What is the appropriate oral dosing regimen for Vancomycin (Vanco) upon discharge?

Oral Vancomycin Dosing Regimens for Discharge

For Clostridioides difficile infection (CDI), the recommended oral vancomycin dosing regimen upon discharge is 125 mg four times daily for 10 days. 1, 2, 3

Vancomycin Dosing for CDI

Initial Episode Treatment

• Non-severe to severe CDI: Vancomycin 125 mg orally four times daily for 10 days 2, 3, 1
• Fulminant CDI: Vancomycin 500 mg orally four times daily (with consideration of adding IV metronidazole if ileus is present) 2

For Recurrent CDI

• First recurrence:

  • If metronidazole was used initially: Vancomycin 125 mg four times daily for 10 days 2
  • If standard vancomycin was used initially: Consider tapered and pulsed vancomycin regimen 2, 3

• Tapered and pulsed regimen:

  • 125 mg four times daily for 10-14 days
  • 125 mg twice daily for 7 days
  • 125 mg once daily for 7 days
  • 125 mg every 2-3 days for 2-8 weeks 2, 3

• Second or subsequent recurrences:

  • Tapered and pulsed vancomycin regimen
  • Alternative: Vancomycin 125 mg four times daily for 10 days followed by rifaximin 400 mg three times daily for 20 days 2

Evidence Supporting the Recommendation

Research has demonstrated that the 125 mg four times daily dose is as effective as higher doses (500 mg four times daily) for treating CDI, with no significant differences in clinical response 4. Higher doses do result in higher fecal concentrations but are unnecessary since even the standard dose achieves fecal levels far exceeding the MIC90 for C. difficile 5.

The FDA-approved dosing for vancomycin capsules for C. difficile-associated diarrhea is 125 mg administered orally four times daily for 10 days 1.

Important Considerations

• Loading dose consideration: Some patients may have lower fecal vancomycin levels during the first day of treatment when receiving the standard 125 mg dose. Consider a loading dose of 250 mg four times daily for the first 24-48 hours in severe cases 5.

• Monitoring: For patients >65 years of age, monitor renal function during and following treatment due to increased risk of nephrotoxicity, even with oral administration 1.

• Concurrent antibiotics: If the patient requires concurrent antibiotics for other infections, be aware that this increases the risk of CDI recurrence. Consider using antibiotics less frequently implicated with CDI 3.

• Discharge planning: Ensure the patient has sufficient medication to complete the full 10-day course and understands the importance of completing the entire regimen.

• Follow-up: Schedule follow-up to monitor for recurrence, which occurs in approximately 20-25% of patients 3.

For Staphylococcal Enterocolitis (Alternative Indication)

If treating staphylococcal enterocolitis (including MRSA), the recommended dosage is 500 mg to 2 g administered orally in 3 or 4 divided doses for 7 to 10 days 1.

Remember that oral vancomycin is not systemically absorbed and is not effective for other types of infections beyond CDI and staphylococcal enterocolitis 1.