Vancomycin is a glycopeptide antibiotic medication used to treat certain bacterial infections. It is administered intravenously (injection into a vein) to treat complicated skin infections, bloodstream infections, endocarditis, bone and joint infections, and meningitis caused by methicillin-resistant Staphylococcus aureus (medications used to treat MRSA). Blood levels may be measured to determine the correct dose. Vancomycin is also taken orally (by mouth) to treat Clostridioides difficile infections. When taken orally, it is poorly absorbed.
Common side effects include pain at the injection site and allergic reactions. Occasionally, hearing loss, low blood pressure, or bone marrow suppression occur. Safety in pregnancy is not clear, but no evidence of harm has been found, and it is likely safe for use when breastfeeding. It is a type of glycopeptide antibiotic and works by blocking the construction of a cell wall.
Vancomycin was approved for medical use in the United States in 1958. It is on the World Health Organization's List of Essential Medicines. The WHO classifies vancomycin as critically important for human medicine. It is available as a generic medication. Vancomycin is made by the soil bacterium Amycolatopsis orientalis.
Medical uses Vancomycin is indicated for the treatment of serious, life-threatening infections by Gram-positive bacteria of both aerobic and anaerobic types that are unresponsive to other antibiotics.
The increasing emergence of vancomycin-resistant enterococci (VRE) has resulted in the development of guidelines for use by the Centers for Disease Control Hospital Infection Control Practices Advisory Committee. These guidelines restrict use of vancomycin to these indications: treatment of serious infections caused by susceptible organisms resistant to penicillins, such as methicillin-resistant S. aureus (MRSA) and multidrug-resistant S. epidermidis (MRSE), treatment of infections in individuals with serious allergy to penicillins, treatment of pseudomembranous colitis caused by C. difficile; in particular, in cases of relapse or where the infection is unresponsive to metronidazole treatment (for this indication, vancomycin is given orally rather than intravenously), treatment of infections caused by Gram-positive microorganisms in patients with serious allergies to beta-lactam antimicrobials, antibacterial prophylaxis for endocarditis after certain procedures in penicillin-hypersensitive people at high risk, surgical prophylaxis for major procedures involving implantation of prostheses in institutions with a high rate of MRSA or MRSE, early in treatment as an empiric antibiotic for possible MRSA infection while waiting for culture identification of the infecting organism, halting the progression of primary sclerosing cholangitis and preventing symptoms; vancomycin does not cure the patient and success is limited, treatment of endophthalmitis by intravitreal injection for Gram-positive bacteria coverage; it has been used to prevent the condition but is not recommended due to the risk of side effects.
Spectrum of susceptibility Vancomycin is a last-resort medication for the treatment of sepsis and lower respiratory tract, skin, and bone infections caused by Gram-positive bacteria. The minimum inhibitory concentration susceptibility data for a few medically significant bacteria are: S. aureus: 0.25 μg/mL to 4.0 μg/mL S. aureus (methicillin resistant or MRSA): 1 μg/mL to 138 μg/mL S. epidermidis: ≤0.12 μg/mL to 6.25 μg/mL
Although once described as narrow-spectrum, numerous studies have now shown that vancomycin decreases the levels of a wide spectrum of bacteria, including members of the Gram-negative Bacteroidota that are important in the human gut.
Side effects Oral administration Common side effects associated with oral vancomycin administration (used to treat intestinal infections) include: gastrointestinal adverse effects (such as abdominal pain and nausea); dysgeusia (distorted sense of taste), in case of administration of vancomycin oral solution, but not in case of vancomycin capsules.
Intravenous administration Serum vancomycin levels may be monitored in an effort to reduce side effects, but the value of such monitoring has been questioned. Peak and trough levels are usually monitored, and for research purposes the area under the concentration curve is also sometimes used. Toxicity is best monitored by looking at trough values. Immunoassays are commonly used to measure vancomycin levels.
Common adverse drug reactions (≥1% of patients) associated with intravenous vancomycin include: pain, redness, or swelling at the injection site; vancomycin flushing syndrome (VFS), previously known as red man syndrome (or "redman syndrome"); thrombophlebitis, which is common when administered through peripheral catheters but not when central venous catheters are used, although central venous catheters are a predisposing factor for upper-extremity deep-vein thrombosis.
Damage to the kidneys (nephrotoxicity) and to the hearing (ototoxicity) were side effects of the early, impure versions of vancomycin, and were prominent in clinical trials conducted in the mid-1950s. Later trials using purer forms of vancomycin found nephrotoxicity is an infrequent adverse effect (0.1% to 1% of patients), but this is accentuated in the presence of aminoglycosides.
Rare adverse effects associated with intravenous vancomycin (<0.1% of patients) include anaphylaxis, toxic epidermal necrolysis, erythema multiforme, superinfection, thrombocytopenia, neutropenia, leukopenia, tinnitus, dizziness and/or ototoxicity, and DRESS syndrome.
Vancomycin can induce platelet-reactive antibodies in the patient, leading to severe thrombocytopenia and bleeding with florid petechial hemorrhages, ecchymoses, and wet purpura.
