Vancocin

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Vancocin

Classes

Glycopeptide Antibiotics
Intestinal Antibiotics

Administration

Oral Administration Oral Solid Formulations

May be administered with or without food. Swallow whole; do not crush or chew.

Oral Liquid Formulations

Powder for oral solution
Shake well before each administration.
Measure dosage with a calibrated spoon, cup, or oral syringe.[62844]

Reconstitution
Available as a compounding kit containing 1 bottle of vancomycin powder and 1 bottle of grape-flavored diluent.
Various bottle sizes are available, which, when reconstituted, produce either a 25 or 50 mg/mL vancomycin oral solution. Select the appropriate bottle size/concentration for the individual patient.
Remove the cap from the bottle containing the vancomycin powder. Tap the top of the induction seal to loosen the powder. Slowly peel back the foil seal.
Shake the bottle containing grape-flavored diluent for a few seconds before removing the cap.
Open the diluent bottle and empty about half of the contents into the vancomycin powder bottle.
Replace the cap and shake the mixture vertically for approximately 45 seconds.
Add the remaining diluent into the vancomycin powder bottle.
Replace the cap and shake the bottle for approximately 30 seconds.
Storage: Store under refrigeration at 2 to 8 degrees C (36 to 46 degrees F); do not freeze. Discard any unused solution after 14 days. Keep container tightly closed and protect from light.[62844]

Extemporaneous Compounding-Oral

If a commercial oral product is not available, vancomycin powder for injection (not including ADD-Vantage vials) may be used for enteral administration. Dilute the appropriate dose in 1 ounce of water. Common flavoring syrups may be added to the solution to improve palatability. Prepare the solution just before administration. Administer orally or via a nasogastric tube.[40937]

Injectable Administration

Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.

Intravenous Administration

Intermittent IV Infusion
Powder vials for injection
Reconstitution
Reconstitute vials with Sterile Water for Injection to yield a 50 mg/mL solution.
Reconstitute the 250 mg vial with 5 mL of Sterile Water for Injection.
Reconstitute the 500 mg vial with 10 mL of Sterile Water for Injection.
Reconstitute the 750 mg vial with 15 mL of Sterile Water for Injection.
Reconstitute the 1,000 mg vial with 20 mL of Sterile Water for Injection.
Reconstitute the 1,250 mg vial with 25 mL of Sterile Water for Injection.
Reconstitute the 1,500 mg vial with 30 mL of Sterile Water for Injection.
Further dilution is required before administration.
Storage: Reconstituted vials may be stored in the refrigerator for up to 14 days.[40937] [63969]

Dilution
Further dilute the reconstituted solution with a compatible IV solution to a final concentration of 5 mg/mL.
Dilute the 250 mg reconstituted vial with 50 mL of infusion solution.
Dilute the 500 mg reconstituted vial with 100 mL of infusion solution.
Dilute the 750 mg reconstituted vial with 150 mL of infusion solution.
Dilute the 1,000 mg reconstituted vial with 200 mL of infusion solution.
Dilute the 1,250 mg reconstituted vial with 250 mL of infusion solution.
Dilute the 1,500 mg reconstituted vial with 300 mL of infusion solution.
A final concentration of 5 mg/mL is recommended for administration; however, a concentration of up to 10 mg/mL may be used in patients in need of fluid restriction. Higher concentrations may increase the risk of infusion-related reactions.
Storage: Solutions diluted with 5% Dextrose Injection or 0.9% Sodium Chloride Injection may be stored in the refrigerator for up to 14 days. Solutions diluted with 5% Dextrose Injection and 0.9% Sodium Chloride Injection, Lactated Ringer's Injection, Lactated Ringer's and 5% Dextrose Injection, Normosol-M and 5% Dextrose Injection, or Isolyte E may be stored in the refrigerator for up to 96 hours.[40937] [63969]

Bulk vials for injection
Reconstitution
Reconstitute vials with Sterile Water for Injection.
Reconstitute the 5 g vial with 100 mL of Sterile Water for Injection to yield a 500 mg/10 mL (50 mg/mL) solution.
Reconstitute the 10 g vial with 95 mL of Sterile Water for Injection to yield a 500 mg/5 mL (100 mg/mL) solution.
Penetrate the bulk vial once with a suitable sterile dispensing set that allows measured distribution of the contents. Use the entire contents of the bulk vial during reconstitution.
Further dilution is required before administration.
Storage: Once penetration of the bulk vial has occurred with the sterile dispensing set, withdraw contents promptly. A maximum of 4 hours from initial penetration may be allowed to complete fluid aliquoting/transferring operations before discarding the container.[40953] [40955]

Dilution
Further dilute the reconstituted solution with a compatible IV solution to a final concentration of 5 mg/mL. Concentrations of up to 10 mg/mL may be used in patients in need of fluid restriction; higher concentrations may increase the risk of infusion-related reactions.
Compatible fluids include 5% Dextrose Injection, 0.9% Sodium Chloride Injection, 5% Dextrose Injection and 0.9% Sodium Chloride Injection, Lactated Ringer's Injection, Lactated Ringer's and 5% Dextrose Injection, Normosol-M and 5% Dextrose Injection, or Isolyte E.
Storage: Specific storage instructions after dilution are not provided in the FDA-approved labeling for bulk products. Use compounded admixtures as soon as feasible.[40953] [40955] Product labeling for the vancomycin 1 g vials product states that solutions diluted in 5% Dextrose Injection or 0.9% Sodium Chloride Injection are stable for 96 hours under refrigeration.[40937]

ADD-Vantage IV solution
Reconstitution
Reconstitute only with 0.9% Sodium Chloride Injection or 5% Dextrose Injection in the appropriate flexible diluent container provided. For 500 mg vials, use at least a 100 mL diluent container and for 750 mg and 1 g vials, use only the 250 mL diluent container.
Remove the protective covers from the top of the vial and vial port. Remove vial cap (do not access with a syringe) and vial port cover. Screw the vial into the vial port until it will go no further to assure a seal. Once vial is sealed to the port, do not remove. To activate the contents of the vial, squeeze the bottom of the diluent container gently to inflate the portion of the container surrounding the end of the drug vial. With the other hand, push the drug vial down into the container telescoping walls of the container and grasp the inner cap of the vial through the walls of the container. Pull the inner cap from the drug vial. Verify the rubber stopper has been pulled out, allowing the drug and diluent to mix. Mix the container contents thoroughly.
Storage: The admixture solution may be stored for up to 24 hours at room temperature or in the refrigerator for up to 14 days.
Do not use in series connections with flexible containers.[40957]

Pre-mixed Galaxy IV solution
Preparation
Thaw frozen containers at room temperature (25 degrees C or 77 degrees F) or under refrigeration (5 degrees C or 41 degrees F). Do not force thaw by immersion in water baths or by microwave irradiation. Check for leaks by squeezing bag firmly.
Do not add supplementary medication.
Contents of the solution may precipitate in the frozen state and should dissolve with little or no agitation once the solution has reached room temperature.
Storage: The thawed solution is stable for 72 hours at room temperature or 30 days under refrigeration. Do not refreeze thawed product.
Do not use plastic containers in series connections as this could result in an embolism due to residual air being drawn from the primary container before administration of the fluid from the secondary container is complete.[40956]

Flexible bag IV solution
Preparation
Remove the flexible bag from the aluminum overpouch. Check for leaks by squeezing bag firmly.
Do not add supplementary medication.
Storage: The solution is stable for 28 days at room temperature (up to 25 degrees C or 77 degrees F) after removal from the aluminum overpouch.
Do not use flexible bags in series connections as this could result in an embolism due to residual air being drawn from the primary container before administration of the fluid from the secondary container is complete.[63968]

Intermittent IV infusion
Infuse over at least 1 hour to reduce the risk of infusion-related reactions. Larger loading doses may require extended infusion times (at least 2 to 3 hours).
Infusion rates of 10 to 15 mg/minute are recommended.[40937] [40953] [40955] [40957] [65262]

Plasmapheresis
Administer dose after plasmapheresis.[33359]

Continuous IV Infusion†
NOTE: Vancomycin is not FDA-approved to be administered by continuous IV infusion.
Reconstitution
Reconstitution for continuous infusion is not specifically discussed in the literature. Follow manufacturer instructions.[40937] [40953] [40955] [63969]

Dilution
A study in 12 adults used 1 or 2 g of vancomycin diluted in 1,000 mL of 0.9% Sodium Chloride Injection and infused over 24 hours. Doses were reconstituted less than 12 hours before infusion and refrigerated at 4 degrees C until administration.[40974]
A study in 10 adults used 2 g of vancomycin diluted in 250 mL of 5% Dextrose Injection and infused over 24 hours.[40975]
A study in 75 adults used 15 to 60 mg/kg/day, rounded to the nearest 250 mg dose, diluted in 500 mL of unspecified fluid and infused over 24 hours.[65316]
A study in 94 adults used 10 g of vancomycin diluted in 1,000 mL of 5% Dextrose Injection and infused over 24 to 48 hours.[65317] [65320]
A study in 60 adults used 40 to 60 mg/kg/day of vancomycin diluted in 50 mL of 5% Dextrose Injection and infused over 12 hours twice daily.[65318]
A study in 76 adults used 1 g of vancomycin diluted in 50 mL of unspecified fluid and infused 2 g at a rate of 4.2 mL/hour, 1 g at a rate of 2.1 mL/hour, and 500 mg at a rate of 1 mL/hour.[65319]
Stability:
A study used 10 g of vancomycin diluted in 1,000 mL of 5% Dextrose Injection.[65320]
Doses were stored at 4 degrees C until approximately 15 minutes before use. Doses were infused at room temperature for 24 to 48 hours. The concentration of vancomycin in the remaining fluid of the infusion sets was approximately equivalent to the initial concentration (10 g/L).
Additionally, samples of concentrated solutions (up to 83 g/L) were incubated at increasing temperatures up to 50 degrees C for up to 72 hours. Samples degraded less than 5% when kept for 72 hours at up to 37 degrees C. Samples exposed to 50 degrees C showed more than 7% degradation.

Continuous IV infusion
Continuous infusion regimens usually start after an initial loading dose.[65262]
Doses have been administered over 12 to 48 hours.[40974] [40975] [65316] [65317] [65318] [65319] [65320]

Vancomycin Desensitization†
NOTE: Vancomycin is not FDA-approved for desensitization.
NOTE: Once the desensitization process is complete, do not miss scheduled vancomycin doses to avoid drug-free periods, or the desensitization process will have to be repeated. Desensitization is required before any subsequent vancomycin use in hypersensitive patients as desensitization does not extend beyond the time frame that vancomycin has been stopped.[27463]
NOTE: Concomitant use of medications that may induce histamine response may lead to unsuccessful desensitization, and the use of these medications should be temporarily withheld, changed to an alternative, or given in restricted amounts. Medications that are potential histamine inducers included ciprofloxacin, barbiturates, opioids (fentanyl rarely induces histamine), neuromuscular antagonists (succinylcholine and benzylisoquinolinium compounds, not steroidal compounds), propofol, plasma expanders (dextran, polygeline), and radiocontrast agents.[27463]

Preparation and administration of infusions for rapid vancomycin desensitization (Lerner and Dwyer protocol) [27461]
Dilution
Prepare the standard solution by diluting 500 mg vancomycin in 250 mL of 0.9% Sodium Chloride Injection or 5% Dextrose Injection.
Label as "Infusion 5: vancomycin 2 mg/mL".
Draw 10 mL of the standard vancomycin 2 mg/mL solution and place in 100 mL 0.9% Sodium Chloride Injection or 5% Dextrose Injection.
Label as "Infusion 4: vancomycin 0.2 mg/mL".
Draw 10 mL of the vancomycin 0.2 mg/mL solution and place in 100 mL 0.9% Sodium Chloride Injection or 5% Dextrose Injection.
Label as "Infusion 3: vancomycin 0.02 mg/mL".
Draw 10 mL of the vancomycin 0.02 mg/mL solution and place in 100 mL 0.9% Sodium Chloride Injection or 5% Dextrose Injection.
Label as "Infusion 2: vancomycin 0.002 mg/mL".
Draw 10 mL of the standard vancomycin 0.002 mg/mL solution and place in 100 mL 0.9% Sodium Chloride Injection or 5% Dextrose Injection.
Label as "Infusion 1: vancomycin 0.0002 mg/mL".

Intermittent IV infusion
Give diphenhydramine and a corticosteroid 15 minutes before initiating the protocol, then every 6 hours throughout the protocol.
Administer the 5 infusions in succession at an initial rate of 30 mL/hour and increase by 30 mL/hour as tolerated every 5 minutes up to a maximum rate of 300 mL/hour.
If pruritus, hypotension, rash, or difficulty breathing occurs, stop the infusion and reinfuse the previously tolerated infusion at the highest tolerated rate. This step may be repeated up to 3 times for any given concentration.
Upon completion of Infusion 5, immediately administer the required dose of vancomycin over 2 hours. Decrease rate if the patient becomes symptomatic, or alternatively, increase rate if the patient tolerates dose.
Administer diphenhydramine 60 minutes before each subsequent dose.

