How do you administer Vanco (vancomycin) plus injection?

How to Administer Vancomycin Plus Injection

Vancomycin must be administered intravenously as a diluted solution infused over at least 60 minutes to avoid rapid-infusion-related reactions including hypotension, shock, and cardiac arrest. 1

Route and Rate of Administration

• Never administer vancomycin as a rapid IV bolus or push - this can cause exaggerated hypotension, shock, and rarely cardiac arrest 1
• Infuse vancomycin over a minimum of 60 minutes to prevent infusion-related reactions including red man syndrome, hypotension, flushing, erythema, urticaria, and pruritus 2, 1
• Dilute vancomycin to a concentration of 2.5-5 g/L before administration to minimize thrombophlebitis 2
• Do not give vancomycin intramuscularly - IM injection causes pain, tenderness, and tissue necrosis 1
• Ensure secure IV access - extravasation causes tissue necrosis 1
• Rotate venous access sites to minimize thrombophlebitis 2

Standard Dosing Regimens

For Serious Systemic Infections (Bacteremia, Endocarditis, Pneumonia, Osteomyelitis)

• Administer 15-20 mg/kg/dose IV every 8-12 hours (not to exceed 2 g per dose) in patients with normal renal function 2
• Consider a loading dose of 25-30 mg/kg (actual body weight) in critically ill patients with sepsis, meningitis, pneumonia, or infective endocarditis 2
• Prolong the loading dose infusion to 2 hours and consider premedication with an antihistamine to reduce risk of red man syndrome and anaphylaxis 2
• Target trough concentrations of 15-20 mcg/mL for serious infections including bacteremia, endocarditis, osteomyelitis, meningitis, pneumonia, and severe skin/soft tissue infections 2

For Uncomplicated Skin/Soft Tissue Infections

• Administer 1 g IV every 12 hours in patients with normal renal function who are not obese 2
• Trough monitoring is not required for most patients with skin/soft tissue infections who have normal renal function and are not obese 2

For Fulminant Clostridioides difficile Infection

• Administer vancomycin 500 mg orally (not IV) four times daily for fulminant CDI with hypotension, shock, ileus, or megacolon 3
• Add IV metronidazole 500 mg every 8 hours together with oral vancomycin, particularly if ileus is present 3
• Consider rectal vancomycin 500 mg in 100 mL normal saline every 6 hours if ileus prevents oral administration 3

Therapeutic Drug Monitoring

• Obtain trough concentrations before the fourth or fifth dose at steady state 2
• Do not monitor peak vancomycin concentrations - trough levels are the most accurate and practical method to guide dosing 2
• Mandatory trough monitoring is required for:
  • Serious infections (bacteremia, endocarditis, osteomyelitis, meningitis, pneumonia, severe SSTI) 2
  • Morbidly obese patients 2
  • Patients with renal dysfunction including those on dialysis 2
  • Patients with fluctuating volumes of distribution 2

Renal Dosing Adjustments

• Dosage modification is imperative in patients with impaired renal function since vancomycin is primarily excreted by the kidneys 1, 4
• Monitor renal function in all patients receiving vancomycin, especially those with underlying renal impairment or receiving concomitant nephrotoxic drugs 1
• The risk of acute kidney injury increases as serum levels increase - maintain appropriate trough concentrations 1

For Hemodialysis Patients

• Administer a 20 mg/kg loading dose infused during the last hour of the dialysis session 2
• Then give 500 mg during the last 30 minutes of each subsequent dialysis session 2

Pediatric Dosing

• Administer 15 mg/kg/dose IV every 6 hours in children with serious or invasive disease 2
• Consider targeting trough concentrations of 15-20 mcg/mL in children with serious infections (bacteremia, endocarditis, osteomyelitis, meningitis, pneumonia, severe SSTI), though efficacy and safety data are limited 2

Critical Safety Considerations

Monitoring for Toxicity

• Monitor for ototoxicity - vancomycin can cause transient or permanent hearing loss, especially with excessive doses, underlying hearing loss, or concomitant ototoxic agents like aminoglycosides 1
• Serial auditory function tests may be helpful to minimize ototoxicity risk 1
• Monitor complete blood count periodically - reversible neutropenia has been reported with prolonged therapy 1
• Avoid excessively high serum concentrations (>30 mcg/mL) which may be associated with ototoxicity 5, 4

Drug Interactions

• Monitor renal function closely when combining vancomycin with nephrotoxic drugs including amphotericin B, aminoglycosides, bacitracin, polymyxin B, colistin, viomycin, or cisplatin 1
• Be aware that concomitant anesthetic agents increase the frequency of infusion-related events - consider administering vancomycin as a 60-minute infusion prior to anesthetic induction 2, 1

Common Pitfalls to Avoid

• Do not use standard doses (500 mg every 6 hours or 1 g every 12 hours) regardless of patient characteristics - dosing must be individualized based on weight, renal function, and infection severity 6
• Do not delay vancomycin in febrile patients with gram-positive cocci on blood culture - this increases mortality with virulent organisms 3
• Do not continue vancomycin unnecessarily - de-escalate to appropriate β-lactam therapy when culture results show susceptible organisms 3
• Stopping the infusion usually results in prompt cessation of infusion-related reactions if they occur 1