Historically, vancomycin has been considered a nephrotoxic and ototoxic drug, based on numerous case reports in the medical literature following initial approval by the FDA in 1958. But as its use increased with the spread of MRSA beginning in the 1970s, toxicity risks were reassessed. With the removal of impurities present in earlier formulations of the drug, and with the introduction of therapeutic drug monitoring, the risk of severe toxicity has been reduced.
Nephrotoxicity The extent of nephrotoxicity for vancomycin remains controversial. In the 1980s, vancomycin with a purity > 90% was available, and kidney toxicity defined by an increase in serum creatinine of at least 0.5 mg/dL occurred in only about 5% of patients. But dosing guidelines from the 1980s until 2008 recommended vancomycin trough concentrations between 5 and 15 μg/mL. Concern for treatment failures prompted recommendations for higher dosing (troughs 15 to 20 μg/mL) for serious infection, and acute kidney injury (AKI) rates attributable to the vancomycin increased.
Importantly, the risk of AKI increases with co-administration of other known nephrotoxins, in particular aminoglycosides. Furthermore, the sort of infections treated with vancomycin may also cause AKI, and sepsis is the most common cause of AKI in critically ill patients. Finally, studies in humans are mainly associations studies, where the cause of AKI is usually multifactorial.
Animal studies have demonstrated that higher doses and longer duration of vancomycin exposure correlates with increased histopathologic damage and elevations in urinary biomarkers of AKI.37-38 Damage is most prevalent at the proximal tubule, which is further supported by urinary biomarkers, such as kidney injury molecule-1 (KIM-1), clusterin, and osteopontin (OPN). In humans, insulin-like growth factor binding protein 7 (IGFBP7) as part of the nephrocheck test.
The mechanisms underlying the pathogenesis of vancomycin nephrotoxicity are multifactorial but include interstitial nephritis, tubular injury due to oxidative stress, and cast formation.
Therapeutic drug monitoring can be used during vancomycin therapy to minimize the risk of nephrotoxicity associated with excessive drug exposure. Immunoassays are commonly utilized for measuring vancomycin levels.
In children, concomitant administration of vancomycin and piperacillin/tazobactam has been associated with an elevated incidence of AKI relative to other antibiotic regimens.
Ototoxicity Attempts to establish rates of vancomycin-induced ototoxicity are even more difficult due to lack of good data. The consensus is that clearly related cases of vancomycin ototoxicity are rare. The association between vancomycin serum levels and ototoxicity is also uncertain. Cases of ototoxicity have been reported in patients whose vancomycin serum level exceeded 80 μg/mL, but cases have also been reported in patients with therapeutic levels. Thus it remains unknown whether therapeutic drug monitoring of vancomycin for the purpose of maintaining "therapeutic" levels prevents ototoxicity. Still, therapeutic drug monitoring can be used during vancomycin therapy to minimize the risk of ototoxicity associated with excessive drug exposure.
Interactions with other nephrotoxins Another area of controversy and uncertainty is whether and to what extent vancomycin increases the toxicity of other nephrotoxins. Clinical studies have yielded various results, but animal models indicate that the nephrotoxic effect probably increases when vancomycin is added to nephrotoxins such as aminoglycosides. A dose- or serum level-effect relationship has not been established.
Vancomycin flushing reaction
Vancomycin is recommended to be administered in a dilute solution slowly, over at least 60 min (maximum rate of 10 mg/min for doses >500 mg) due to the high incidence of pain and thrombophlebitis and to avoid an infusion reaction known as vancomycin flushing reaction. This phenomenon has been often clinically referred to as "red man syndrome". The reaction usually appears within 4 to 10 min after the commencement or soon after the completion of an infusion and is characterized by flushing and/or an erythematous rash that affects the face, neck, and upper torso, attributed to the release of histamine from mast cells. This reaction is caused by the interaction of vancomycin with MRGPRX2, a GPCR-mediating IgE-independent mast cell degranulation. Less frequently, hypotension and angioedema occur. Symptoms may be treated or prevented with antihistamines, including diphenhydramine, and are less likely to occur with slow infusion.
Dosing considerations The recommended intravenous dosage in adults is 500 mg every 6 hours or 1000 mg every 12 hours, with modification to achieve a therapeutic range as needed. The recommended oral dosage in the treatment of antibiotic-induced pseudomembranous enterocolitis is 125 to 500 mg every 6 hours for 7 to 10 days. Text was copied from this source, which is available under a Creative Commons Attribution 4.0 International License .
Dose optimization and target attainment of vancomycin in children involves adjusting the dosage to maximize effectiveness while minimizing the risk of adverse effects, specifically acute kidney injury. Dose optimization is achieved by therapeutic drug monitoring (TDM), which allows measurement of vancomycin levels in the blood. TDM using area under the curve (AUC)-guided dosing, preferably with Bayesian forecasting, is recommended to ensure that the AUC0-24h/minimal inhibitory concentration (MIC) ratio is maintained above a certain threshold (400–600) associated with optimal efficacy.
Routes of administration
In the United States, vancomycin is approved by the Food and Drug Administration for intravenous and oral administration.
Intravenous Vancomycin must be given intravenously for systemic therapy since it is poorly absorbed from the intestine. Vancomycin is a large hydrophilic molecule that partitions poorly across the gastrointestinal mucosa. Due to its short half-life, it is often injected twice daily.
Oral