Preparation and administration of infusions for slow vancomycin desensitization (Lin protocol) [27462]
Dilution
Day 1: 0.5 mg in 500 mL 0.9% Sodium Chloride Injection (0.001 mg/mL) IV infusion.
Day 2: 5 mg in 500 mL 0.9% Sodium Chloride Injection (0.01 mg/mL) IV infusion.
Day 3: 50 mg in 500 mL 0.9% Sodium Chloride Injection (0.1 mg/mL) IV infusion.
Day 4: 50 mg in 500 mL 0.9% Sodium Chloride Injection (0.1 mg/mL) IV infusion.
Day 5: 250 mg in 500 mL 0.9% Sodium Chloride Injection or 5% Dextrose Injection (0.5 mg/mL) IV infusion.
Day 6: 500 mg in 500 mL 0.9% Sodium Chloride Injection or 5% Dextrose Injection (1 mg/mL) IV.

Intermittent IV infusion
Concurrently start diphenhydramine and an H2-blocker with the first vancomycin dose, and continue at regular dosing intervals throughout the desensitization protocol.
Administer 1 infusion on 6 consecutive days at a rate of 100 mL/hour.
Administer the required vancomycin dose on day 7. Consider discontinuation of diphenhydramine and the H2-blocker.

Intrathecal Administration

NOTE: Vancomycin is not FDA-approved for intrathecal administration.
Reconstitution
Use preservative-free product.[61814]
A concentration of 10 mg in 1 mL of 0.9% Sodium Chloride Injection has been used.[65336]

Intrathecal injection†
Administer via lumbar puncture.

Other Injectable Administration

Intraventricular Administration†
NOTE: Vancomycin is not FDA-approved for intraventricular administration.
Reconstitution
Use preservative-free product.[61814]
Concentrations of 10 mg in 1 to 10 mL of 0.9% Sodium Chloride Injection have been used.[65335] [65336]

Intraventricular injection
Reports describe varying amounts of CSF aspirated into the syringe containing the vancomycin dose for instillation and potentially followed by a 2 mL flush of 0.9% Sodium Chloride Injection.[65334] [65335] [65337]
When administered through a ventricular drain, the drain should be clamped for 15 to 60 minutes to allow the antimicrobial solution to equilibrate in the CSF before opening the drain.[61814]

Rectal Administration Extemporaneous Compounding-Rectal

Retention Enema (using powder for injection)
Doses of 500 mg to 1 g diluted in volumes of 100 to 500 mL of 0.9% Sodium Chloride Injection have been utilized.[56690] [56692] [56693] [62877]
While no specific dilution instructions have been described, preparation of the enema per the instructions associated with each specific powder for injection product would seem warranted.
Stability should coincide with specific powder for injection product labeling.[40937] [40953] [40955] [63969]

Instillation
While guidelines do not provide specific instillation recommendations, a method of instilling the dose over 15 minutes with clamping of the tube for 1 to 2 hours has been described.[56692] Specific patient circumstances will likely dictate the duration of the dwell.

Adverse Reactions

Severe

renal failure (unspecified) / Delayed / 0-7.0
hearing loss / Delayed / Incidence not known
ototoxicity / Delayed / Incidence not known
azotemia / Delayed / Incidence not known
interstitial nephritis / Delayed / Incidence not known
cardiac arrest / Early / Incidence not known
vasculitis / Delayed / Incidence not known
anaphylactoid reactions / Rapid / Incidence not known
agranulocytosis / Delayed / Incidence not known
exfoliative dermatitis / Delayed / Incidence not known
toxic epidermal necrolysis / Delayed / Incidence not known
Stevens-Johnson syndrome / Delayed / Incidence not known
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) / Delayed / Incidence not known
acute generalized exanthematous pustulosis (AGEP) / Delayed / Incidence not known
C. difficile-associated diarrhea / Delayed / Incidence not known
hemorrhagic occlusive retinal vasculitis / Delayed / Incidence not known
visual impairment / Early / Incidence not known

Moderate

hypokalemia / Delayed / 13.0-13.0
neutropenia / Delayed / 2.0-12.0
peripheral edema / Delayed / 6.0-6.0
vancomycin infusion reaction / Rapid / Incidence not known
sinus tachycardia / Rapid / Incidence not known
hypotension / Rapid / Incidence not known
dyspnea / Early / Incidence not known
erythema / Early / Incidence not known
phlebitis / Rapid / Incidence not known
wheezing / Rapid / Incidence not known
thrombocytopenia / Delayed / Incidence not known
anemia / Delayed / Incidence not known
eosinophilia / Delayed / Incidence not known
constipation / Delayed / Incidence not known
superinfection / Delayed / Incidence not known
pseudomembranous colitis / Delayed / Incidence not known
depression / Delayed / Incidence not known

Mild

nausea / Early / 17.0-17.0
abdominal pain / Early / 15.0-15.0
fever / Early / 9.0-9.0
diarrhea / Early / 9.0-9.0
vomiting / Early / 9.0-9.0
flatulence / Early / 8.0-8.0
infection / Delayed / 8.0-8.0
headache / Early / 7.0-7.0
back pain / Delayed / 6.0-6.0
fatigue / Early / 5.0-5.0
dizziness / Early / Incidence not known
vertigo / Early / Incidence not known
tinnitus / Delayed / Incidence not known
pruritus / Rapid / Incidence not known
flushing / Rapid / Incidence not known
urticaria / Rapid / Incidence not known
paresthesias / Delayed / Incidence not known
injection site reaction / Rapid / Incidence not known
rash / Early / Incidence not known
chills / Rapid / Incidence not known
insomnia / Early / Incidence not known

Common Brand Names

FIRVANQ, Vancocin, Vancocin Powder, VANCOSOL

Dea Class

Description

Intravenous and oral glycopeptide antibiotic
Used intravenously for septicemia, infective endocarditis, skin and skin structure infections, bone infections, and lower respiratory tract infections and orally for C. difficile-associated diarrhea (CDAD) and enterocolitis due to S. aureus
Therapeutic drug monitoring recommended with intravenous therapy

Dosage And Indications

For the treatment of infective endocarditis. Intravenous dosage Adults

25 to 30 mg/kg (actual body weight) IV loading dose for seriously-ill patients, then 15 to 20 mg/kg/dose (actual body weight) IV every 8 to 12 hours per guidelines.[35013] [46693] [60294] The FDA-approved dosage is 500 mg IV every 6 hours or 1 g IV every 12 hours.[40956] Adjust dose based on serum concentrations. Doses are not likely to achieve successful outcomes if S. aureus MICs are more than 1 mcg/mL.[35013] [46693] Guidelines recommend vancomycin monotherapy for 4 weeks for native valve endocarditis (NVE) due to highly penicillin-susceptible Viridans group streptococci (VGS) and S. gallolyticus (bovis) infections or relatively penicillin-resistant VGS for patients unable to tolerate penicillins or ceftriaxone as well as penicillin-resistant VGS infections. Treat prosthetic valve endocarditis (PVE) caused by VGS for 6 weeks. Vancomycin may be used for 4 weeks for NVE and for 6 weeks for PVE caused by S. pneumoniae for patients intolerant of beta-lactams. Consider adding vancomycin and rifampin to cefotaxime or ceftriaxone for infections due to cefotaxime-resistant S. pneumoniae. Vancomycin for 4 to 6 weeks is an alternative for infections due to S. pyogenes in patients intolerant to beta-lactams. Vancomycin is also recommended for 6 weeks for NVE due to staphylococci for patients with anaphylactoid-type hypersensitivity reactions to beta-lactams or methicillin-resistant strains. Vancomycin plus rifampin for at least 6 weeks and gentamicin for 2 weeks is recommended for PVE caused by methicillin-resistant staphylococci. Use vancomycin plus gentamicin for 6 weeks for NVE or PVE due to penicillin-resistant Enterococcus in patients unable to tolerate a beta-lactam. For patients with acute (days) culture-negative NVE, vancomycin plus cefepime could be reasonable empiric therapy, and for patients with subacute (weeks) culture-negative NVE, vancomycin plus ampicillin; sulbactam could be reasonable empiric therapy. For patients with early (less than 1 year after surgery) culture-negative PVE, vancomycin plus cefepime, rifampin, and gentamicin could be reasonable empiric therapy, and for late culture-negative PVE, an initial treatment option could include ceftriaxone and vancomycin. Treat culture-negative endocarditis for 4 to 6 weeks.[60294]

Children and Adolescents

40 to 60 mg/kg/day IV divided every 6 to 12 hours is recommended by guidelines. Adjust dosage based on serum concentrations.[46693] [60295] A loading dose of 20 to 25 mg/kg IV may be considered in seriously ill patients.[46693] The FDA-approved dosage for pediatric patients is 40 mg/kg/day IV divided every 6 hours.[40937] Guidelines recommend gentamicin plus ampicillin; sulbactam with or without vancomycin for culture-negative, community-acquired native valve endocarditis (NVE) or late (more than 1 year after surgery) prosthetic valve endocarditis (PVE); alternately, vancomycin plus gentamicin may be used. Treat for 4 to 6 weeks for NVE and for 6 weeks with rifampin for PVE. Vancomycin plus gentamicin, cefepime, and rifampin (if prosthetic material is present) is recommended for culture-negative nosocomial endocarditis associated with vascular cannulae or early (less than 1 year after surgery) PVE; treat for 4 to 6 weeks, with a longer course for PVE. For endocarditis due to relatively penicillin-resistant streptococci, including enterococci, vancomycin, in combination with gentamicin for the first 2 weeks or the entire course for enterococci, is recommended as an alternative; vancomycin is also an alternative for streptococcal endocarditis highly susceptible to penicillin. For streptococcal endocarditis, treat for 4 weeks for NVE and 6 weeks for PVE; treat for 6 weeks for NVE and PVE due to enterococci. Vancomycin, with or without gentamicin for the first 3 to 5 days, is recommended for methicillin-resistant S. aureus endocarditis; vancomycin, with or without gentamicin for the first 3 to 5 days, is an alternative for staphylococcal endocarditis susceptible to or resistant to penicillin G. Add rifampin (for the entire course) plus gentamicin (for the first 2 weeks of therapy) for staphylococcal PVE. For native valve staphylococcal endocarditis susceptible to oxacillin, treat for 4 to 6 weeks. For native valve staphylococcal endocarditis resistant to oxacillin or prosthetic valve staphylococcal endocarditis, treat for at least 6 weeks.[60295]

Infants

60 mg/kg/day IV divided every 6 hours in combination with appropriate antimicrobial therapy depending on causative microorganism is recommended by guidelines. A loading dose of 20 to 25 mg/kg IV may be considered in seriously ill patients. Adjust dosage based on serum concentrations.[46693] The FDA-approved dosage for pediatric patients is 40 mg/kg/day IV divided every 6 hours.[40937]

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours is recommended by the American Academy of Pediatrics (AAP).[63245] The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.[40937] The dosing interval of vancomycin may need to be extended in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587]

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours is recommended by the American Academy of Pediatrics (AAP).[63245] The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.[40937] The dosing interval of vancomycin may need to be extended in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587]

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours is recommended by the American Academy of Pediatrics (AAP).[63245] The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.[40937] The dosing interval of vancomycin may need to be extended in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587]

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

For the treatment of pseudomembranous colitis due to C. difficile infection. For the treatment of initial episode of pseudomembranous colitis due to C. difficile infection and first recurrence in patients previously treated with metronidazole. Oral dosage Adults

125 mg PO 4 times daily for 10 days as a first-line therapy.[28468] [62844] [62877]

Infants, Children, and Adolescents

10 mg/kg/dose (Max: 125 mg/dose) PO 4 times daily for 10 days as a first or second line therapy. The FDA-approved dose is 40 mg/kg/day (Max: 2 g/day) PO divided 3 to 4 times daily for 7 to 10 days.

For the treatment of fulminant pseudomembranous colitis due to C. difficile infection. Oral dosage Adults

500 mg PO or via nasogastric tube 4 times daily with IV metronidazole. If clinical improvement after 48 to 72 hours, consider decreasing the dose to 125 mg PO every 6 hours for 10 days. If an ileus is present, consider adding vancomycin as a retention enema.[62877]

Infants, Children, and Adolescents

10 mg/kg/dose (Max: 500 mg/dose) PO 4 times daily for 10 days; consider adding metronidazole IV.

Rectal dosage† Adults

500 mg in 100 mL of 0.9% Sodium Chloride Injection rectally every 6 hours as adjunctive therapy if ileus present. Other dosing regimens have been described in case reports including 500 mg every 4 hours and 1 g every 8 to 12 hours. Volumes of 250 to 500 mL of 0.9% Sodium Chloride Injection have also been described. Decompression of the megacolon may also be beneficial.

Infants, Children, and Adolescents

Rectal vancomycin is suggested as adjunctive therapy; however, very limited dosing data are available. A case report in a 4-year-old boy with toxic megacolon due to C. difficile infection describes the use of rectal vancomycin 125 mg in 25 mL of 0.9% Sodium Chloride Injection 4 times daily for 1 month. Decompression of the megacolon may also be beneficial. A rectal vancomycin dose of 500 mg in 100 mL of 0.9% Sodium Chloride Injection every 6 hours is recommended in adults. Other dosing regimens have been described in case reports in adults including 500 mg every 4 hours and 1 g every 8 to 12 hours. These doses/volume (i.e., 500 mg in 100 mL of 0.9% Sodium Chloride Injection) may be acceptable for older children and adolescents of appropriate weight.

