From the Guidelines
Vancomycin is contraindicated in patients with a history of allergic reactions to the medication, and its use should be cautiously considered in patients with pre-existing renal impairment, hearing loss, or tinnitus due to the risk of nephrotoxicity and ototoxicity.
- The risk of nephrotoxicity is a significant concern, particularly when vancomycin is used in combination with other nephrotoxic agents, and patients with renal impairment may require dose adjustments and close monitoring 1.
- Ototoxicity is also a potential risk, and patients with hearing loss or tinnitus may need to avoid vancomycin or have their doses carefully monitored 1.
- Red man syndrome, a hypersensitivity reaction characterized by flushing and rash, is another potential contraindication, particularly in patients who have experienced this reaction in the past 1.
- The benefits of vancomycin in treating serious Gram-positive infections may outweigh the potential risks in some patients, particularly those with life-threatening conditions such as endocarditis or sepsis, and the decision to use vancomycin should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 1.
- Vancomycin dosing should be carefully considered, with recommended doses of 15–20 mg/kg/day every 8–12 h, adjusted for the patient's estimated creatinine clearance, and trough concentrations of 15–20 lg/mL are recommended for serious infections such as bacteremia, infective endocarditis, osteomyelitis, meningitis, pneumonia, and severe skin and soft tissue infections 1.
From the FDA Drug Label
Contraindications to Vancomycin
Vancomycin hydrochloride for injection is contraindicated in patients with known hypersensitivity to vancomycin 2.
Warnings and Precautions
The following are warnings and precautions related to the use of vancomycin:
- Infusion reactions: Rapid bolus administration may be associated with exaggerated hypotension, including shock and rarely cardiac arrest 2.
- Nephrotoxicity: Systemic vancomycin exposure may result in acute kidney injury (AKI), and the risk of AKI increases as systemic exposure/serum levels increase 2.
- Ototoxicity: Ototoxicity has occurred in patients receiving vancomycin hydrochloride for injection, and it may be transient or permanent 2.
- Severe dermatologic reactions: Severe dermatologic reactions such as toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS), drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), and linear IgA bullous dermatosis (LABD) have been reported in association with the use of vancomycin 2.
- Clostridium difficile associated diarrhea (CDAD): CDAD has been reported with use of nearly all antibacterial agents, including vancomycin hydrochloride for injection 2.
- Hemorrhagic occlusive retinal vasculitis (HORV): HORV, including permanent loss of vision, occurred in patients receiving intracameral or intravitreal administration of vancomycin during or after cataract surgery 2.
Special Considerations
Vancomycin should be used with caution in patients with:
- Renal insufficiency: The risk of toxicity is appreciably increased by high, prolonged blood concentrations 2.
- Underlying hearing loss: Ototoxicity has been reported mostly in patients who have been given excessive doses or who are receiving concomitant therapy with another ototoxic agent 2.
From the Research
Contraindications to Vancomycin
The contraindications to vancomycin are not explicitly stated in the provided studies. However, the studies do mention certain conditions and factors that may increase the risk of adverse reactions or reduce the effectiveness of vancomycin.
Conditions that May Increase the Risk of Adverse Reactions
- Renal dysfunction: High blood concentration trough levels, high values after 1 to 2 hours infusion, and extension of t1/2 were associated with nephrotoxicity 3
- Hepatic dysfunction: High total bilirubin (T-Bil) and low total protein (TP) were associated with hepatic dysfunction 3
- Hypertension or diabetes: These conditions were associated with a higher outbreak rate of side effects 3
- Prolonged therapy: Inadequate doses and prolonged therapy may increase the risk of nephrotoxicity, ototoxicity, and other adverse reactions 4, 5
Factors that May Reduce the Effectiveness of Vancomycin
- Resistance: Vancomycin-resistant strains of bacteria, such as Enterococcus faecium, may reduce the effectiveness of vancomycin 5
- High minimum inhibitory concentrations (MICs): Strains with high MICs may be associated with high therapeutic failure rates 5
- Inadequate dosing: Inadequate doses may result in subtherapeutic levels and treatment failures 4, 6
Adverse Reactions
The studies mention several adverse reactions associated with vancomycin, including: