Drug Monograph
Vancomycin (IV)
vancomycin hydrochloride for injection
Pharmacokinetic Profile
Half-Life
4–6 h (normal renal); 7.5 days (anephric)
Metabolism
No apparent hepatic metabolism
Protein Binding
~55%
Bioavailability
100% (IV); negligible orally
Volume of Distribution
0.3–0.43 L/kg
Clinical Information
Drug Class
Glycopeptide antibiotic
Available Doses
500 mg, 750 mg, 1 g, 1.25 g, 1.5 g vials/bags
Route
Intravenous infusion
Renal Adjustment
Required — dose/interval adjustment
Hepatic Adjustment
Not required
Pregnancy
Limited data; use if benefits outweigh risks
Lactation
Present in breast milk; caution advised
Schedule / Legal Status
Prescription only (not scheduled)
Generic Available
Yes
Therapeutic Index
Narrow — TDM required
Indications
| Indication | Approved Population | Therapy Type | Status |
|---|---|---|---|
| Septicemia due to susceptible Gram-positive organisms including MRSA | Adults and pediatrics (neonates and older) | Monotherapy or combination | FDA Approved |
| Infective endocarditis caused by staphylococci, streptococci, or enterococci | Adults and pediatrics | Monotherapy or combination (with gentamicin/rifampin) | FDA Approved |
| Skin and skin structure infections due to susceptible organisms | Adults and pediatrics | Monotherapy | FDA Approved |
| Bone infections (osteomyelitis) due to susceptible organisms | Adults and pediatrics | Monotherapy | FDA Approved |
| Lower respiratory tract infections including hospital-acquired pneumonia | Adults and pediatrics | Monotherapy or combination | FDA Approved |
Vancomycin remains the cornerstone antibiotic for serious infections caused by methicillin-resistant Staphylococcus aureus (MRSA) and other Gram-positive pathogens resistant to beta-lactam agents. It is the preferred empiric choice when MRSA is suspected in critically ill patients with bloodstream infections, pneumonia, or endocarditis, with therapy subsequently adjusted once susceptibility data become available. Vancomycin is also the primary alternative for patients with serious beta-lactam allergy who require treatment for methicillin-susceptible staphylococcal or streptococcal infections.
Off-Label Uses
Surgical prophylaxis (cardiac, orthopaedic, neurosurgical): Administered as a single pre-operative dose when MRSA colonisation rates are high or the patient has a documented beta-lactam allergy. Evidence quality: Moderate (AHA/STS/ASHP guidelines).
MRSA meningitis: Used intravenously (often with intrathecal administration) for central nervous system MRSA infections. Evidence quality: Moderate (IDSA 2011 MRSA guideline).
Peritonitis in peritoneal dialysis: Administered intraperitoneally for Gram-positive peritonitis in PD patients. Evidence quality: High (ISPD guidelines).
Empiric febrile neutropenia coverage: Added when there is concern for resistant Gram-positive line infection. Evidence quality: Low.
Dosing
Adult Dosing — By Clinical Scenario
| Clinical Scenario | Starting Dose | Maintenance Dose | Maximum Dose | Notes |
|---|---|---|---|---|
| MRSA bacteremia / sepsis | 15–20 mg/kg IV | 15–20 mg/kg q8–12h | AUC-guided (target 400–600) | Based on actual body weight; target AUC/MIC 400–600 mg·h/L (ASHP/IDSA 2020) Minimum 4–6 weeks for complicated bacteremia |
| Critically ill / ICU — suspected MRSA (loading dose) | 25–30 mg/kg IV once | 15–20 mg/kg q8–12h | AUC-guided | Loading dose based on actual body weight; infuse over 2–3 hours; premedicate with antihistamine Reassess within 24–48 h with AUC monitoring |
| Infective endocarditis — native valve MRSA | 15–20 mg/kg IV q8–12h | AUC-guided | AUC/MIC 400–600 | Duration: minimum 6 weeks (AHA/IDSA) Consider adding gentamicin for enterococcal endocarditis |
| Infective endocarditis — prosthetic valve | 15–20 mg/kg IV q8–12h | AUC-guided | AUC/MIC 400–600 | Duration: minimum 6 weeks; combine with rifampin and gentamicin (AHA) Rifampin 300 mg PO q8h + gentamicin first 2 wks |