For the treatment of first recurrence of pseudomembranous colitis due to C. difficile infection in patients initially treated with vancomycin, metronidazole, or fidaxomicin. Oral dosage Adults

125 mg PO 4 times daily for 10 to 14 days, then 125 mg PO 2 times daily for 1 week, then 125 mg PO once daily for 1 week, then 125 mg PO every 2 to 3 days for 2 to 8 weeks, or alternately, 125 mg PO 4 times daily for 10 days.

Infants, Children, and Adolescents

10 mg/kg/dose (Max: 125 mg/dose) PO 4 times daily for 10 days.

For the treatment of second/subsequent episodes of pseudomembranous colitis due to C. difficile infection. Oral dosage Adults

125 mg PO 4 times daily for 10 days followed by rifaximin for 20 days, or 125 mg PO 4 times daily for 10 to 14 days, then 125 mg PO 2 times daily for 1 week, then 125 mg PO once daily for 1 week, then 125 mg PO every 2 to 3 days for 2 to 8 weeks.[62877] A 6-week tapered regimen has also been successful; 125 mg PO 4 times daily for 1 week, then 125 mg PO twice daily for 1 week, then 125 mg PO once daily for 1 week, then 125 mg PO every other day for 1 week, then 125 mg PO every 3 days for 2 weeks.

Infants, Children, and Adolescents

10 mg/kg/dose (Max: 500 mg/dose) PO 4 times daily for 10 days followed by rifaximin for 20 days, or 10 mg/kg/dose (Max: 125 mg/dose) PO 4 times daily for 10 to 14 days, then 10 mg/kg/dose (Max: 125 mg/dose) PO 2 times daily for 1 week, then 10 mg/kg/dose (Max: 125 mg/dose) PO once daily for 1 week, then 10 mg/kg/dose (Max: 125 mg/dose) PO every 2 to 3 days for 2 to 8 weeks.

For the treatment of third/subsequent episodes of pseudomembranous colitis due to C. difficile infection prior to fecal microbiota transplantation. Oral dosage Adults

125 mg PO 4 times daily for 10 days.

For the treatment of pseudomembranous colitis due to C. difficile infection in patients with inflammatory bowel disease (IBD). Oral dosage Adults

125 mg PO 4 times daily for at least 14 days.

For the treatment of pseudomembranous colitis due to C. difficile infection when no oral treatment is possible†. Rectal dosage† Adults

250 mg rectally once daily to 1,000 mg rectally 4 times daily with or without intravenous metronidazole or tigecycline.

For the treatment of enterocolitis due to S. aureus. Oral dosage Adults

500 mg to 2 g/day PO divided 3 to 4 times daily for 7 to 10 days.

Infants, Children, and Adolescents

40 mg/kg/day (Max: 2 g/day) PO divided 3 to 4 times daily for 7 to 10 days.

For the treatment of bacteremia and sepsis. For the treatment of bacteremia. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day); adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

Continuous Intravenous Infusion dosage†

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.[65262]

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia.

Infants, Children, and Adolescents

10 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 15 to 25 mcg/mL. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years. MRSA guidelines recommend a treatment duration of at least 2 weeks for uncomplicated bacteremia and 4 to 6 weeks for complicated bacteremia.

Neonates

For the treatment of sepsis. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours; adjust dose based on target PK/PD parameter. Start within 1 hour for septic shock or within 3 hours for possible sepsis without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. The FDA-approved dosage is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day); adjust dose based on target PK/PD parameter. Start within 1 hour for septic shock or within 3 hours for possible sepsis without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. The FDA-approved dosage is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.[64985] The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.[64985] The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.[64985] The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.[64985] The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.[64985] The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. Neonates younger than 37 weeks gestational age were excluded from guideline scope.[64985] The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. Neonates younger than 37 weeks gestational age were excluded from guideline scope.[64985] The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. Neonates younger than 37 weeks gestational age were excluded from guideline scope.[64985] The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

Continuous Intravenous Infusion dosage†

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.[65262]

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L. Start within 1 hour for septic shock or within 3 hours for possible sepsis without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.

Infants, Children, and Adolescents

10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.[64985]

Neonates

10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. Neonates younger than 37 weeks gestational age were excluded from guideline scope.[64985]

For the treatment of skin and skin structure infections, including cellulitis, erysipelas, skin abscesses, furunculosis, carbuncle, burn wound infection, necrotizing infections, diabetic foot ulcer, pyomyositis, and surgical incision site infections. For the treatment of nonpurulent skin infections, such as cellulitis or erysipelas. Intravenous dosage Adults

15 to 20 mg/kg/dose (Max: 2,000 mg/dose) IV every 8 to 12 hours for 5 to 14 days; adjust dose based on target PK/PD parameter. The FDA-approved dose is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Infants, Children, and Adolescents

40 to 60 mg/kg/day IV divided every 6 hours (Max: 2,000 mg/dose) for 5 to 14 days; adjust dose based on target PK/PD parameter.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 5 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 5 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 5 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

For the treatment of complicated skin infections, such as traumatic wound infection, burn wound infection, and infected ulcers. Intravenous dosage Adults

15 to 20 mg/kg/dose (Max: 2,000 mg/dose) IV every 8 to 12 hours for 7 to 14 days; adjust dose based on target PK/PD parameter. The FDA-approved dose is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Infants, Children, and Adolescents

60 mg/kg/day IV divided every 6 hours (Max: 2,000 mg/dose) for 7 to 14 days; adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 7 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 7 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 7 to 14 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

For the treatment of diabetic foot ulcer. Intravenous dosage Adults

15 to 20 mg/kg/dose (Max: 2,000 mg/dose) IV every 8 to 12 hours for moderate or severe infections in patients with risk factors for methicillin-resistant S. aureus; adjust dose based on target PK/PD parameter. Continue treatment for up to 28 days if infection is improving but is extensive and resolving slower than expected or if patient has severe peripheral artery disease. The FDA-approved dosage is 500 mg IV every 6 hours or 1 g IV every 12 hours.

For the treatment of pyomyositis. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. The FDA-approved dose is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. The FDA-approved dose is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 14 to 21 days plus ampicillin; sulbactam, piperacillin; tazobactam, or a carbapenem for patients with underlying conditions; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

For the treatment of surgical incision site infections. Intravenous dosage Adults

15 to 20 mg/kg/dose (Max: 2,000 mg/dose) IV every 8 to 12 hours for incisional surgical site infections of the axilla or perineum or the trunk or extremity away from the axilla or perineum; adjust dose based on target PK/PD parameter. The FDA-approved dose is 500 mg IV every 6 hours or 1 g IV every 12 hours.

For the treatment of necrotizing infections of the skin, fascia, and muscle. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. The FDA-approved dose is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. The FDA-approved dose is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies,

consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours as a part of broad empiric therapy, for methicillin-resistant S. aureus infections, or in patients with severe penicillin hypersensitivity and S. aureus or Streptococcus infections; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

For the treatment of purulent skin infections, such as furunculosis, carbuncle, skin abscess. Intravenous dosage Adults

15 to 20 mg/kg/dose (Max: 2,000 mg/dose) IV every 8 to 12 hours for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter. The FDA-approved dose is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Infants, Children, and Adolescents

40 to 60 mg/kg/day IV divided every 6 hours (Max: 2,000 mg/dose) for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for 5 to 10 days plus incision and drainage; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

For the treatment of mastitis. Intravenous dosage Adults

15 mg/kg/dose IV every 12 hours for 10 to 14 days.

For the treatment of neonatal mastitis. Intravenous dosage Infants 1 to 2 months

40 to 60 mg/kg/day IV divided every 6 hours. [57437] [64275]

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours.[57437] [64275]

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours.[57437] [64275]

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours.[57437] [64275]

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours.[57437] [64275]

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours.[57437] [64275]

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours.[57437] [64275]

For the treatment of serious gram-positive infections, including lower respiratory tract infections (LRTIs) such as community-acquired pneumonia (CAP), nosocomial pneumonia, and pleural empyema†. For the treatment of nonspecific LRTIs. Intravenous dosage Adults

Obese Adults

Children and Adolescents 12 to 17 years

Obese Children and Adolescents 12 to 17 years

Infants and Children 3 months to 11 years

Obese Infants and Children 3 months to 11 years

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. The FDA-approved dose is 40 mg/kg/day IV divided every 6 hours.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.[63969] The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.[63969] The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587]

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The FDA-approved dose is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.[63969] The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587]

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

Continuous Intravenous Infusion dosage†

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.[65262]

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L.

Infants, Children, and Adolescents

Neonates

For the treatment of community-acquired pneumonia (CAP). Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours for at least 7 days; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter.

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours for at least 7 days; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours for at least 7 days; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

Continuous Intravenous Infusion dosage†

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L for at least 7 days.

Infants, Children, and Adolescents

10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL for at least 7 days. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.

Neonates

For the treatment of nosocomial pneumonia. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours for 7 days; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) for 7 days; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Children and Adolescents 12 to 17 years

Obese Children and Adolescents 12 to 17 years

Infants and Children 3 months to 11 years

Obese Infants and Children 3 months to 11 years

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours for at least 7 days; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

Continuous Intravenous Infusion dosage†

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L for at least 7 days.

Infants, Children, and Adolescents

Neonates

For the treatment of hospital-acquired or postprocedural pleural empyema†. Intravenous dosage Adults

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day); adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Treat for at least 2 weeks after drainage and defervescence as part of combination therapy.

Children and Adolescents 12 to 17 years

Obese Children and Adolescents 12 to 17 years

Infants and Children 3 months to 11 years

Obese Infants and Children 3 months to 11 years

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for at least 2 weeks after drainage and defervescence as part of combination therapy.

Continuous Intravenous Infusion dosage†

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L. Treat for a minimum of 2 weeks after drainage and defervescence as part of combination therapy.

Infants, Children, and Adolescents

10 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 15 to 25 mg/L. Treat for at least 2 weeks after drainage and defervescence as part of combination therapy. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.

For surgical infection prophylaxis†. Intravenous dosage Adults

15 mg/kg/dose IV as a single dose within 120 minutes prior to the surgical incision. No intraoperative redosing and a duration of prophylaxis less than 24 hours for most procedures are recommended. A longer prophylaxis duration of 48 hours for certain cardiothoracic procedures is controversial. Vancomycin is recommended as alternate therapy for patients with beta-lactam allergy undergoing cardiothoracic, hernia repair, neurosurgical, orthopedic, clean urologic, vascular, heart or lung transplantation, and plastic surgery procedures. Vancomycin is also recommended in combination with another appropriate antimicrobial (i.e., aminoglycoside, aztreonam, or fluoroquinolone) as alternate therapy for patients with beta-lactam allergy undergoing gastroduodenal, biliary tract, hysterectomy, urologic with prosthesis, and abdominal transplantation procedures.

Infants, Children, and Adolescents

15 mg/kg/dose IV as a single dose within 120 minutes prior to the surgical incision. No intraoperative redosing and a duration of prophylaxis less than 24 hours for most procedures are recommended. A longer prophylaxis duration of 48 hours for certain cardiothoracic procedures is controversial. Vancomycin is recommended as alternate therapy for patients with beta-lactam allergy undergoing cardiothoracic, hernia repair, neurosurgical, orthopedic, clean urologic, vascular, heart or lung transplantation, and plastic surgery procedures. Vancomycin is also recommended in combination with another appropriate antimicrobial (i.e., aminoglycoside, aztreonam, or fluoroquinolone) as alternate therapy for patients with beta-lactam allergy undergoing gastroduodenal, biliary tract, urologic with prosthesis, and abdominal transplantation procedures.

For the treatment of CNS infections†, including meningitis†, ventriculitis† (including shunt-related infections), brain abscess†, subdural empyema†, spinal epidural abscess†, and septic thrombosis of the cavernous or dural venous sinus†. For the treatment of meningitis† and ventriculitis†. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day); adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV may be considered in critically ill patients. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg IV may be considered in critically ill patients. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Infants 1 to 2 months

60 mg/kg/day IV divided every 6 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Neonates 8 days and older weighing more than 2 kg

15 mg/kg/dose IV every 6 to 8 hours; adjust dose based on target PK/PD parameter.[32690] [51871] Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587] Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Neonates 8 days and older weighing 1.2 to 2 kg

15 mg/kg/dose IV every 8 to 12 hours; adjust dose based on target PK/PD parameter.[51871] Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587] Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Neonates 8 days and older weighing less than 1.2 kg

15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter.[51871] Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587] Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Neonates 0 to 7 days weighing more than 2 kg

15 mg/kg/dose IV every 8 to 12 hours; adjust dose based on target PK/PD parameter. [51871] Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587] Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Neonates 0 to 7 days weighing 1.2 to 2 kg

15 mg/kg/dose IV every 12 to 18 hours; adjust dose based on target PK/PD parameter.[51871] Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587] Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Neonates 0 to 7 days weighing less than 1.2 kg

Continuous Intravenous Infusion dosage

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Infants, Children, and Adolescents

10 to 15 mg/kg/dose (20 mg/kg/dose in critically ill patients) IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 15 to 25 mcg/mL. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (aged 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Neonates

10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations. Treat for 10 to 14 days. In patients with repeatedly positive CSF cultures on appropriate therapy, treat for 10 to 14 days after the last positive culture. Add rifampin if MRSA is susceptible and prosthetic material is present. For pneumococcal meningitis, consider adding rifampin if ceftriaxone/cefotaxime MIC is more than 2 mcg/mL.

