeutic: antibiotic Pregnancy Category: B

Availability

125 mg, 250 mg capsules; 1 g, 10 g oral powder; 500 mg, 1 g, 5 g, 10 g injection

Action

Bactericidal action is due to inhibition of cell-wall biosynthesis and alteration of bacterial cell-membrane permeability and ribonucleic acid (RNA) synthesis.

Therapeutic Effect

Active against many gram-positive organisms.

Uses

Parenterally for potentially life-threatening infections in patients allergic, nonsensitive, or resistant to other less toxic antimicrobial drugs. Used orally only in Clostridium difficile colitis (not effective by oral route for treatment of systemic infections).

Contraindications

Known hypersensitivity to vancomycin, allergy to corn or corn products, previous hearing loss, concurrent or sequential use of other ototoxic or nephrotoxic agents, IM administration.

Cautious Use

Neonates; children; older adults; impaired kidney function, renal failure, renal impairment, concomitant administration of aminoglycosides; hearing impairment; colitis, inflammatory disorders of the intestine; pregnancy (category B), lactation.

Route & Dosage

Systemic Infections Adult: IV 500 mg q6h or 1 g q12h, infuse over 60–90 min Child: IV 10 mg/kg q6h, infuse over 60–90 min Neonate: IV 15 mg/kg, then 10 mg/kg/d divided q8–12h, infuse over 60–90 min Clostridium difficile Colitis Adult: PO 125–500 mg q6h Child: PO 40 mg/kg/d divided q6h (max: 2 g/d) Neonate: PO 10 mg/kg/d in divided doses Renal Impairment Clcr 40–60 mL/min: dose q24h; <40 mL/min: extend interval based on monitoring levels Hemodialysis: Not dialyzed

Administration

Oral

• Oral solution is prepared by adding to 10 g oral powder 115 mL of distilled water. The solution may be further diluted in 10 g of water.

Intravenous PREPARE: Intermittent: Reconstitute 500 mg vial or 1 g vial with 10 mL or 20 mL, respectively, of sterile water for injection to yield 50 mg/mL. • Further dilute each 500 mg with at least 100 mL and each 1 g with at least 200 mL of D5W, NS, or RL.  ADMINISTER: Intermittent: Give a single dose at a rate of 10 mg/min or over NOT LESS than 60 min. Avoid rapid infusion, which may cause sudden hypotension. • Monitor IV site closely; necrosis and tissue sloughing will result from extravasation.  INCOMPATIBILITIES Solution/additive: Aminophylline, barbiturates, aztreonam (high concentration), calcium chloride, chloramphenicol, chlorothiazide, dexamethasone, erythromycin, heparin, methicillin, sodium bicarbonate, warfarin. Y-site: Albumin, amphotericin B cholesteryl, aztreonam, bivalirudin, cefazolin, cefepime, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, foscarnet, gatifloxacin, heparin, idarubicin, nafcillin, omeprazole, piperacillin/tazobactam, sargramostim, ticarcillin, ticarcillin/clavulanate, warfarin.

• Store oral and parenteral solutions in refrigerator for up to 14 d; after further dilution, parenteral solution is stable 24 h at room temperature.

Adverse Effects (≥1%)

Special Senses: Ototoxicity (auditory portion of eighth cranial nerve). Urogenital: Nephrotoxicity leading to uremia. Body as a Whole: Hypersensitivity reactions (chills, fever, skin rash, urticaria, shock-like state), anaphylactoid reaction with vascular collapse, superinfections, severe pain, thrombophlebitis at injection site, generalized tingling following rapid IV infusion. Hematologic: Transient leukopenia, eosinophilia. GI: Nausea, warmth. Other: Injection reaction that includes hypotension accompanied by flushing and erythematous rash on face and upper body ("red-neck syndrome") following rapid IV infusion.

Interactions

Drug: Adds to toxicity of ototoxic and nephrotoxic drugs (aminoglycosides, amphotericin B, colistin, capreomycin; cidofovir; cisplatin; cyclosporine; foscarnet; ganciclovir; IV pentamidine; polymyxin B; streptozocin; tacrolimus). Cholestyramine, colestipol can decrease absorption of oral vancomycin; may increase risk of lactic acidosis with metformin.

Pharmacokinetics

Absorption: Not absorbed. Peak: 30 min after end of infusion. Distribution: Diffuses into pleural, ascitic, pericardial, and synovial fluids; small amount penetrates CSF if meninges are inflamed; crosses placenta. Elimination: 80–90% of IV dose excreted in urine within 24 h; PO dose excreted in feces. Half-Life: 4–8 h.

Nursing Implications

Assessment & Drug Effects

• Monitor BP and heart rate continuously through period of drug administration.
• Lab tests: Monitor urinalysis, kidney & liver functions, and hematologic studies periodically. Monitor serial tests of vancomycin blood levels (peak and trough) in patients with borderline kidney function, in infants and neonates, and in patients >60 y.
• Assess hearing. Drug may cause damage to auditory branch (not vestibular branch) of eighth cranial nerve, with consequent deafness, which may be permanent.
• Be aware that serum levels of 60–80 mcg/mL are associated with ototoxicity. Tinnitus and high-tone hearing loss may precede deafness, which may progress even after drug is withdrawn. Older adults and those on high doses are especially susceptible.
• Monitor I&O: Report changes in I&O ratio and pattern. Oliguria or cloudy or pink urine may be a sign of nephrotoxicity (also manifested by transient elevations in BUN, albumin, and hyaline and granular casts in urine).

Patient & Family Education

• Notify physician promptly of ringing in ears.
• Adhere to drug regimen (i.e., do not increase, decrease, or interrupt dosage. The full course of prescribed drug therapy must be completed).

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Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; Canadian drug name; Prototype drug