| MRSA osteomyelitis | 15–20 mg/kg IV q8–12h | AUC-guided | AUC/MIC 400–600 | Duration: 4–6 weeks IV minimum (IDSA) Surgical debridement usually required |
| Hospital-acquired / ventilator-associated pneumonia | 15–20 mg/kg IV q8–12h | AUC-guided | AUC/MIC 400–600 | Duration: 7–14 days depending on clinical response (ATS/IDSA) Poor lung penetration; consider linezolid if poor response |
| MRSA meningitis | 15–20 mg/kg IV q8–12h | AUC-guided | AUC/MIC 400–600 | Duration: minimum 2 weeks; consider adding rifampin 600 mg/day (IDSA) CSF penetration limited with non-inflamed meninges |
| Skin and soft tissue — severe/complicated | 15–20 mg/kg IV q8–12h | AUC-guided | AUC/MIC 400–600 | Step down to oral therapy (TMP-SMX, doxycycline, or linezolid) when clinically stable Duration: 7–14 days total |
| Surgical prophylaxis (beta-lactam allergy or high MRSA risk) | 15 mg/kg IV once | Single dose pre-op | 15 mg/kg (max 2 g) | Infuse starting 1–2 hours before incision; allow full infusion to complete before incision Repeat at 12h if surgery >6h or major blood loss |
Pediatric Dosing
| Clinical Scenario | Starting Dose | Maintenance Dose | Maximum Dose | Notes |
|---|---|---|---|---|
| Neonates <1 week of age | 15 mg/kg IV once | 10 mg/kg IV q12h | Serum-level guided | Premature neonates may need longer intervals Close TDM required; target AUC ≥400 (ASHP/IDSA 2020) |
| Neonates 1 week to 1 month | 15 mg/kg IV once | 10 mg/kg IV q8h | Serum-level guided | Adjust based on gestational age and serum creatinine AAP neonatal dosing guides available |
| Serious MRSA — children 3 months to <12 years | 60–80 mg/kg/day div q6h | AUC-guided | 3,000–3,600 mg/day | ASHP/IDSA 2020; target AUC/MIC 400–600 Most children should not exceed 3,000 mg/day |
| Serious MRSA — children ≥12 years | 60–70 mg/kg/day div q6–8h | AUC-guided | 3,600 mg/day | Transition to adult protocols when appropriate Early monitoring within 48 h of initiation |
Renal Impairment — Dose Adjustment
| Clinical Scenario | Starting Dose | Maintenance Dose | Maximum Dose | Notes |
|---|---|---|---|---|
| CrCl >50 mL/min | 15–20 mg/kg | Standard q8–12h | AUC-guided | No adjustment typically needed; monitor levels |
| CrCl 20–49 mL/min | ≥15 mg/kg once | Extend interval to q24–48h | Level-guided | Initial dose should not be reduced; extend interval based on levels AUC monitoring essential |
| CrCl <20 mL/min (not on dialysis) | ≥15 mg/kg once | Re-dose based on levels | Level-guided | Measure concentration at 24h post-first dose to guide re-dosing Half-life markedly prolonged |
| Intermittent haemodialysis (low-flux) | 25 mg/kg loading | ~10 mg/kg post-HD | Pre-HD level guided (target 15–20 mg/L) | Draw pre-dialysis levels before each session Vancomycin poorly removed by low-flux HD |
| Intermittent haemodialysis (high-flux) | 25 mg/kg loading | Re-dose post-HD based on levels | Pre-HD level guided | High-flux membranes remove more vancomycin; larger replacement doses may be needed |
| Continuous renal replacement therapy (CRRT) | 20–25 mg/kg loading | 7.5–10 mg/kg q12h (adjust) | AUC-guided | Clearance depends on CRRT modality, flow rate, and membrane type Monitor levels q24–48h during CRRT |
Clinical Pearl: AUC-Guided Dosing (2020 Paradigm Shift)
The 2020 ASHP/IDSA/PIDS/SIDP consensus guideline shifted vancomycin monitoring from trough-based dosing (target 15–20 mg/L) to AUC/MIC-guided dosing (target 400–600 mg·h/L, assuming MIC of 1 mg/L by broth microdilution). This shift was driven by evidence that higher trough targets increased nephrotoxicity without improving efficacy. Bayesian software is the preferred method for AUC estimation, though two-level first-order pharmacokinetic equations are an acceptable alternative. When neither approach is available, trough-only monitoring may still be used, with the understanding that AUC-guided dosing is associated with lower rates of acute kidney injury.
Pharmacology
Mechanism of Action
Vancomycin is a tricyclic glycopeptide antibiotic derived from Amycolatopsis orientalis that exerts bactericidal activity primarily by binding to the D-alanyl-D-alanine terminus of peptidoglycan precursors in the bacterial cell wall. This binding prevents the transglycosylation and transpeptidation steps required for cell wall cross-linking, causing the nascent cell wall to weaken and the bacterium to lyse. Additionally, vancomycin disrupts bacterial cell membrane permeability and inhibits RNA synthesis, contributing to its overall bactericidal effect. Activity is concentration-independent and best predicted by the AUC/MIC ratio. Vancomycin is active against most Gram-positive organisms including MRSA, coagulase-negative staphylococci, streptococci, and most enterococci, but has no meaningful activity against Gram-negative bacteria, mycobacteria, or fungi.
ADME Profile
| Parameter | Value | Clinical Implication |
|---|---|---|
| Absorption | Not absorbed orally; IV route provides 100% bioavailability | Oral vancomycin used only for C. difficile colitis (local GI effect); systemic infections require IV |
| Distribution | Vd 0.3–0.43 L/kg; ~55% protein bound; penetrates pleural, pericardial, ascitic, synovial fluids | Poor CSF penetration unless meninges inflamed; adequate penetration into bone, lung tissue, and cardiac vegetations at therapeutic concentrations |
| Metabolism | No apparent hepatic metabolism; no active metabolites | No hepatic dose adjustment required; no CYP450 involvement; minimal drug interaction potential via metabolic pathways |
| Elimination | ~75–90% excreted unchanged renally; t½ 4–6 h (normal renal function), 7.5 days (anephric) | Dose adjustment mandatory in renal impairment; poorly removed by conventional haemodialysis (low-flux); significant removal with high-flux membranes |
Side Effects
≥10%
Very Common
| Adverse Effect | Incidence | Clinical Note |
|---|---|---|
| Vancomycin infusion reaction (VIR / “Red Man Syndrome”) | 3.7–47% | Rate-dependent histamine release; prevented by slowing infusion rate (≤10 mg/min) and pre-medicating with diphenhydramine; not a true allergy |
| Phlebitis / infusion-site reactions | Common (variable) | Concentration- and time-dependent endothelial toxicity; reduced by diluting to ≤5 mg/mL, using larger veins or central access, and rotating peripheral sites |
1–10%
Common
| Adverse Effect | Incidence | Clinical Note |
|---|---|---|
| Nephrotoxicity (AKI) | 5–7% | Risk increases with trough-based dosing (15–20 mg/L targets), concurrent nephrotoxins, and prolonged courses; AUC-guided dosing reduces risk |
| Nausea | ~2–7% | Usually mild; may relate to infusion rate |
| Fever / chills | ~2–5% | Distinguish from underlying infection; may also reflect drug fever |
| Rash (non-VIR) | ~2–5% | Maculopapular rash; evaluate for DRESS if accompanied by eosinophilia and systemic symptoms |
| Hypotension (infusion-related) | ~1–5% | Histamine-mediated; responds to slowing/stopping infusion and IV fluids |
Serious
Serious (Regardless of Frequency)
| Adverse Effect | Estimated Frequency | Typical Onset | Required Action |
|---|---|---|---|
| Acute kidney injury (severe) | 5–15% (with aggressive dosing) | Days 4–17 of therapy | Hold vancomycin, reassess levels, consider alternative agent; usually reversible with dose reduction or discontinuation |
| Ototoxicity (hearing loss, tinnitus, vertigo) | Rare (<2%) | Variable; may be delayed | Audiometric monitoring if prolonged course or concurrent ototoxic agents; discontinue if hearing loss confirmed; may be irreversible |
| Neutropenia (reversible) | ~2% (more common with courses >14 days) | Typically after 7–14 days | Monitor CBC weekly for prolonged courses; usually reverses promptly upon discontinuation |
| Thrombocytopenia | Rare | Any time during therapy | Monitor platelets; discontinue vancomycin if drug-induced thrombocytopenia confirmed |
| DRESS syndrome | Very rare | 2–8 weeks after initiation | Immediate discontinuation; do not rechallenge; dermatology and possible ICU consult |
| Toxic epidermal necrolysis (TEN) / Stevens-Johnson syndrome (SJS) | Very rare | Days to weeks | Immediate discontinuation; supportive care; permanent contraindication to re-exposure |
| Linear IgA bullous dermatosis (LABD) | Very rare | Days to weeks | Discontinue; dermatology referral; resolves after drug withdrawal |
| Anaphylaxis | Very rare (~3% of all hypersensitivity events) | During or shortly after infusion | Stop infusion immediately; epinephrine, airway management; permanent discontinuation; distinct from VIR |
Discontinuation
Discontinuation Rates
Adults
~9–15%
Top reasons: Nephrotoxicity, VIR, rash/dermatologic reactions, drug fever
Pediatrics
~5–10%
Top reasons: VIR, rash, nephrotoxicity (especially with concurrent piperacillin-tazobactam)
| Reason for Discontinuation | Incidence | Context |
|---|---|---|
| Nephrotoxicity / rising creatinine | 3–7% | Most common reason; reversible after stopping; higher rates with aggressive trough targets and concurrent aminoglycosides |
| Vancomycin infusion reaction | 2–5% | Majority can be managed with rate reduction and antihistamines; true discontinuation for refractory VIR |
| Rash / dermatologic reactions | 1–3% | Includes maculopapular rash and rare severe reactions (DRESS, SJS/TEN, LABD) |
| Neutropenia | ~1–2% | Usually after >14 days of therapy; resolves after discontinuation |
Managing Nephrotoxicity
Vancomycin-associated nephrotoxicity is the most clinically significant dose-limiting adverse effect. The 2020 consensus guideline demonstrated that transitioning from trough-based monitoring (15–20 mg/L) to AUC-guided dosing (target 400–600 mg·h/L) significantly reduced nephrotoxicity rates (from approximately 15% down to 5–8% in institutional studies) without sacrificing efficacy. The risk is compounded by concurrent use of other nephrotoxins (particularly piperacillin-tazobactam and aminoglycosides), prolonged treatment courses, ICU admission, and pre-existing renal impairment. If acute kidney injury develops, hold vancomycin, re-evaluate levels, and consider alternative agents such as daptomycin (for bacteremia/endocarditis) or linezolid (for pneumonia).
Drug Interactions
Vancomycin has no significant hepatic metabolism and is not a substrate, inhibitor, or inducer of CYP450 enzymes. Therefore, most drug interactions are pharmacodynamic in nature, involving additive nephrotoxicity or ototoxicity rather than metabolic interference. The key clinically significant interactions centre on renal toxicity potentiation.
Major
Aminoglycosides (Gentamicin, Tobramycin, Amikacin)
MechanismAdditive nephrotoxicity and ototoxicity via direct tubular injury
EffectSignificantly increased risk of acute kidney injury and hearing loss
ManagementUse combination only when clinically essential (e.g., enterococcal endocarditis); monitor renal function and levels closely; limit aminoglycoside duration
FDA PI + IDSA Guideline
Major
Piperacillin-Tazobactam
MechanismSynergistic nephrotoxicity; mechanism not fully elucidated but consistently demonstrated in large observational studies
EffectIncreased AKI incidence compared to vancomycin alone or vancomycin plus cefepime/meropenem
ManagementConsider cefepime or meropenem as the Gram-negative partner if possible; if combination unavoidable, monitor renal function every 24–48 hours
FDA PI + Multiple RCTs/Meta-analyses
Major
Amphotericin B
MechanismAdditive nephrotoxicity (both agents independently nephrotoxic)
EffectMarkedly increased AKI risk
ManagementMonitor creatinine and electrolytes daily; use liposomal amphotericin if possible; consider alternative antifungal
Lexicomp
Moderate
NSAIDs
MechanismNSAIDs reduce renal perfusion via prostaglandin inhibition, compounding vancomycin’s nephrotoxic potential
EffectIncreased risk of AKI, particularly in volume-depleted patients
ManagementUse paracetamol for analgesia when possible; monitor renal function; ensure adequate hydration
Lexicomp
Moderate
Loop Diuretics (Furosemide)
MechanismAdditive ototoxicity; furosemide may also increase vancomycin levels via reduced renal clearance in dehydrated states
EffectPotential hearing damage and nephrotoxicity
ManagementAvoid excessive diuresis; monitor auditory function if prolonged combination use; maintain euvolemia
FDA PI
Moderate
Anaesthetic Agents
MechanismEnhanced histamine release and vasodilation during concurrent vancomycin infusion and anaesthesia
EffectErythema, flushing, hypotension mimicking or worsening VIR
ManagementComplete vancomycin infusion before induction of anaesthesia if possible; infuse slowly
FDA PI
Minor
Warfarin
MechanismAlterations in gut flora from antibiotic therapy may increase vitamin K-dependent factor sensitivity
EffectPotentially increased INR
ManagementMonitor INR more frequently during vancomycin course; adjust warfarin dose as needed
Case Reports
Minor
Neuromuscular Blocking Agents