Intrathecal dosage (preservative-free formulations only) Adults

5 to 20 mg/day intrathecally; however, most studies have used a 10 or 20 mg dose. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Infants, Children, and Adolescents

5 to 20 mg/day intrathecally; however, most studies have used a 10 or 20 mg dose.[32690] [61814] Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Intraventricular dosage (preservative-free formulations only) Adults with slit ventricles with external ventricular drain output of less than 50 mL/24 hours

5 mg intraventricularly every third day. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with slit ventricles with external ventricular drain output of 50 to 100 mL/24 hours

5 mg intraventricularly every second day. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with slit ventricles with external ventricular drain output of 100 to 150 mL/24 hours

5 mg intraventricularly once daily. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with s lit ventricles with external ventricular drain output of 150 to 200 mL/24 hours

10 mg intraventricularly once daily. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with slit ventricles with external ventricular drain output of 200 to 250 mL/24 hours

15 mg intraventricularly once daily. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with normal size ventricles with external ventricular drain output of less than 50 mL/24 hours

10 mg intraventricularly every third day. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with normal size ventricles with external ventricular drain output of 50 to 100 mL/24 hours

10 mg intraventricularly every second day. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with normal size ventricles with external ventricular drain output of 100 to 150 mL/24 hours

10 mg intraventricularly once daily. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with normal size ventricles with external ventricular drain output of 150 to 200 mL/24 hours

15 mg intraventricularly once daily. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with normal size ventricles with external ventricular drain output of 200 to 250 mL/24 hours

20 mg intraventricularly once daily. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with enlarged ventricles with external ventricular drain output of less than 50 mL/24 hours

15 to 20 mg intraventricularly every third day. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with enlarged ventricles with external ventricular drain output of 50 to 100 mL/24 hours

15 to 20 mg intraventricularly every second day. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with enlarged ventricles with external ventricular drain output of 100 to 150 mL/24 hours

15 to 20 mg intraventricularly once daily. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with enlarged ventricles with external ventricular drain output of 150 to 200 mL/24 hours

20 to 25 mg intraventricularly once daily. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Adults with enlarged ventricles with external ventricular drain output of 200 to 250 mL/24 hours

25 to 30 mg intraventricularly once daily. Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

Infants, Children, and Adolescents

5 to 20 mg/day intraventricularly; however, most studies have used a 10 or 20 mg dose.[32690] [61814] Use in addition to systemic vancomycin therapy. Adjust dose as necessary based on vancomycin CSF concentrations and MIC of the organism.

For the treatment of brain abscess†, subdural empyema†, spinal epidural abscess†, and septic thrombosis of the cavernous or dural venous sinus† due to methicillin-resistant S. aureus†. Intravenous dosage Adults

Obese Adults

Children and Adolescents 12 to 17 years

Obese Children and Adolescents 12 to 17 years

Infants and Children 3 months to 11 years

Obese Infants and Children 3 months to 11 years

Infants 1 to 2 months

60 mg/kg/day IV divided every 6 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat with or without rifampin for 4 to 6 weeks.

Neonates 8 days and older weighing more than 2 kg

Neonates 8 days and older weighing 1.2 to 2 kg

Neonates 8 days and older weighing less than 1.2 kg

Neonates 0 to 7 days weighing more than 2 kg

15 mg/kg/dose IV every 8 to 12 hours; adjust dose based on target PK/PD parameter.[32690] [51871] Consider loading dose of 20 mg/kg IV. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587] Treat with or without rifampin for 4 to 6 weeks.

Neonates 0 to 7 days weighing 1.2 to 2 kg

Neonates 0 to 7 days weighing less than 1.2 kg

Continuous Intravenous Infusion dosage

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L. Treat with or without rifampin for 4 to 6 weeks.

Infants, Children, and Adolescents

Neonates

For vancomycin desensitization† in patients with vancomycin hypersensitivity who require vancomycin therapy.
NOTE: Several vancomycin desensitization protocols have been reported in the literature and are based on case reports or small case series.[27463] A couple of methods are described below.
For rapid vancomycin desensitization† (Lerner and Dwyer protocol). Intravenous dosage Adults

Administer 5 infusions in succession at an initial rate of 30 mL/hour and increase by 30 mL/hour as tolerated every 5 minutes (Max: 300 mL/hour). Infusion 1: 0.02 mg/100 mL IV; Infusion 2: 0.2 mg/100 mL IV; Infusion 3: 2 mg/100 mL IV; Infusion 4: 20 mg/100mL IV; Infusion 5: 500 mg/250 mL IV. Immediately administer the required vancomycin dose after Infusion 5. If the patient does not tolerate an infusion, stop the infusion and reinfuse at the previously tolerated infusion at the highest tolerated rate; may repeat this step up to 3 times for any given concentration.[27461] [27463]

For slow vancomycin desensitization† (Lin protocol). Intravenous dosage Adults

Administer 1 infusion on 6 consecutive days at a rate of 100 mL/hour. Infusion 1: 0.5 mg/500 mL IV; Infusion 2: 5 mg/500 mL IV; Infusion 3: 50 mg/500 mL IV; Infusion 4: 50 mg/500 mL IV; Infusion 5: 250 mg/500 mL IV; Infusion 6: 500 mg/500 mL IV. Administer the required vancomycin dose on day 7.

For perinatal Group B streptococcal infection prophylaxis† in persons allergic to penicillin. Intravenous dosage Adults

20 mg/kg/dose (Max: 2 g/dose) IV every 8 hours starting at the time of labor or rupture of membranes and continuing until delivery. Vancomycin is recommended as an alternative for persons with a high-risk or unknown penicillin allergy with a clindamycin-resistant Group B Streptococcus isolate. Antibiotics administered for at least 4 hours before delivery have been found to be highly effective at preventing the transmission of Group B Streptococcus.

Adolescents

For the empiric treatment of febrile neutropenia†. Intravenous dosage Adults

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day); adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Guidelines recommend vancomycin in patients at increased risk for MRSA or enterococcal infections.

Continuous Intravenous Infusion dosage

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.[65262]

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L. Guidelines recommend vancomycin in patients at increased risk for MRSA or enterococcal infections.

For the treatment of bone and joint infections, including osteomyelitis, infectious arthritis†, infectious bursitis†, and orthopedic device-related infection†. For the treatment of unspecified osteomyelitis due to methicillin-resistant S. aureus. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours for at least 8 weeks, which may be followed by long-term suppressive therapy; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. May consider the addition of rifampin; for patients with concurrent bacteremia, add rifampin after bacteremia clearance. The FDA-approved dosage is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) for at least 8 weeks, which may be followed by long-term suppressive therapy; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. May consider the addition of rifampin; for patients with concurrent bacteremia, add rifampin after bacteremia clearance. The FDA-approved dosage is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients.[46693] Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 40 mg/kg/day IV divided every 6 hours.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 12 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

20 mg/kg/dose IV loading dose, followed by 20 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

20 mg/kg/dose IV loading dose, followed by 15 mg/kg/dose IV every 24 hours; adjust dose based on target PK/PD parameter. The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. The FDA-approved dosage is 15 mg/kg/dose IV initially, then 10 mg/kg/dose IV every 12 hours for the first week of life, then increase to every 8 hours.

Continuous Intravenous Infusion dosage†

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.[65262]

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L for at least 8 weeks, which may be followed by long-term suppressive therapy. May consider the addition of rifampin; for patients with concurrent bacteremia, add rifampin after bacteremia clearance.

Infants, Children, and Adolescents 3 months to 17 years

10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.

Infants 1 to 2 months

10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.

Neonates

10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations.

For the treatment of infectious arthritis† due to methicillin-resistant S. aureus. Intravenous dosage Adults

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day); adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Treat for 1 to 2 weeks or until clinically improved, followed by oral step-down therapy for 2 to 4 weeks.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.

Infants 1 to 2 months

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

Continuous Intravenous Infusion dosage

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.[65262]

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L. Treat for 1 to 2 weeks or until clinically improved, followed by oral step-down therapy for 2 to 4 weeks.

Infants, Children, and Adolescents 3 months to 17 years

10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.

Infants 1 to 2 months

Neonates

10 to 15 mg/kg/dose IV loading dose, followed by 15 to 40 mg/kg/day continuous IV infusion, based on postmenstrual age and renal function, to achieve a steady-state concentration of 15 to 25 mcg/mL. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections. Study data have shown that continuous infusions are well tolerated in neonates and may also result in improved achievement of optimal target concentrations.

For the treatment of prosthetic joint infection† due to S. aureus. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours for 2 to 6 weeks plus rifampin followed by oral step-down therapy, which may be followed by long-term suppressive therapy; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) for 2 to 6 weeks plus rifampin followed by oral step-down therapy, which may be followed by long-term suppressive therapy; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Continuous Intravenous Infusion dosage†

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.[65262]

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L for 2 to 6 weeks plus rifampin followed by oral step-down therapy, which may be followed by long-term suppressive therapy.

For the treatment of spinal implant infection† due to methicillin-resistant S. aureus. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours plus rifampin followed by long-term suppressive therapy; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) plus rifampin followed by long-term suppressive therapy; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Continuous Intravenous Infusion dosage

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.[65262]

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L plus rifampin followed by long-term suppressive therapy.

For the treatment of native vertebral osteomyelitis due to Staphylococcus sp., beta-hemolytic Streptococcus sp., or P. acnes†. Intravenous dosage Adults

Obese Adults

Continuous Intravenous Infusion dosage† Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L for 6 weeks.

For the treatment of native vertebral osteomyelitis due to Enterococcus sp.. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours for 6 weeks; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Add an aminoglycoside for 4 to 6 weeks in patients with endocarditis or bacteremia; may consider shorter aminoglycoside duration in patients with bacteremia. The FDA-approved dosage is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) for 6 weeks; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Add an aminoglycoside for 4 to 6 weeks in patients with endocarditis or bacteremia; may consider shorter aminoglycoside duration in patients with bacteremia. The FDA-approved dosage is 500 mg IV every 6 hours or 1 g IV every 12 hours.

Continuous Intravenous Infusion dosage† Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L for 6 weeks. Add an aminoglycoside for 4 to 6 weeks in patients with endocarditis or bacteremia; may consider shorter aminoglycoside duration in patients with bacteremia.

For the treatment of prosthetic joint infection† due to Enterococcus sp.. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours for 4 to 6 weeks with or without an aminoglycoside, which may be followed by long-term suppressive therapy; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) for 4 to 6 weeks with or without an aminoglycoside, which may be followed by long-term suppressive therapy; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Continuous Intravenous Infusion dosage

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.[65262]

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L for 4 to 6 weeks with or without an aminoglycoside, which may be followed by long-term suppressive therapy.

For the treatment of prosthetic joint infection† due to beta-hemolytic Streptococcus sp. or P. acnes†. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours for 4 to 6 weeks, which may be followed by long-term suppressive therapy; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) for 4 to 6 weeks, which may be followed by long-term suppressive therapy; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Continuous Intravenous Infusion dosage

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.[65262]

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L for 4 to 6 weeks, which may be followed by long-term suppressive therapy.

For the treatment of infectious bursitis† due to methicillin-resistant S. aureus. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours for 2 to 3 weeks; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) for 2 to 3 weeks; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 2 to 3 weeks; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 2 to 3 weeks; adjust dose based on target PK/PD parameter. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.

Children 1 to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 2 to 3 weeks; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.

Obese Children 1 to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 2 to 3 weeks; adjust dose based on target PK/PD parameter. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.

Continuous Intravenous Infusion dosage

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L for 2 to 3 weeks. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.

Children and Adolescents

10 to 20 mg/kg/dose IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL for 2 to 3 weeks. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (age 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years.

For the treatment of intraabdominal infections†, including peritonitis†, appendicitis†, intraabdominal abscess†, biliary tract infections† (cholecystitis†, cholangitis†), neonatal necrotizing enterocolitis†, spontaneous bacterial peritonitis†, and peritoneal dialysis-related peritonitis†. For the treatment of complicated community-acquired, healthcare-acquired, or hospital-acquired intraabdominal infections† with adequate source control. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day); adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hour

s (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.

Neonates older than 28 weeks gestation and SCr less than 0.7 mg/dL

Neonates older than 28 weeks gestation and SCr 0.7 to 0.9 mg/dL

Neonates older than 28 weeks gestation and SCr 1 to 1.2 mg/dL

Neonates 28 weeks gestation and younger and SCr less than 0.5 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.5 to 0.7 mg/dL

Neonates 28 weeks gestation and younger and SCr 0.8 to 1 mg/dL

Continuous Intravenous Infusion dosage

NOTE: Guidelines recommend that continuous infusion regimens may be a reasonable alternative when the AUC target cannot be achieved with conventional intermittent infusion dosing.

Adults

15 to 20 mg/kg/dose IV loading dose, followed by 30 to 60 mg/kg/day continuous IV infusion to achieve a steady-state concentration of 20 to 25 mg/L. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.

Infants, Children, and Adolescents

10 to 15 mg/kg/dose (20 mg/kg/dose in critically ill patients) IV loading dose, followed by continuous IV infusion of 30 to 60 mg/kg/day IV to achieve a steady-state concentration of 15 to 25 mcg/mL. Pediatric patients younger than 8 years have been shown to require higher doses than older patients to achieve target vancomycin serum concentrations. In a study in 240 pediatric patients (aged 31 days and older) converted to a continuous infusion regimen, the mean doses required to achieve a vancomycin serum concentration of 15 to 20 mg/L were approximately 50 mg/kg/day IV in patients 8 years and younger and approximately 45 mg/kg/day IV in patients older than 8 years. Treat for 3 to 7 days as part of combination therapy. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.

Neonates

For the treatment of peritoneal dialysis-related peritonitis†. Intermittent Intraperitoneal dosage† Adults

15 to 30 mg/kg/dose intraperitoneally every 5 to 7 days; adjust dose based on serum concentration target of more than 15 mcg/mL. Supplemental doses may be needed for automated PD. Treat for 14 to 21 days.

Infants, Children, and Adolescents

30 mg/kg/dose intraperitoneally once, followed by 15 mg/kg/dose every 3 to 5 days; adjust dose based on serum concentration and redose when less than 15 mcg/mL. Treat for 14 to 21 days.

Continuous Intraperitoneal dosage† Adults

30 mg/kg/bag intraperitoneal loading dose, followed by 1.5 mg/kg/bag in each dialysate exchange. Treat for 14 to 21 days.

Infants, Children, and Adolescents

1,000 mg/L intraperitoneal loading dose, followed by 25 mg/L in each dialysate exchange. Treat for 14 to 21 days.

For the treatment of uncomplicated intraabdominal infections†. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours. Consider loading dose in critically ill patients. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day). Consider loading dose in critically ill patients. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day). Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day). Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day). Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day). Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.

For the treatment of spontaneous bacterial peritonitis†. Intravenous dosage Adults

Obese Adults

For the treatment of systemic anthrax† infection. Intravenous dosage Adults

60 mg/kg/day IV divided every 8 hours. Maintain vancomycin serum trough concentrations of 15 to 20 mg/L. Vancomycin, in combination with a protein synthesis inhibitor (i.e., clindamycin, linezolid), is an alternative therapy for the treatment of systemic anthrax infection without CNS involvement in adults. Treatment should continue for at least 14 days or until clinical criteria for improvement are met. Prophylaxis to complete an antimicrobial course of up to 60 days will be required.

Infants, Children, and Adolescents

60 mg/kg/day IV divided every 8 hours. Adjust dose based on target PK/PD parameter. Vancomycin, in combination with appropriate antimicrobial therapy, is an alternative therapy for the treatment of systemic anthrax infection. For systemic infection without CNS involvement, dual combination IV therapy with vancomycin and a protein synthesis inhibitor (i.e., clindamycin, linezolid) is recommended. For documented or suspected CNS infection, triple IV therapy with vancomycin, a fluoroquinolone, and a protein synthesis inhibitor is recommended. For systemic infection in which meningitis can be excluded, treatment should continue for at least 14 days or until clinical criteria for improvement are met. For systemic infection in which meningitis cannot be excluded, treatment should continue for at least 2 to 3 weeks or until clinical criteria for improvement are met. Prophylaxis to complete an antimicrobial course of up to 60 days will be required in both cases.[57108]

Neonates 32 weeks gestation and older and SCr less than 0.7 mg/dL

20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 12 hours.[57108] [63245] The dosing of vancomycin may need to be adjusted in neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been suggested.[51586] [51587] Adjust dose based on target PK/PD parameter. Vancomycin, in combination with a protein synthesis inhibitor (i.e., clindamycin, linezolid), is an alternative therapy for the treatment of systemic anthrax infection without CNS involvement in neonates. Treatment should continue for at least 14 days or until clinical criteria for improvement are met. Prophylaxis to complete an antimicrobial course of up to 60 days will be required.[57108]

Neonates 32 weeks gestation and older and SCr 0.7 to 0.9 mg/dL

20 mg/kg IV loading dose, followed by 20 mg/kg/dose IV every 24 hours.[57108] [63245] Adjust dose based on target PK/PD parameter. Vancomycin, in combination with a protein synthesis inhibitor (i.e., clindamycin, linezolid), is an alternative therapy for the treatment of systemic anthrax infection without CNS involvement in neonates. Treatment should continue for at least 14 days or until clinical criteria for improvement are met. Prophylaxis to complete an antimicrobial course of up to 60 days will be required.[57108]

Neonates 32 weeks gestation and older and SCr 1 to 1.2 mg/dL

20 mg/kg IV loading dose, followed by 15 mg/kg/dose IV every 24 hours.[57108] [63245] Adjust dose based on target PK/PD parameter. Vancomycin, in combination with a protein synthesis inhibitor (i.e., clindamycin, linezolid), is an alternative therapy for the treatment of systemic anthrax infection without CNS involvement in neonates. Treatment should continue for at least 14 days or until clinical criteria for improvement are met. Prophylaxis to complete an antimicrobial course of up to 60 days will be required.[57108]

For the adjunctive treatment of severe diphtheria†. Intravenous dosage Adults

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day); adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Use in combination with IV penicillin G and a macrolide as an adjunct to diphtheria antitoxin.

Children and Adolescents 12 to 17 years

Obese Children and Adolescents 12 to 17 years

Infants and Children 3 months to 11 years

Obese Infants and Children 3 months to 11 years

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Use in combination with IV penicillin G and a macrolide as an adjunct to diphtheria antitoxin.

For bacterial infection prophylaxis† after penetrating central nervous system trauma. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV may be considered in critically ill patients. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, a loading dose of 20 to 35 mg/kg IV may be considered in critically ill patients. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.

Infants 1 to 2 months

60 mg/kg/day IV divided every 6 hours plus ciprofloxacin for 5 days or until CSF leak is closed, whichever is longer, as an alternative; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.

For secondary C. difficile infection prophylaxis† (i.e., long-term suppressive therapy†). Oral dosage Adults

125 mg PO once daily. May increase dose to 125 mg PO 2 or 3 times daily if patients continue to experience loose stools at lower doses. Secondary prophylaxis may be considered in patients who are not candidates for fecal microbiota transplantation, relapsed after fecal microbiota transplantation, require ongoing or frequent antibiotic courses, or are at high risk of recurrence during systemic antibiotic use.

For the treatment of chorioamnionitis† or intraamniotic infection†. Intravenous dosage Adults

20 mg/kg/dose (Max: 2,000 mg/dose) IV every 8 to 12 hours during the intrapartum period as part of alternative combination therapy. Give 1 additional dose after cesarean delivery; an additional dose is generally not needed after vaginal delivery. Other risk factors such as bacteremia or persistent postpartum fever may require additional therapy.

Adolescents

For the treatment of acute exacerbations of bronchiectasis†. Intravenous dosage Adults

20 to 35 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours for 14 days; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Obese Adults

20 to 25 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours (Usual Max: 4,500 mg/day) for 14 days; adjust dose based on target PK/PD parameter. Consider loading dose in critically ill patients.

Children and Adolescents 12 to 17 years

60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients.

Obese Children and Adolescents 12 to 17 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 days; adjust dose based on target PK/PD parameter.

Infants and Children 3 months to 11 years

60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 days; adjust dose based on target PK/PD parameter. Data are insufficient to recommend a loading dose in nonobese pediatric patients; however, based on adult studies, consider loading dose of 20 to 35 mg/kg IV in critically ill patients.

Obese Infants and Children 3 months to 11 years

20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for 14 days; adjust dose based on target PK/PD parameter.

Infants 1 to 2 months

45 to 60 mg/kg/day IV divided every 6 to 8 hours for 14 days; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients.

†Indicates off-label use

Dosing Considerations

Hepatic Impairment

Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.

Renal Impairment

Oral dosing
Specific guidelines for dosage adjustments of the oral formulation in renal impairment are not available; it appears no dosage adjustment is needed.[28468] [62844]

Intravenous dosing
The manufacturer's renal adjustment recommendations and conventional IV dosing nomograms will likely not lead to an appropriate AUC/MIC target of 400 to 600 mg x hour/L as defined by guidelines. Individualize IV dosage based on patient-specific factors and modify based on therapeutic drug monitoring.[65262]

Adult patients† [65347] [65348] [65349]
CrCl more than 65 mL/min per 70 kg: No dosage adjustment necessary.
CrCl 40 to 65 mL/min per 70 kg: Extend IV dosing interval to every 12 hours.
CrCl 20 to 39 mL/min per 70 kg: Extend IV dosing interval to every 24 hours.
CrCl 10 to 20 mL/min per 70 kg: Extend IV dosing interval to every 48 hours.

Infants, Children, and Adolescents† [32569]
GFR more than 50 mL/minute/1.73 m2: No initial adjustment; monitor serum concentrations.
GFR 30 to 50 mL/minute/1.73 m2: Extend IV dosing interval to every 12 hours
GFR 10 to 29 mL/minute/1.73 m2: Extend IV dosing interval to every 18 to 24 hours.
GFR less than 10 mL/minute/1.73 m2: Dose as needed per serum concentration monitoring.
Neonates older than 28 weeks gestation†
SCr less than 0.7 mg/dL: 15 mg/kg/dose IV every 12 hours.
SCr 0.7 to 0.9 mg/dL: 20 mg/kg/dose IV every 24 hours.
SCr 1 to 1.2 mg/dL: 15 mg/kg/dose IV every 24 hours.
SCr 1.3 to 1.6 mg/dL: 10 mg/kg/dose IV every 24 hours.
SCr more than 1.6 mg/dL: 15 mg/kg/dose IV every 48 hours.

Neonates 28 weeks gestation and younger†
SCr less than 0.5 mg/dL: 15 mg/kg/dose IV every 12 hours.
SCr 0.5 to 0.7 mg/dL: 20 mg/kg/dose IV every 24 hours.
SCr 0.8 to 1 mg/dL: 15 mg/kg/dose IV every 24 hours.
SCr 1.1 to 1.4 mg/dL: 10 mg/kg/dose IV every 24 hours.
SCr more than 1.4 mg/dL: 15 mg/kg/dose IV every 48 hours.

Intermittent hemodialysis
For IV dosing, maintaining predialysis serum vancomycin concentrations between 15 and 20 mg/L is likely to attain the AUC target of 400 to 600 mg x hour/L in the previous 24 hours with higher AUC/MIC values occurring on days prior. Predialysis serum concentration monitoring should be performed at least weekly and should drive subsequent dosing. Loading and maintenance doses should be based on the timing of the dose and dialyzer permeability. Vancomycin dosing data are limited in pediatric patients receiving hemodialysis; therefore, recommendations are based on guideline recommendations for adult patients.[65262]

Adult and Pediatric patients - dosing after dialysis ends† [65262]
Low permeability dialyzer: 25 mg/kg/dose (actual body weight) IV loading dose; 7.5 mg/kg/dose (actual body weight) IV maintenance dose (generally 3 times per week).
High permeability dialyzer: 25 mg/kg/dose (actual body weight) IV loading dose; 10 mg/kg/dose (actual body weight) IV maintenance dose (generally 3 times per week).

Adult and Pediatric patients - intradialytic dosing† [65262]
Low permeability dialyzer: 30 mg/kg/dose (actual body weight) IV loading dose; 7.5 to 10 mg/kg/dose (actual body weight) IV maintenance dose (generally 3 times per week).
High permeability dialyzer: 35 mg/kg/dose (actual body weight) IV loading dose; 10 to 15 mg/kg/dose (actual body weight) IV maintenance dose (generally 3 times per week).

