NICU and Pharmacy
29 to 35
- Administer each dose over 1 to 2 hours.
- Take serum trough level before 3rd dose. Adjust dose interval if
necessary and continue to monitor trough levels : See “Special
- Intramuscular injection – must not be given by this route
- Known hypersensitivity to vancomycin
- Infusion rate – must be given over 1 to 2 hours. See Possible Adverse
- Renal impairment – use with caution.
- Concurrent therapy with nephrotoxic/ototoxic drugs. See Drug
- Preterm infants, especially those with extreme immaturity.
- Hearing loss – avoid or use cautiously. Monitor levels.
Vancomycin is an glycopeptide antimicrobial, chemically unrelated to any
other antimicrobial agent. Acting at a site different from other penicillins,
vancomycin inhibits bacterial cell wall synthesis and may also cause secondary
damage to the cytoplasmic membrane and inhibition of bacterial RNA synthesis.
It is bactericidal against many gram-positive organisms. In vitro susceptibility
includes Listeria monocytogenes, and species of Lactobacillus, Actinomyces ,
Clostridium, and Bacillus.
Gram-negative bacteria, mycobacteria and fungi are resistant.
There are increasing reports of high-level acquired vancomycin resistance
amongst enterococci with apparent resistance transfer to other Gram-positive
organisms notably Staph.aureus.8 Organisms with high-level resistance to
vancomycin demonstrate cross-resistance to teicoplanin. Low-level resistance in
enterococci to vancomycin does not appear to be transferable to teicoplanin;
however low-level resistance to staphylococcus strains shows cross-resistance to
Vancomycin is administered intravenously and is poorly absorbed when given
orally. There is no apparent metabolism and it is excreted unchanged by
glomerular filtration. The mean elimination half-life from plasma is 4 to 6
hours in adults with normal renal function. Protein binding is approximately
55%. It does not readily diffuse across the meninges into the cerebrospinal
Possible Adverse Effects2
- Anaphylactoid reactions during or after infusion. Severe reactions may
require treatment with adrenaline, corticosteroids & oxygen.
- “Red man Syndrome” – flushing of upper body (red neck), or pain and
muscle spasm of the chest & back. Associated with too rapid infusion.
- Hypotension, palpitations, tachycardia (associated with too rapid
- Pain and thrombophlebitis as vancomycin is extremely irritant to the
tissues. Dilute appropriately and rotate infusion sites.
- Neutropenia (reversible on discontinuation), thrombocytopenia (rarely)
- Renal failure
The following are possible interactions with drugs commonly used in NICU:
- Amikacin, amphotericin B, gentamicin, other aminoglycosides:
- Dobutamine, dopamine, frusemide: decrease in vancomycin clearance due to
increase in cardiac output.
- Frusemide: ototoxicity.
- Indomethacin: decrease in vancomycin clearance. May require a 50%
reduction in vancomycin dose. Monitor vancomycin levels.
- Suxamethonium: increase in neuromuscular blockade. This may be
associated with too rapid administration of vancomycin. Use cautiously with
- Zidovudine: neutropenia. Use vancomycin cautiously with all drugs which
may cause neutropenia. Monitor FBC.
- Not to be administered intramuscularly. Vancomycin is irritant to
tissues and can cause pain and possible necrosis.
- Monitoring: (results are available within 3 hours)7
Trough levels only are required.
Take trough (within one hour prior to next dose): 10 – 15 mg/L.
Peak levels are not required in patients with normal renal function.