BSN Tracker

vancomycin

Brand: Vancocin

⚠ BBW TDM Required Prototype Drug
Drug Class: antibiotic
Drug Family: antibiotic
Subclass: glycopeptide
Organ Systems: infectious-disease

Mechanism of Action

Binds with high affinity to the D-Ala-D-Ala terminus of peptidoglycan precursors (Lipid II), preventing transglycosylation and transpeptidation; cell wall synthesis is inhibited; bactericidal against most gram-positive organisms; does not cross the lipid-rich outer membrane of gram-negatives.

D-Ala-D-Ala terminus of peptidoglycan precursors

Indications

  • MRSA infections (bacteremia, pneumonia, endocarditis, osteomyelitis — IV)
  • severe skin/soft tissue infections (MRSA)
  • Clostridioides difficile colitis (oral — not absorbed)
  • beta-lactam-allergic patient with serious gram-positive infections
  • empiric therapy in high-risk hospital patients

Contraindications

  • allergy to vancomycin

Adverse Effects

Common

  • nephrotoxicity (AUC/MIC-guided dosing reduces risk)
  • ototoxicity (trough >20 mg/L)
  • red man syndrome (infusion reaction — flushing, pruritus, erythema of face/neck/trunk — not an allergy)

Serious

  • acute kidney injury
  • ototoxicity (tinnitus, hearing loss)
  • DRESS syndrome
  • neutropenia and thrombocytopenia (prolonged courses)

Pharmacokinetics (ADME)

Absorption IV: near complete distribution; oral formulation is NOT absorbed — used only for C. diff in gut lumen
Distribution Protein binding 30–55%; Vd 0.4–1 L/kg; crosses inflamed meninges
Metabolism Not metabolized
Excretion Entirely renal (glomerular filtration); dramatic dose reduction required in CKD; supplement dose after dialysis
Half-life 4–6 hours (normal renal function); 7–9 days (anuric patients)
Onset End of infusion
Peak End of infusion (avoid measuring peak — not used for monitoring)
Duration q8–12h (normal renal function)
Protein Binding 30–55%
Vd 0.4–1 L/kg

Drug Interactions

Drug / Agent Mechanism Severity
aminoglycosides additive nephrotoxicity and ototoxicity major
loop diuretics (furosemide) additive nephrotoxicity and ototoxicity moderate
NSAIDs additive nephrotoxicity moderate

Nursing Considerations

  1. Infuse over minimum 60 minutes (1–2 g doses); faster infusion causes red man syndrome — if occurs, slow infusion and administer antihistamine (diphenhydramine); this is not an allergy
  2. AUC/MIC-guided monitoring is now standard per 2020 guidelines: target AUC24/MIC 400–600 mg·h/L for serious MRSA infections; this replaces trough-only monitoring
  3. Monitor renal function (SCr, BUN) and urine output every 24–48 hours; hold and notify prescriber if SCr rises >0.5 mg/dL from baseline or urine output <0.5 mL/kg/h
  4. Oral vancomycin for C. diff is NOT interchangeable with IV vancomycin — oral vancomycin stays in the gut (not absorbed) and has no systemic effect; IV vancomycin is not effective for C. diff

Clinical Pearls

  • The 2020 ASHP/IDSA/SIDP consensus guidelines recommend replacing trough-only monitoring with AUC/MIC-guided monitoring for vancomycin to minimize nephrotoxicity while maintaining efficacy against MRSA
  • Vancomycin-resistant enterococci (VRE) have modified the D-Ala-D-Ala to D-Ala-D-Lac, reducing vancomycin affinity 1000-fold — this is a major resistance mechanism that has spread widely in healthcare settings

Safety Profile

Pregnancy use-with-caution
Lactation use-with-caution
Renal Adjustment Required
Hepatic Adjustment Not required
TDM Required
Guideline Update pending

Concordance Terms

Cross-referenced clinical concepts — click any term to see all content where it appears.

Antibiotic Beta-lactam-allergic Patient With Serious Gram-positive Infections Clostridioides Difficile Colitis (oral — Not Absorbed) Empiric Therapy In High-risk Hospital Patients MRSA Infections (bacteremia, Pneumonia, Endocarditis, Osteomyelitis — IV) Severe Skin/soft Tissue Infections (MRSA)
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