From the Guidelines
Vancomycin is primarily indicated for serious infections caused by methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant coagulase-negative staphylococci, and for patients with severe penicillin allergies who cannot tolerate beta-lactam antibiotics. The most recent and highest quality study, 1, suggests that vancomycin continues to be the standard of care for most patients with MRSA bacteremia, despite being suboptimal for various reasons. Specific indications for vancomycin include:
- Complicated skin and soft tissue infections
- Bacteremia
- Endocarditis
- Pneumonia
- Osteomyelitis
- Meningitis caused by susceptible gram-positive organisms Vancomycin is also used for:
- Clostridioides difficile infections (administered orally)
- Surgical prophylaxis in patients with beta-lactam allergies
- Empiric therapy in healthcare settings with high MRSA prevalence The typical adult intravenous dosing is 15-20 mg/kg (actual body weight) every 8-12 hours, with adjustments based on renal function and therapeutic drug monitoring, as recommended by 1 and 1. Target trough concentrations are typically 10-15 μg/mL for most infections and 15-20 μg/mL for more severe infections like endocarditis, osteomyelitis, or meningitis, as suggested by 1 and 1. Vancomycin works by inhibiting bacterial cell wall synthesis by binding to D-alanyl-D-alanine residues, preventing proper peptidoglycan cross-linking. Due to increasing resistance and potential nephrotoxicity, vancomycin should be used judiciously and with appropriate monitoring of drug levels and renal function, as emphasized by 1. It is essential to note that the use of vancomycin should be guided by the most recent clinical practice guidelines and the patient's specific clinical context.
From the FDA Drug Label
Vancomycin Injection is a glycopeptide antibacterial indicated for the treatment of the following infections in adult and pediatric patients for whom appropriate dosing with this formulation can be achieved: • Septicemia (1.1) • Infective Endocarditis (1.2) • Skin and Skin Structure Infections (1.3) • Bone Infections (1.4) • Lower Respiratory Tract Infections (1.5)
The indications for starting vancomycin are:
- Septicemia
- Infective Endocarditis
- Skin and Skin Structure Infections
- Bone Infections
- Lower Respiratory Tract Infections 2
From the Research
Indications for Vancomycin Therapy
The indications for starting vancomycin therapy are as follows:
- Serious staphylococcal infections in patients who are intolerant to the penicillins and cephalosporins or when the organism is resistant to the commonly used bactericidal agents 3
- Streptococcal endocarditis in patients intolerant to penicillin G; in enterococcal infections, it is used with an associated aminoglycoside 3
- Other serious infections caused by organisms resistant to the commonly used agents such as corynebacterial endocarditis 3
- Acute staphylococcal ileocolitis, for which vancomycin is given orally or orally and intravenously if indicated 3
- Methicillin-resistant Staphylococcus aureus (MRSA) infections, although the emergence of less-susceptible strains and increased nephrotoxicity with high-dose therapy are challenging its current role as first-line therapy 4
Considerations for Vancomycin Use
When considering vancomycin therapy, the following factors should be taken into account:
- Minimum inhibitory concentration (MIC) of the organism, as high MICs may require higher vancomycin doses 5
- Patient factors such as age, body weight, and creatinine clearance, which can affect vancomycin concentrations 6
- Potential adverse effects, including nephrotoxicity, ototoxicity, and hypersensitivity reactions 7
Dosage and Administration
Vancomycin is typically given intravenously in a dose of 1 g every 12 hours in patients with normal renal function 3. However, the dosage regimen may need to be adjusted based on patient factors and the severity of the infection. A new dosing nomogram has been developed to help achieve target vancomycin trough concentrations more rapidly 6.