Can Vancomycin Capsules Be Opened?
No, vancomycin capsules should not be opened for patients with difficulty swallowing; instead, use the intravenous formulation administered orally or request a compounded oral solution.
Rationale for Not Opening Capsules
The evidence does not support opening vancomycin capsules as a standard practice for several important reasons:
Stability concerns: Research demonstrates that vancomycin capsule preparations showed evidence of mold growth after 60 days at room temperature and crystallization when stored, suggesting the capsule formulation is designed to maintain drug stability and protect the contents from environmental exposure 1.
Lack of guideline support: Multiple guidelines addressing oral vancomycin use for Clostridioides difficile infection never mention opening capsules as an acceptable practice, suggesting this is not a recommended approach 2, 3.
Dosing accuracy: Opening capsules risks inaccurate dosing, particularly critical given that vancomycin for C. difficile requires precise 125 mg four times daily dosing for optimal outcomes 2, 3.
Recommended Alternatives for Patients with Swallowing Difficulties
First-Line Option: IV Vancomycin Given Orally
Intravenous vancomycin formulations can be administered orally when capsules cannot be swallowed, though you must verify the specific IV formulation's package insert confirms this is an approved indication 2.
This approach is explicitly recognized in treatment guidelines: "Not all intravenous formulation of vancomycin can be given orally and it is advised to refer to the medication package inserts to ascertain approved indications before use. Intravenous vancomycin given orally is an option when oral capsular form of vancomycin is not available" 2.
The reconstituted IV solution maintains potency for 60 days under refrigeration, providing adequate stability for oral administration 1.
Second-Line Option: Compounded Oral Solution
Vancomycin oral solution kits (such as grape-flavored preparations) are commercially available and specifically designed for oral administration 1.
These preparations maintain a clear appearance and demonstrate superior stability compared to reconstituted IV formulations, with a standard 30-day shelf life 1.
Oral solution kits showed no crystallization over 60 days, unlike capsule and IV preparations 1.
Clinical Considerations
Dosing Remains Unchanged
Whether using IV formulation orally or oral solution, maintain the standard 125 mg four times daily for 10 days for C. difficile infection 2, 3.
For severe C. difficile infection, the same dose applies but requires closer monitoring 3.
For fulminant cases, increase to 500 mg four times daily orally plus intravenous metronidazole 500 mg every 8 hours 2, 3.
Common Pitfall to Avoid
Do not assume all IV vancomycin products are approved for oral use—this varies by manufacturer and must be verified in the package insert before administration 2.
Avoid using intravenous vancomycin systemically when oral administration is the goal, as vancomycin is poorly absorbed from the gastrointestinal tract and oral administration is specifically intended for local gut activity against C. difficile 4, 5.