Peritoneal dialysis†
Adult and Pediatric patients
Serum concentrations above 15 mcg/mL are recommended when administered intraperitoneally. Clearance of vancomycin by intermittent peritoneal dialysis is highly variable.[53190] [61676]

Continuous renal replacement therapy (CRRT)†
NOTE: Various CRRT modalities include continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), continuous venovenous hemodiafiltration (CVVHDF), continuous venovenous high-flux hemodialysis (CVVHFD), continuous arteriovenous hemofiltration (CAVH), continuous arteriovenous hemodialysis (CAVHD), and continuous arteriovenous hemodiafiltration (CAVHDF). Dosing should take into consideration patient-specific factors (e.g. intrinsic renal function), type of infection, the duration of renal replacement therapy, the effluent flow rate, and the replacement solution administered.[42303] For CRRT operating in an uninterrupted fashion, vancomycin clearance is relatively constant over the dosing interval, although clearance may decline as the hemodiafilter clogs over time. Vancomycin clearance is related closely to the rate of ultrafiltrate/dialysate flow.[65262] Definitive dosage recommendations have not been established in pediatric patients; therefore, recommendations are based on guideline recommendations for adult patients.[24879] [41118] [41119] [41120] [42303]

Adult and Pediatric patients
Loading doses of 20 to 25 mg/kg/dose (actual body weight) IV should be used in patients receiving CRRT at conventional, KDIGO-recommended effluent rates of 20 to 25 mL/kg/h. Initial maintenance doses with these effluent rates should be 7.5 to 10 mg/kg/dose (actual body weight) IV every 12 hours. Further maintenance dosing should be based on serum concentration monitoring conducted within the first 24 hours. In fluid overloaded patients, doses may be reduced as patients become euvolemic and drug Vd decreases. Continuous infusion vancomycin may be considered in these patients, especially when high CRRT ultrafiltrate/dialysate flow rates are employed.[65262]

Hybrid hemodialysis†
NOTE: Hybrid treatments include prolonged intermittent renal replacement therapy (PIRRT), sustained low-efficiency dialysis (SLED), slow extended daily dialysis/diafiltration (SLEDD-f), and extended daily dialysis (EDD). Dosing should take into consideration patient-specific factors (e.g. intrinsic renal function), the type of infection, the duration of renal replacement therapy, the ultrafiltration rate, the dialysis flow rate, and how often dialysis sessions occur.[65397]

Adult and Pediatric patients
NOTE: Vancomycin dosing data are limited in pediatric patients receiving hybrid hemodialysis; therefore, recommendations are based on guideline recommendations for adult patients.[65262]

Loading doses of 20 to 25 mg/kg/dose (actual body weight) IV and initial doses should not be delayed until the end of the dialysis session. Maintenance doses of 15 mg/kg/dose (actual body weight) IV should be administered after the dialysis session ends or during the final 60 to 90 minutes of dialysis. Concentration monitoring should guide further maintenance doses. Serum concentrations obtained 2 hours after the vancomycin infusion and immediately prior to PIRRT can be used to calculate the AUC for dosing modifications.[65262]

Drug Interactions

Acetaminophen; Ibuprofen: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Acyclovir: (Moderate) Closely monitor renal function if concomitant use with acyclovir and vancomycin is necessary. Both drugs can cause nephrotoxicity, which may be additive when used together.
Adefovir: (Moderate) Adefovir is eliminated renally by a combination of glomerular filtration and active tubular secretion; coadministration of adefovir dipivoxil with drugs that reduce renal function or compete for active tubular secretion, such as parenteral vancomycin, may decrease adefovir elimination by competing for common renal tubular transport systems, thereby increasing serum concentrations of adefovir and/or vancomycin. Additionally, chronic coadministration of adefovir with nephrotoxic drugs, such as vancomycin, may increase the risk of developing nephrotoxicity, even in patients who have normal renal function. Renal function should be monitored closely and vancomycin doses should be adjusted according to vancomycin serum concentrations.
Aldesleukin, IL-2: (Moderate) Aldesleukin may cause nephrotoxicity. Concurrent administration of drugs possessing nephrotoxic effects with Aldesleukin, such as vancomycin, may increase the risk of kidney dysfunction. In addition, reduced kidney function secondary to Aldesleukin treatment may delay elimination of concomitant medications and increase the risk of adverse events from those drugs.
Alfentanil: (Moderate) The concurrent administration of vancomycin and anesthetics, like alfentanil, has been associated with erythema, histamine-like flushing, and anaphylactoid reactions.
Amikacin: (Major) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as aminoglycosides, can lead to additive nephrotoxicity. Both vancomycin and aminoglycosides may cause ototoxicity as well. In a clinical study, vancomycin coadministration, high aminoglycoside trough concentrations, and heart failure independently predicted acute kidney injury during aminoglycoside treatment. Renal function should be monitored closely, and vancomycin and aminoglycoside doses should be adjusted according to serum concentrations as clinically indicated.
Aminoglycosides: (Major) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as aminoglycosides, can lead to additive nephrotoxicity. Both vancomycin and aminoglycosides may cause ototoxicity as well. In a clinical study, vancomycin coadministration, high aminoglycoside trough concentrations, and heart failure independently predicted acute kidney injury during aminoglycoside treatment. Renal function should be monitored closely, and vancomycin and aminoglycoside doses should be adjusted according to serum concentrations as clinically indicated.
Amlodipine; Celecoxib: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Amphotericin B lipid complex (ABLC): (Moderate) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as Amphotericin B, can lead to additive nephrotoxicity. Amphotericin B dosage reduction may be necessary if renal impairment occurs.
Amphotericin B liposomal (LAmB): (Moderate) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as Amphotericin B, can lead to additive nephrotoxicity. Amphotericin B dosage reduction may be necessary if renal impairment occurs.
Amphotericin B: (Moderate) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as Amphotericin B, can lead to additive nephrotoxicity. Amphotericin B dosage reduction may be necessary if renal impairment occurs.
Aprotinin: (Moderate) The manufacturer recommends using aprotinin cautiously in patients that are receiving drugs that can affect renal function, such as vancomycin, as the risk of renal impairment may be increased.
Atracurium: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bacitracin: (Moderate) Additive nephrotoxicity may occur with concurrent use of systemic bacitracin and other nephrotoxic agents. When possible, avoid concomitant administration of systemic bacitracin and other nephrotoxic drugs such as vancomycin. Renal function should be monitored closely and vancomycin doses should be adjusted according to vancomycin serum concentrations if these drugs must be used together.
Beractant: (Major) Some surfactant-anti-infective mixtures have been shown to affect the in vivo activity of exogenous pulmonary surfactants when they are administered via inhalation. Pulmonary surfactants, such as beractant should not be mixed with anti-infectives that are commonly administered via nebulization such as vancomycin.
Bleomycin: (Minor) Previous treatment with nephrotoxic agents, like vancomycin, may result in decreased bleomycin clearance if renal function has been impaired. Monitor for signs/symptoms of bleomycin toxicity in patients with concomittant or prior vancomycin therapy.
Bupivacaine; Meloxicam: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Calfactant: (Major) Some surfactant-anti-infective mixtures have been shown to affect the in vivo activity of exogenous pulmonary surfactants when they are administered via inhalation. Pulmonary surfactants should not be mixed with anti-infectives that are commonly administered via nebulization such as vancomycin.
Capreomycin: (Major) Since capreomycin is eliminated by the kidney, coadministration of with other potentially nephrotoxic drugs, including vancomycin, may increase serum concentrations of either drug. Theoretically, the chronic coadministration of these drugs may increase the risk of developing nephrotoxicity, even in patients who have normal renal function. Monitor patients for changes in renal function if these drugs are coadministered.
Celecoxib: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Celecoxib; Tramadol: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Chlorpheniramine; Ibuprofen; Pseudoephedrine: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Cholestyramine: (Major) The concurrent use of anion-exchange resins and oral vancomycin is contraindicated by clinical practice guidelines. Per FDA-approved labeling, administer other drugs at least 1 hour before or 4 to 6 hours after cholestyramine (or as great an interval as possible). Cholestyramine can bind other drugs, such as oral vancomycin, when given concurrently.
Cidofovir: (Contraindicated) The administration of cidofovir other potentially nephrotoxic agents, such as IV vancomycin, is contraindicated. These agents should be discontinued at least 7 days prior to beginning cidofovir.
Cisatracurium: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Cisplatin: (Moderate) Closely monitor renal function and audiometric testing if concomitant use with cisplatin and vancomycin is necessary. Both cisplatin and vancomycin can cause nephrotoxicity and ototoxicity, which may be additive when used together.
Clindamycin: (Moderate) Concomitant use of vancomycin and clindamycin may result in additive nephrotoxicity. Monitor for renal toxicity if concomitant use is required.
Colesevelam: (Major) The concurrent use of anion-exchange resins and oral vancomycin is contraindicated by clinical practice guidelines. Per FDA-approved labeling, administer other drugs at least 4 hours before colesevelam. Colesevelam can bind other drugs, such as oral vancomycin, when given concurrently.
Colestipol: (Major) The concurrent use of anion-exchange resins and oral vancomycin is contraindicated by clinical practice guidelines. Per FDA-approved labeling, administer other drugs at least 1 hour before or 4 hours after colestipol (or as great an interval as possible). Colestipol can bind other drugs, such as oral vancomycin, when given concurrently.
Colistimethate, Colistin, Polymyxin E: (Major) Since colistimethate sodium is eliminated by the kidney, coadministration with other potentially nephrotoxic drugs, including vancomycin, may increase serum concentrations of either drug. The chronic coadministration of these drugs may increase the risk of developing nephrotoxicity, even in patients who have normal renal function. Monitor patients for changes in renal function if these drugs must be coadministered.
Colistin: (Major) Since colistimethate sodium is eliminated by the kidney, coadministration with other potentially nephrotoxic drugs, including vancomycin, may increase serum concentrations of either drug. The chronic coadministration of these drugs may increase the risk of developing nephrotoxicity, even in patients who have normal renal function. Monitor patients for changes in renal function if these drugs must be coadministered.
Cyclosporine: (Minor) Additive nephrotoxicity can occur if cyclosporine is administered with other nephrotoxic drugs such as vancomycin. Renal function should be monitored closely and vancomycin doses should be adjusted according to vancomycin serum concentrations.
Deferasirox: (Moderate) Acute renal failure has been reported during treatment with deferasirox. Coadministration of deferasirox with other potentially nephrotoxic drugs, including vancomycin, may increase the risk of this toxicity. Monitor serum creatinine and/or creatinine clearance in patients who are receiving deferasirox and nephrotoxic drugs concomitantly.
Desogestrel; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Diclofenac: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Diclofenac; Misoprostol: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Dienogest; Estradiol valerate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Diflunisal: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Diphenhydramine; Ibuprofen: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Diphenhydramine; Naproxen: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Donepezil; Memantine: (Moderate) Cationic drugs that are eliminated by renal tubular secretion, such as vancomycin, may compete with memantine for common renal tubular transport systems, thus possibly decreasing the elimination of one of the drugs. Although theoretical, careful patient monitoring of response to memantine and/or vancomycin is recommended to assess for needed dosage adjustments. In selected individuals, vancomycin serum concentration monitoring may be appropriate.
Doravirine; Lamivudine; Tenofovir disoproxil fumarate: (Moderate) Tenofovir should be avoided with concurrent or recent use of a nephrotoxic agent, such as vancomycin. Patients receiving these drugs together should be carefully monitored for changes in serum creatinine and phosphorus. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir; a majority of cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents.
Drospirenone: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Drospirenone; Estetrol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Drospirenone; Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Drospirenone; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Drospirenone; Ethinyl Estradiol; Levomefolate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Efavirenz; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir should be avoided with concurrent or recent use of a nephrotoxic agent, such as vancomycin. Patients receiving these drugs together should be carefully monitored for changes in serum creatinine and phosphorus. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir; a majority of cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents.
Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir should be avoided with concurrent or recent use of a nephrotoxic agent, such as vancomycin. Patients receiving these drugs together should be carefully monitored for changes in serum creatinine and phosphorus. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir; a majority of cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents.
Elagolix; Estradiol; Norethindrone acetate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir should be avoided with concurrent or recent use of a nephrotoxic agent, such as vancomycin. Patients receiving these drugs together should be carefully monitored for changes in serum creatinine and phosphorus. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir; a majority of cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents.
Emtricitabine; Rilpivirine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir should be avoided with concurrent or recent use of a nephrotoxic agent, such as vancomycin. Patients receiving these drugs together should be carefully monitored for changes in serum creatinine and phosphorus. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir; a majority of cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents.
Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir should be avoided with concurrent or recent use of a nephrotoxic agent, such as vancomycin. Patients receiving these drugs together should be carefully monitored for changes in serum creatinine and phosphorus. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir; a majority of cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents.
Entecavir: (Moderate) Vancomycin and entecavir both undergo renal tubular secretion. Monitor patients closely for adverse events when these drugs are coadministered. Elevated serum concentrations of either drug may occur.
Estradiol; Levonorgestrel: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Estradiol; Norethindrone: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Estradiol; Norgestimate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Ethacrynic Acid: (Major) Vancomycin should be used cautiously with other ototoxic drugs such as ethacrynic acid.
Ethinyl Estradiol; Norelgestromin: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Ethinyl Estradiol; Norethindrone Acetate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Ethinyl Estradiol; Norgestrel: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Ethynodiol Diacetate; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Etodolac: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Etonogestrel; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Fenoprofen: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Fentanyl: (Moderate) The concurrent administration of vancomycin and anesthetics has been associated with erythema, histamine-like flushing, and anaphylactoid reactions. Infusion-related events may be minimized by the administration of vancomycin as a 60-minute infusion prior to anesthetic induction.
Flurbiprofen: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Foscarnet: (Major) The risk of renal toxicity may be increased if foscarnet is used in conjunction with other nephrotoxic agents such as parenteral vancomycin. Nephrotoxicity is also possible in patients receiving oral vancomycin for pseudomembranous colitis, should systemic absorption occur through significantly altered GI mucosa. Renal function should be monitored closely and vancomycin doses should be adjusted according to vancomycin serum concentrations.
Furosemide: (Moderate) Vancomycin should be used cautiously with other ototoxic drugs such as furosemide.
Ganciclovir: (Moderate) Concurrent use of nephrotoxic agents, such as vancomycin, with ganciclovir should be done cautiously to avoid additive nephrotoxicity. Renal function should be monitored closely and vancomycin doses should be adjusted according to vancomycin serum concentrations.
General anesthetics: (Moderate) The concurrent administration of vancomycin and anesthetics has been associated with erythema, histamine-like flushing, and anaphylactoid reactions.
Gentamicin: (Major) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as aminoglycosides, can lead to additive nephrotoxicity. Both vancomycin and aminoglycosides may cause ototoxicity as well. In a clinical study, vancomycin coadministration, high aminoglycoside trough concentrations, and heart failure independently predicted acute kidney injury during aminoglycoside treatment. Renal function should be monitored closely, and vancomycin and aminoglycoside doses should be adjusted according to serum concentrations as clinically indicated.
Gold: (Minor) Both vancomycin and gold compounds can cause nephrotoxicity. Auranofin has been reported to cause a nephrotic syndrome or glomerulonephritis with proteinuria and hematuria. Monitor renal function carefully during concurrent therapy.
Hyaluronidase, Recombinant; Immune Globulin: (Moderate) Immune Globulin (IG) products have been reported to be associated with renal dysfunction, acute renal failure, osmotic nephrosis, and death. Patients predisposed to acute renal failure include patients receiving known nephrotoxic drugs like vancomycin. Coadminister IG products at the minimum concentration available and the minimum rate of infusion practicable. Also, closely monitor renal function.
Hydrocodone; Ibuprofen: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Ibandronate: (Moderate) Theoretically, coadministration of intravenous ibandronate with other potentially nephrotoxic drugs like vancomycin may increase the risk of developing nephrotoxicity.
Ibuprofen: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Ibuprofen; Famotidine: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Ibuprofen; Oxycodone: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Ibuprofen; Pseudoephedrine: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Immune Globulin IV, IVIG, IGIV: (Moderate) Immune Globulin (IG) products have been reported to be associated with renal dysfunction, acute renal failure, osmotic nephrosis, and death. Patients predisposed to acute renal failure include patients receiving known nephrotoxic drugs like vancomycin. Coadminister IG products at the minimum concentration available and the minimum rate of infusion practicable. Also, closely monitor renal function.
Indomethacin: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Inotersen: (Moderate) Use caution with concomitant use of inotersen and vancomycin due to the risk of glomerulonephritis and nephrotoxicity.
Ketoprofen: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Ketorolac: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Lamivudine; Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir should be avoided with concurrent or recent use of a nephrotoxic agent, such as vancomycin. Patients receiving these drugs together should be carefully monitored for changes in serum creatinine and phosphorus. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir; a majority of cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents.
Leuprolide; Norethindrone: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Levonorgestrel: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Levonorgestrel; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Levonorgestrel; Ethinyl Estradiol; Ferrous Bisglycinate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma conc

entrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Levonorgestrel; Ethinyl Estradiol; Ferrous Fumarate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Lithium: (Moderate) Moderate to significant dietary sodium changes, or changes in sodium and fluid intake, may affect lithium excretion. Systemic sodium chloride administration may result in increased lithium excretion and therefore, decreased serum lithium concentrations. In addition, high fluid intake may increase lithium excretion. For patients receiving sodium-containing intravenous fluids, symptom control and lithium concentrations should be carefully monitored. It is recommended that patients taking lithium maintain consistent dietary sodium consumption and adequate fluid intake during the initial stabilization period and throughout lithium treatment. Supplemental oral sodium and fluid should be only be administered under careful medical supervision.
Lorazepam: (Moderate) The concurrent administration of vancomycin and anesthetics has been associated with erythema, histamine-like flushing, and anaphylactoid reactions.
Mannitol: (Major) Avoid use of mannitol and vancomycin, if possible. Concomitant administration of nephrotoxic drugs, such as vancomycin, increases the risk of renal failure after administration of mannitol.
Meclofenamate Sodium: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Mefenamic Acid: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Meloxicam: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Memantine: (Moderate) Cationic drugs that are eliminated by renal tubular secretion, such as vancomycin, may compete with memantine for common renal tubular transport systems, thus possibly decreasing the elimination of one of the drugs. Although theoretical, careful patient monitoring of response to memantine and/or vancomycin is recommended to assess for needed dosage adjustments. In selected individuals, vancomycin serum concentration monitoring may be appropriate.
Methohexital: (Moderate) The concurrent administration of vancomycin and anesthetics has been associated with erythema, histamine-like flushing, and anaphylactoid reactions.
Methotrexate: (Major) Avoid concomitant use of methotrexate with vancomycin due to the risk of additive nephrotoxicity as well as an increased risk of severe methotrexate-related adverse reactions. Recent exposure to vancomycin, in the absence of overt renal impairment, may also adversely affect methotrexate excretion and increase risk of toxicity. If concomitant use is unavoidable, closely monitor for adverse reactions. Vancomycin and methotrexate are both nephrotoxic drugs; methotrexate is also renally eliminated. Coadministration of methotrexate with vancomycin may result in decreased renal function as well as increased methotrexate plasma concentrations. In a case report, two patients who had received a methotrexate-containing chemotherapy regimen initially displayed appropriate methotrexate clearance. However, administration of vancomycin in between chemotherapy treatment cycles appears to have caused markedly prolonged methotrexate clearance (i.e., 170 to 231 hours to reach serum methotrexate concentrations of less than 0.2 micro-M). Subclinical renal impairment was documented in both cases following vancomycin administration, which eventually resolved; subsequent methotrexate cycles, of the same dose, showed appropriate clearance.
Mivacurium: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Nabumetone: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Naproxen: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Naproxen; Esomeprazole: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Naproxen; Pseudoephedrine: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Neuromuscular blockers: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Nonsteroidal antiinflammatory drugs: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Norethindrone Acetate; Ethinyl Estradiol; Ferrous fumarate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Norethindrone: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Norethindrone; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Norethindrone; Ethinyl Estradiol; Ferrous fumarate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Norgestimate; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Norgestrel: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Oral Contraceptives: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Oxaliplatin: (Major) Avoid coadministration of oxaliplatin with vancomycin due to the risk of increased oxaliplatin-related adverse reactions. Vancomycin is known to be potentially nephrotoxic; because platinum-containing drugs like oxaliplatin are eliminated primarily through the kidney, oxaliplatin clearance may be decreased by coadministration with nephrotoxic agents.
Oxaprozin: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Pamidronate: (Moderate) Coadministration of pamidronate with other nephrotoxic drugs, like vancomycin, may increase the risk of developing nephrotoxicity following pamidronate administration, even in patients who have normal renal function.
Pancuronium: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Paromomycin: (Major) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as aminoglycosides, can lead to additive nephrotoxicity. Both vancomycin and aminoglycosides may cause ototoxicity as well. In a clinical study, vancomycin coadministration, high aminoglycoside trough concentrations, and heart failure independently predicted acute kidney injury during aminoglycoside treatment. Renal function should be monitored closely, and vancomycin and aminoglycoside doses should be adjusted according to serum concentrations as clinically indicated.
Pentamidine: (Major) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as systemic pentamidine, can lead to additive nephrotoxicity. Renal function should be monitored closely and vancomycin doses should be adjusted according to vancomycin serum concentrations.
Piperacillin; Tazobactam: (Moderate) Piperacillin; tazobactam, when used concomitantly with vancomycin, may increase the risk of acute kidney injury. A limited number of retrospective studies have detected an increased incidence of acute kidney injury in patients administered concomitant piperacillin; tazobactam and vancomycin as compared to those who received vancomycin alone. Careful patient monitoring while on concurrent therapy with vancomycin is recommended.
Piroxicam: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Plazomicin: (Major) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as aminoglycosides, can lead to additive nephrotoxicity. Both vancomycin and aminoglycosides may cause ototoxicity as well. In a clinical study, vancomycin coadministration, high aminoglycoside trough concentrations, and heart failure independently predicted acute kidney injury during aminoglycoside treatment. Renal function should be monitored closely, and vancomycin and aminoglycoside doses should be adjusted according to serum concentrations as clinically indicated.
Polymyxin B: (Major) Systemic polymyxin B should not be used concurrently or sequentially with other drugs that have the potential for nephrotoxicity or neurotoxicity such as vancomycin. Topical products containing polymyxin B, especially when they are applied over a large body surface area, should be used cautiously with any of the above drugs. If concurrent systemic use is necessary, renal function should be monitored closely and vancomycin doses should be adjusted according to vancomycin serum concentrations. Diminishing urine output and a rising BUN are indications to discontinue systemic polymyxin B therapy.
Poractant Alfa: (Major) Some surfactant-anti-infective mixtures have been shown to affect the in vivo activity of exogenous pulmonary surfactants when they are administered via inhalation. Pulmonary surfactants should not be mixed with anti-infectives that are commonly administered via nebulization such as vancomycin.
Relugolix; Estradiol; Norethindrone acetate: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Remifentanil: (Moderate) The concurrent administration of vancomycin and anesthetics has been associated with erythema, histamine-like flushing, and anaphylactoid reactions.
Rocuronium: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Salicylates: (Minor) Due to the inhibition of renal prostaglandins by salicylates, concurrent use of salicylates and other nephrotoxic agents, such as vancomycin, may lead to additive nephrotoxicity.
Segesterone Acetate; Ethinyl Estradiol: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Sodium picosulfate; Magnesium oxide; Anhydrous citric acid: (Major) Prior or concomitant use of antibiotics with sodium picosulfate; magnesium oxide; anhydrous citric acid may reduce efficacy of the bowel preparation as conversion of sodium picosulfate to its active metabolite bis-(p-hydroxy-phenyl)-pyridyl-2-methane (BHPM) is mediated by colonic bacteria. If possible, avoid coadministration. Certain antibiotics (i.e., tetracyclines and quinolones) may chelate with the magnesium in sodium picosulfate; magnesium oxide; anhydrous citric acid solution. Therefore, these antibiotics should be taken at least 2 hours before and not less than 6 hours after the administration of sodium picosulfate; magnesium oxide; anhydrous citric acid solution.
Streptomycin: (Major) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as aminoglycosides, can lead to additive nephrotoxicity. Both vancomycin and aminoglycosides may cause ototoxicity as well. In a clinical study, vancomycin coadministration, high aminoglycoside trough concentrations, and heart failure independently predicted acute kidney injury during aminoglycoside treatment. Renal function should be monitored closely, and vancomycin and aminoglycoside doses should be adjusted according to serum concentrations as clinically indicated.
Streptozocin: (Moderate) Concomitant use of parenteral vancomycin with other nephrotoxic drug, such as streptozocin, can lead to additive nephrotoxicity.
Succinylcholine: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Sufentanil: (Moderate) The concurrent administration of vancomycin and anesthetics has been associated with erythema, histamine-like flushing, and anaphylactoid reactions.
Sulindac: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Sumatriptan; Naproxen: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Tacrolimus: (Moderate) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as tacrolimus, can lead to additive nephrotoxicity. Monitor renal function closely and adjust vancomycin or tacrolimus doses according to serum concentrations.
Tenofovir Alafenamide: (Moderate) Monitor for changes in renal function if tenofovir alafenamide is administered in combination with a nephrotoxic agent, such as vancomycin. Tenofovir is primarily excreted via the kidneys by a combination of glomerular filtration and active tubular secretion. Coadministration of tenofovir alafenamide with a drug that reduces renal function or competes for active tubular secretion may increase concentrations of tenofovir and other renally eliminated drugs; thus, increasing the risk of developing renal-related adverse reactions.
Tenofovir Disoproxil Fumarate: (Moderate) Tenofovir should be avoided with concurrent or recent use of a nephrotoxic agent, such as vancomycin. Patients receiving these drugs together should be carefully monitored for changes in serum creatinine and phosphorus. Renal impairment, which may include hypophosphatemia, has been reported with the use of tenofovir; a majority of cases occurring in patients who have underlying systemic or renal disease or who are concurrently taking nephrotoxic agents.
Tobramycin: (Major) Concomitant use of parenteral vancomycin with other nephrotoxic drugs, such as aminoglycosides, can lead to additive nephrotoxicity. Both vancomycin and aminoglycosides may cause ototoxicity as well. In a clinical study, vancomycin coadministration, high aminoglycoside trough concentrations, and heart failure independently predicted acute kidney injury during aminoglycoside treatment. Renal function should be monitored closely, and vancomycin and aminoglycoside doses should be adjusted according to serum concentrations as clinically indicated.
Tolmetin: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Tolvaptan: (Moderate) Coadministration of tolvaptan and hypertonic saline (e.g., 3% NaCl injection solution) is not recommended. The use of hypertonic sodium chloride in combination with tolvaptan may result in a too rapid correction of hyponatremia and increase the risk of osmotic demyelination (i.e., central pontine myelinolysis).
Trospium: (Moderate) Both trospium and vancomycin are eliminated by active renal tubular secretion; coadministration has the potential to increase serum concentrations of trospium or vancomycin due to competition for the drug elimination pathway. Careful patient monitoring and dosage adjustment of trospium and/or vancomycin is recommended.
Valacyclovir: (Moderate) Closely monitor renal function if concomitant use with valacyclovir and vancomycin is necessary. Both drugs can cause nephrotoxicity, which may be additive when used together.
Valdecoxib: (Minor) It is possible that additive nephrotoxicity may occur in patients who receive NSAIDs concurrently with other nephrotoxic agents, including vancomycin.
Valganciclovir: (Moderate) Concurrent use of nephrotoxic agents, such as vancomycin, with valganciclovir should be done cautiously to avoid additive nephrotoxicity.
Vecuronium: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Voclosporin: (Moderate) Concomitant use of voclosporin and vancomycin may result in additive nephrotoxicity. Monitor for renal toxicity if concomitant use is required.
Warfarin: (Moderate) The concomitant use of warfarin with many classes of antibiotics, including aminoglycosides, may result in an increased INR thereby potentiating the risk for bleeding. Inhibition of vitamin K synthesis due to alterations in the intestinal flora may be a mechanism; however, concurrent infection is also a potential risk factor for elevated INR. Monitor patients for signs and symptoms of bleeding. Additionally, increased monitoring of the INR, especially during initiation and upon discontinuation of the antibiotic, may be necessary.
Zoledronic Acid: (Moderate) Coadministration of zoledronic acid with other potentially nephrotoxic drugs, such as vancomycin, may increase serum concentrations of either drug and increase the risk of nephrotoxicity. Monitor patients for changes in renal function if these drugs are coadministered.

