Description and indication for use

Vancomycin is a glycopeptide antibiotic derived from Amycolatopsis orientalis (formerly Nocardia orientalis). Vancomycin is bactericidal against many Gram -ve bacteria. It is used for suspected or proven MRSA infections or an infection caused by other organisms when sensitivity tests indicate no other antibiotic is available.

Dose

IV:

Severe infection

15 mg/kg/dose

Reconstitution/Dilution

Vial = 500 mg.

IV:

To reconstitute add 10 mL of water for injection to 500 mg vial = 50 mg/mL solution.

Withdraw exact dose required and add further dilute with sodium chloride 0.9% or glucose 5% to 5 mg/mL.  DO NOT USE glucose 10% for dilution.

Alternatively: Withdraw 1 mL of 50 mg/mL solution from the vial and add to 9 mL of Sodium Chloride 0.9% or Glucose 5% in a 10 mL syringe = 5 mg/mL. Withdraw required dose – no further dilution necessary.

* If fluid restricted can be diluted to 10 mg/mL and administered via central line only.

Reconstituted vial (50 mg/mL solution) is stable for 24 hours under refrigeration. 

Route and method of administration

Not to be given by IM or SC injection.

IV:

Using Minimum Volume Extension tubing and syringe pump, prime line with syringe containing exact dose of vancomycin.

Infuse over 2 hours (120 minutes).

Draw up 3 mL of Sodium Chloride 0.9% in a 10 mL syringe.  Following completion of the infusion, infuse 2 mLs of the Sodium Chloride 0.9% at the same infusion rate as Vancomycin to flush the line (set volume limit for 2 mLs). Following completion of infusion and flush, disconnect and discard line.

Side effects

Infusion related events - rapid bolus administration may cause:

Hypotension, tachycardia, cardiac arrest (rare), skin flushing, itch, thrombophlebitis (at injection site), “Red Man” Syndrome – flushing or rash on the upper body and neck, muscle spasm of the chest and back.

“Red Man” syndrome appears rapidly and resolves within minutes to hours of ceasing infusion.  If this occurs: cease infusion, re-check dosage and infusion rate.  Wait for symptoms to resolve.  Resume infusion at a slower rate.  Give all subsequent doses at the slower infusion rate.  Report and document the adverse reaction. 

Transient neutropenia, thrombocytopenia (rare), ototoxicity, nephrotoxicity (rare – most reports occur in patients with pre-existing hearing loss or renal impairment and when used in conjunction with other nephrotoxic or ototoxic agents), hypersensitivity reactions (chills, fever, rash).

Contraindications

Known hypersensitivity to Vancomycin.

Caution in patients allergic to Teicoplanin as allergic cross reactions have been reported.

Vancomycin is not indicated for the treatment of minor infections and infections for which other antibiotics are available.

Concurrent use of other ototoxic/nephrotoxic drugs, unless clearly indicated and closely monitored.

Special precautions

Renal impairment – careful monitoring of blood levels is recommended to guide adjustments of dose/dosage interval.

Compatible Solutions

Glucose 5% and 10%.

Sodium Chloride 0.9%.

Compatible with TPN (nutrient and intralipid solutions).

Compatible Drugs

Amikacin, Calcium Gluconate, Insulin, Midazolam, Morphine, Pancuronium Bromide, Pantoprazole, Potassium Chloride (20 mmol/L), Ranitidine.

Incompatibilities

Vancomycin must not be mixed together with the following drugs:

Adrenaline, Aminophylline, Cefotaxime, Dexamethasone, Heparin Sodium (at higher concentrations > 1 unit/mL), Phenobarbitone Sodium, Phenytoin Sodium, Sodium Bicarbonate.

Vancomycin is physically incompatible with beta-lactam antibiotics (eg: Benzylpenicillin, Ceftazidime, Ceftriaxone) – ensure IV lines are adequately flushed with Sodium Chloride 0.9% between administration of these antibiotics.

Drug interactions

Nursing responsibilities

Therapeutic Drug Monitoring:

Ensure serum trough (pre) levels are routinely monitored on commencement of treatment and after dosage changes, as outlined below:

When to monitor:

Neonates (normal renal function): sample immediately prior to 2^nd dose.

Neonates (renal dysfunction): take spot levels and repeat dose only when level is between 5 – 10 mg/L.

Therapeutic range: 10 – 15 mg/L.

Do not inject IM as it is very irritating to tissue, and can cause necrosis.

Infuse slowly to avoid reactions associated with rapid infusion and thrombophlebitis.

If extravasation occurs, check with medical staff regarding possibility of using hyaluronidase around the periphery of the affected area.

Visually inspect IV tubing for particulate matter/discoloration.

Observe urinary output.