vancomycin hydrochloride: clinical use

Prescribing considerations

• Confirm that the pathogen and infection site are appropriate for predominantly Gram-positive activity.
• Base intravenous treatment on patient factors, microbiology, renal function and measured exposure.
• Oral capsules act locally and are not suitable for systemic infection; absorption can become clinically relevant in inflammatory bowel disease or severe colitis.
• Previous vancomycin-associated severe cutaneous adverse reaction precludes re-exposure.

Contraindications and cautions

• Hypersensitivity to vancomycin or a formulation excipient.
• Intramuscular administration is contraindicated because of injection-site necrosis.

Monitoring

• Renal function and fluid status during intravenous treatment.
• Blood concentrations or model-informed exposure assessment for systemic treatment and when clinically significant oral absorption is possible.
• Hearing symptoms, blood count, liver function and urinalysis in higher-risk or prolonged treatment.
• Infusion reactions, clinical response, culture results and superinfection.

Clinical pharmacology

Vancomycin is a tricyclic glycopeptide that binds the D-alanyl-D-alanine terminus of bacterial cell-wall precursors. Intravenous exposure is predominantly eliminated by the kidneys. Oral bioavailability is normally negligible but can increase with severe intestinal inflammation, particularly with impaired renal clearance.

Formulation and product differences

• Hard capsules are for oral use and licensed for C. difficile infection; they must not be opened and do not provide reliable systemic treatment.
• The selected powder requires reconstitution and further dilution for intravenous infusion.
• The selected infusion product may also be prepared for oral or nasogastric administration for C. difficile infection; licensing varies between vial products.

Solution for infusion

Route: Intravenous

Strengths: 500 mg, 1000 mg, 1 g

Capsule

Route: Oral

Strengths: 125 mg, 250 mg