How Supplied

FIRVANQ/Vancocin/Vancomycin/Vancomycin Hydrochloride Oral Pwd F/Recon: 3.8g, 5mL, 7.7g, 15.4g, 250mg
Vancocin/Vancocin Powder/Vancomycin/Vancomycin Hydrochloride Intravenous Inj Pwd F/Sol: 1g, 1.25g, 1.5g, 5g, 10g, 100g, 250mg, 500mg, 750mg
Vancocin/Vancomycin/Vancomycin Hydrochloride Oral Cap: 125mg, 250mg
Vancomycin/Vancomycin Hydrochloride/Vancomycin Hydrochloride, Dextrose/Vancomycin Hydrochloride, Sodium Chloride/Vancomycin, Dextrose/Vancomycin, Sodium Chloride Intravenous Inj Sol: 1mL, 5mg, 1-0.9%, 1-5%, 500-0.9%, 500-5%, 750-0.9%, 750-5%
Vancomycin/Vancomycin Hydrochloride/VANCOSOL Intravenous Inj Pwd: 1g, 5g, 10g

Maximum Dosage

Adults

2 g/day IV/PO per FDA-approved labeling; individualize IV dosage to patient age, weight, indication for use, and serum drug concentration monitoring.

Geriatric

2 g/day IV/PO per FDA-approved labeling; individualize IV dosage to patient age, weight, indication for use, and serum drug concentration monitoring.

Adolescents

40 mg/kg/day IV and 2 g/day PO per FDA-approved product labeling; however, initial doses up to 60 mg/kg/day IV are recommended off-label for severe infections. Individualize IV dosage to patient age, weight, indication for use, and serum drug concentration monitoring.

Children

Infants

40 mg/kg/day IV/PO per FDA-approved product labeling; however, initial doses up to 60 mg/kg/day IV are recommended off-label for severe infections. Individualize IV dosage to patient age, weight, indication for use, and serum drug concentration monitoring.

Neonates

8 days and older: 30 mg/kg/day IV per FDA-approved product labeling; however, doses should be individualized based on patient age, weight, indication for use, and serum drug concentration monitoring.
0 to 7 days: 20 mg/kg/day IV per FDA-approved product labeling; however, doses should be individualized based on patient age, weight, indication for use, and serum drug concentration monitoring.

Mechanism Of Action

Vancomycin is bactericidal and appears to exert its effect by binding to the precursor units of bacterial cell walls, inhibiting their synthesis. It specifically binds with the D-alanyl-D-alanine terminus of the peptide precursor units, inhibiting peptidoglycan polymerase and transpeptidation reactions. This prevents cross-linking of the cell wall peptidoglycan during the second stage of cell synthesis. The net result is an alteration of bacterial cell wall permeability and cell death. In addition, RNA synthesis is inhibited. Vancomycin is not active in vitro to gram-negative organisms, mycobacteria, of fungi.[34153] [40937] [40938]

Vancomycin exhibits 'concentration-independent killing' in which there is saturation of the bacterial killing rate once the drug concentrations approach the minimum inhibitory concentration (MIC).[34142] [34143] [34144] [34145] An AUC/MIC ratio of 400 or more is necessary to achieve clinical effectiveness with vancomycin. In PK/PD models applicable to human methicillin-resistant S. aureus (MRSA) infection, bactericidal activity (i.e., a 1- to 2-log reduction in bacterial inoculum in the animal model) is achieved when the vancomycin AUC/MIC ratio approximates or exceeds 400. Additionally, in vitro data suggest that an AUC of less than 400 potentiates the emergence of MRSA resistance and vancomycin-intermediate S. aureus strains.[65262]

Most strains of S. aureus, S. epidermidis, Streptococcus sp., and Corynebacterium sp. are susceptible to vancomycin. Vancomycin is particularly useful against penicillin- and methicillin-resistant staphylococcal infections and for treating other gram-positive infections in beta-lactam-allergic patients. However, there are a few case reports of S. aureus strains that are insensitive to vancomycin.[34148] While, traditionally, vancomycin has been used to treat enterococcal infections, there is a significant resistance rate in these organisms. Vancomycin-resistant enterococci (VRE) rates up to 12.1% have been reported in bloodstream isolates and up to 25% of ICU enterococcal infections.[34149] [34150] Synergistic bactericidal effects can be achieved when vancomycin is combined with aminoglycosides against gram-positive organisms, but this increases possible toxicity. Vancomycin is useful against a wide variety of clinical infections due to these pathogens. When given orally, vancomycin is also useful in treating C. difficile.[62844]

The susceptibility interpretive criteria for vancomycin are delineated by pathogen. The MICs are defined for S. aureus as susceptible at 2 mcg/mL or less, intermediate at 4 to 8 mcg/mL, and resistant at 16 mcg/mL or more. The MICs are defined for Enterococcus sp. and Staphylococcus sp. other than S. aureus as susceptible at 4 mcg/mL or less, intermediate at 8 to 16 mcg/mL, and resistant at 32 mcg/mL or more.[63320] [63321] However, reports suggest that S. aureus isolates with vancomycin MICs of 1 to 2 mcg/mL may be less likely to be successfully treated with vancomycin.[35013] The MICs are defined for beta-hemolytic Streptococcus sp., viridans group Streptococcus sp., and S. pneumoniae as susceptible at 1 mcg/mL or less.[63320] [63321]

While vancomycin has been a predominant agent to treat gram-positive infections, increasing resistance has started to limit its utility. Vancomycin-resistant enterococci (VRE) is the most common resistant pathogen. There are 6 types of reported vancomycin resistance in enterococci (VanA, VanB, VanC, VanD, VanE, and VanG). Of these, 5 types are acquired resistance, while VanC is an intrinsic resistance found in E. gallinarum and E. casseliflavus. The most common type is VanA resistance. Once exposed to an inducer, like vancomycin, transcription of the enzymes that make the cell-wall precursors is altered. There is an increase in the cell-wall precursors ending in D-alanyl-D-lactate, to which vancomycin has a low binding affinity, and a decrease in the D-alanyl-D-alanine cell-wall precursors, to which vancomycin has a high binding affinity. This results in decreased binding of vancomycin to the receptor sites of the enterococcal cell wall. The genes for this resistance can potentially be spread to other bacteria via plasmids. Exposure to IV and oral vancomycin, antianaerobic antibiotics, and other broad-spectrum antibiotics have all been associated as factors contributing to VRE.[34152] [34153] S. aureus is another concerning organism with increasing resistance to vancomycin. Strains of vancomycin-intermediate S. aureus (VISA), heterogeneous vancomycin-intermediate S. aureus (hVISA), and vancomycin-resistance S. aureus (VRSA) have been described in the literature. Strains of VISA have shown an unusually thickened cell wall that prevents drug penetration. The cell wall also contains dipeptides that bind vancomycin. Fully resistant strains, VRSA, have acquired VanA resistance similar to Enterococcus sp.[34153] [34154] Guidelines suggest that exposure to vancomycin trough serum concentrations of less than 10 mg/L may produce S. aureus strains with VISA-like characteristics.[35013]

Pharmacokinetics

Vancomycin is administered intravenously for the treatment of systemic bacterial infections and orally for the treatment of some GI infections such as pseudomembranous colitis and enterocolitis. Vancomycin is not administered intramuscularly due to severe pain at the injection site.

Affected cytochrome P450 isoenzymes: none

Oral Route

Oral bioavailability of vancomycin is too low to treat systemic infections. Serum concentrations after oral administration are often undetectable even when inflammatory lesions are present. Patients with pseudomembranous colitis, however, may develop detectable serum concentrations after oral administration, especially if they have renal impairment. Due to poor oral bioavailability, oral doses of vancomycin are excreted mainly in the feces with urinary recovery not exceeding 0.76% of the dose.

Intravenous Route

The distribution half-life of vancomycin in adults is approximately 0.5 to 1 hour. After intravenous administration of 1,000 mg (15 mg/kg) over 1 hour, vancomycin plasma concentrations reach a peak of approximately 63 mcg/mL and fall to about 23 mcg/mL 2 hours after infusion, and 8 mcg/mL 11 hours after the end of the infusion. Multiple doses of 500 mg infused over 30 minutes produces mean serum concentrations of approximately 49 mcg/mL at the end of the infusion, 19 mcg/mL 2 hours after the infusion, and 10 mcg/mL 6 hours after the infusion. Vancomycin serum concentrations are highly variable and depend on many patient factors including age, size, fluid status, infection source/type, and renal function. Systemically administered vancomycin is distributed into most body tissues and fluids including pericardial fluid, pleural fluid, ascitic fluid, synovial fluid, urine, peritoneal dialysis fluid, and atrial appendage tissue. Concentrations obtained in tissues and fluids are variable and somewhat dependent on the degree of inflammation present. The volume of distribution coefficient is reported by the manufacturer as 0.3 to 0.43 L/kg; however, literature reports give a range of 0.2 to 1.9 L/kg. Unless the meninges are inflamed, there is little diffusion into CSF (0 to 3.45 mg/L) with corresponding CSF to serum ratios of 0 to 0.18. Inflamed meninges improve penetration into the CSF with reported concentrations of 6.4 to 11.1 mg/L with corresponding CSF to serum ratio of 0.36 to 0.46. Vancomycin is about 55% (range: 44% to 82%) bound to serum protein in healthy volunteers with normal renal function. There is no apparent metabolism of vancomycin. Excretion is mainly by glomerular filtration, with about 80% of the drug excreted in 24 hours in the urine and only small amounts excreted in the feces. In patients with normal renal function, vancomycin has a serum half-life of about 4 to 6 hours. Mean plasma clearance is approximately 0.058 L/kg/hour and mean renal clearance is approximately 0.048 L/kg/hour.

Other Route(s)

Peritoneal Route
Approximately 60% of an intraperitoneal vancomycin dose is absorbed systemically in 6 hours. Serum concentrations of approximately 10 mcg/mL are achieved by an intraperitoneal dose of 30 mg/kg.

Rectal Route (Retention Enema)
Similar to oral administration, patients with pseudomembranous colitis may develop detectable serum concentrations after rectal administration of retention enemas. Patients with renal impairment may be at a higher risk of systemic absorption.

Pregnancy And Lactation

Pregnancy

There are no available data on vancomycin use in pregnant women to assess a risk of major birth defects or miscarriage. Available published data on intravenous vancomycin use in pregnancy during the second and third trimesters have not shown an association with adverse maternal or fetal outcomes.[28468] [63969] The fetal risk of ototoxic and/or nephrotoxic effects from vancomycin when administered during pregnancy is considered to be low.[27016] [33052] Certain formulations of injectable vancomycin contain excipients, such as polyethylene glycol (PEG) 400 and N-acetyl-D-alanine (NADA), which have caused fetal malformations in animal reproductive studies. If vancomycin use is needed during pregnancy, utilize other available formulations.[63968] Systemic absorption of vancomycin is low after oral administration; however, absorption may vary depending on various factors.[28468] [63969] Vancomycin crosses the placenta and can accumulate in amniotic fluid. Cord blood concentrations in 1 newborn were about 76% of the mother's serum concentrations after the mother received vancomycin 1 g IV every 12 hours for 13 days; no maternal nephrotoxicity or ototoxicity was noted.[33051] Congenital abnormalities were not noted in newborns of mothers who received vancomycin 1 g IV every 12 hours for at least 1 week.[33052] In a study evaluating hearing loss and nephrotoxicity in infants of 10 pregnant women treated with IV vancomycin in the second or third trimester, no infant had abnormal sensorineural hearing at 3 months or nephrotoxicity. In a study of 55 pregnant women who received IV vancomycin at the time of delivery, no major adverse reactions were noted in the newborns or the mothers, including no sensorineural hearing loss. Neonatal renal function was not examined.[28468] [63969] Animal data do not demonstrate any risk of teratogenic or toxic effects on the fetus.[28468] [33050] [33054] [28468] [33053]

There is insufficient data on the presence of vancomycin in human milk. There are no data on the effects of vancomycin on the breast-fed infant or milk production. Systemic absorption of vancomycin is low after oral administration; therefore, it is unlikely to result in clinically relevant exposure in nursing infants.[28468] [62844] [63969] In 1 woman treated with intravenous vancomycin 1 g every 12 hours, a single breast-milk concentration of 12.7 mcg/mL was measured at 4 hours after infusion. Her peak and trough serum vancomycin concentrations were 36.1 mcg/mL and12.5 mcg/mL, respectively.[33052] Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for vancomycin and any potential adverse effects on the breast-fed infant from vancomycin or the underlying maternal condition.[28468] [62844] [63969]