MechanismPotential additive neuromuscular blockade effect
EffectProlonged paralysis in rare cases
ManagementMonitor neuromuscular function in perioperative setting; be aware of potential interaction
Case ReportsMonitoring
-
Vancomycin AUC/MIC
Within 24–48h of first dose, then as needed
Routine Target AUC/MIC 400–600 mg·h/L for serious MRSA infections (ASHP/IDSA 2020). Bayesian software is preferred; alternative: two-level first-order PK equations. If AUC monitoring unavailable, trough-only monitoring is acceptable (but inferior). Weekly monitoring for stable patients; more frequent in critically ill or changing renal function. -
Serum Creatinine / BUN
Baseline, then q48–72h (or daily in ICU)
Routine Detect nephrotoxicity early. Increase frequency if concurrent nephrotoxic agents, haemodynamic instability, or pre-existing renal disease. If AKI develops (SCr rise ≥0.5 mg/dL or ≥50% from baseline), reassess dosing or switch therapy. -
CBC with Differential
Baseline, then weekly if course >7 days
Routine Vancomycin-induced neutropenia typically occurs after >14 days of therapy and reverses promptly upon discontinuation. Also monitor for thrombocytopenia and eosinophilia (possible DRESS sentinel). -
Urinalysis
If unexplained creatinine rise
Trigger-based Rule out interstitial nephritis (eosinophiluria, WBC casts) if creatinine rises without clear pre-renal cause. -
Audiometry
If prolonged course (>14 days) or concurrent ototoxins
Trigger-based Serial auditory function tests if high-risk features present (elderly, renal impairment, concurrent aminoglycoside or loop diuretic). Discontinue vancomycin if hearing loss confirmed. -
Signs of VIR
Every infusion (especially first dose)
Routine Observe for flushing, erythema, pruritus, hypotension, and chest/back pain during and after infusion. Most events occur within 10–45 minutes of starting infusion. -
Blood Cultures
Repeat q48–72h until clearance documented
Routine For bacteremia: repeat blood cultures every 48–72 hours to document clearance. Persistent positivity after 5–7 days warrants evaluation for deep-seated infection, metastatic foci, or treatment failure.
Contraindications & Cautions
Absolute Contraindications
- Known hypersensitivity to vancomycin — documented IgE-mediated anaphylaxis to vancomycin (distinct from VIR, which is not a true allergy)
- Prior severe dermatologic reaction — history of DRESS, SJS/TEN, or LABD attributed to vancomycin
Relative Contraindications (Specialist Input Recommended)
- Pre-existing significant renal impairment — vancomycin can be used with careful dose adjustment and close monitoring, but alternative agents (daptomycin, linezolid) may be preferred when feasible
- Pre-existing hearing loss — especially if the patient requires concurrent ototoxic agents; risk-benefit discussion and audiometric monitoring warranted
- Concurrent piperacillin-tazobactam — consider alternative Gram-negative coverage due to elevated AKI risk; ID or pharmacy consult recommended if combination is necessary
Use with Caution
- Obesity (BMI ≥30 kg/m²) — dose based on actual body weight per 2020 guidelines; higher total daily doses may be needed but AUC monitoring becomes particularly important to avoid supratherapeutic exposure
- Elderly patients — renal clearance may be lower than expected from serum creatinine alone; consider cystatin C-based eGFR; greater dose reductions may be needed
- Neonates and premature infants — immature renal function leads to prolonged half-life; extended dosing intervals and close TDM required
- History of VIR — not a contraindication; manage with slower infusion rate, antihistamine premedication, and lower doses given more frequently
- Concurrent nephrotoxic agents — IV contrast, calcineurin inhibitors, cisplatin, aminoglycosides; intensify renal monitoring
FDA Safety Communication
Nephrotoxicity and Ototoxicity
Vancomycin carries warnings regarding nephrotoxicity (acute kidney injury) and ototoxicity (hearing loss), both of which may be irreversible. The risk of AKI increases with higher serum concentrations, concurrent use of other nephrotoxic drugs, prolonged therapy, and in patients with pre-existing renal impairment or critical illness. If AKI develops, dosing should be adjusted or the drug discontinued. Ototoxicity risk is elevated in patients with pre-existing hearing loss, those receiving other ototoxic agents, elderly patients, and those with renal impairment. Serial auditory function tests are recommended for at-risk patients.
