• 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 Considerations” below.

Contraindications^2,3

• Intramuscular injection – must not be given by this route
• Known hypersensitivity to vancomycin

Precautions^3,4

• Infusion rate – must be given over 1 to 2 hours. See Possible Adverse Effects
• Renal impairment – use with caution.
• Concurrent therapy with nephrotoxic/ototoxic drugs. See Drug Interactions
• Preterm infants, especially those with extreme immaturity.
• Hearing loss – avoid or use cautiously. Monitor levels.

Clinical Pharmacology^2,5

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 teicoplanin.

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 fluid.

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.
• Deafness
• Hypotension, palpitations, tachycardia (associated with too rapid infusion
• Rash
• 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

Drug Interactions⁴

The following are possible interactions with drugs commonly used in NICU:

• Amikacin, amphotericin B, gentamicin, other aminoglycosides: nephrotoxicity
• 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 other NMBAs.
• Zidovudine: neutropenia. Use vancomycin cautiously with all drugs which may cause neutropenia. Monitor FBC.
   

Special Considerations^2,7

• 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.