FDA Safety Communication
Hemorrhagic Occlusive Retinal Vasculitis (HORV)
Cases of hemorrhagic occlusive retinal vasculitis, including permanent vision loss, have been reported in patients who received vancomycin via intracameral or intravitreal administration during or after cataract surgery. The safety and efficacy of vancomycin by these routes have not been established. Intravenous or oral vancomycin is not indicated for the prophylaxis of endophthalmitis.
Patient Counselling
Purpose of Therapy
Vancomycin is a strong antibiotic given through a vein to treat serious bacterial infections that do not respond to other antibiotics. It targets infections caused by resistant bacteria, including MRSA. The full prescribed course must be completed even if symptoms improve, because stopping early increases the risk of the bacteria developing resistance and the infection returning.
How to Take
Vancomycin is administered as a slow intravenous infusion, typically over at least 60 minutes per gram of drug. Patients receiving outpatient parenteral antibiotic therapy (OPAT) will receive detailed instructions about infusion timing, line care, and when to call their healthcare team. Blood tests to check drug levels and kidney function will be drawn regularly throughout the course of treatment.
Infusion Reaction (Flushing, Itching, Redness)
Tell patient
A flushing reaction involving the face, neck, and upper body may occur during or shortly after the infusion. This is not a true allergy and is caused by the infusion being given too quickly. Slowing the infusion or taking an antihistamine before future doses usually prevents it.
Call prescriber
If flushing is accompanied by difficulty breathing, throat swelling, severe chest tightness, or significant drop in blood pressure, seek emergency care immediately as this may represent anaphylaxis rather than a simple infusion reaction.
Kidney Function Changes
Tell patient
Vancomycin can affect kidney function, which is why regular blood tests are needed. Staying well hydrated supports kidney health during treatment. Patients should report any decrease in urine output, swelling, or unusual fatigue.
Call prescriber
If urine output drops significantly, if there is noticeable swelling in the legs or face, or if blood test results show worsening kidney function, contact the prescriber promptly as dose adjustment or a change in antibiotic may be needed.
Hearing Changes
Tell patient
Hearing problems are uncommon with modern vancomycin formulations but have been reported, especially in patients with kidney problems or those also receiving other medications that can affect hearing.
Call prescriber
Report any new or worsening ringing in the ears (tinnitus), dizziness, or feeling that hearing is muffled or reduced on either side. Prompt evaluation is essential as early detection may prevent permanent hearing loss.
IV Line Care (OPAT Patients)
Tell patient
Keep the IV site clean and dry. Do not submerge the line in water. Inspect the insertion site daily for redness, swelling, tenderness, or drainage. Secure tubing to prevent accidental dislodgement.
Call prescriber
Contact the healthcare team if the IV site becomes red, painful, or swollen; if there is leaking around the site; if the patient develops a new fever; or if the infusion will not run or alarms persistently.
Diarrhoea During or After Treatment
Tell patient
Antibiotics can disrupt normal gut bacteria. While vancomycin is used to treat C. difficile infections, any antibiotic can also predispose to it. Report persistent watery diarrhoea, especially if bloody or accompanied by abdominal pain and fever.
Call prescriber
If diarrhoea is persistent (more than three loose stools per day for more than two days), bloody, or associated with fever and abdominal cramping, contact the prescriber as stool testing for C. difficile may be required.
Completing the Full Course
Tell patient
Even if you start feeling better early, it is essential to complete the full course of vancomycin as prescribed. Stopping early can allow surviving bacteria to regrow, potentially leading to a harder-to-treat relapse.
Call prescriber
If you experience side effects that make you consider stopping treatment, discuss options with your prescriber before discontinuing. Alternative antibiotics or dose adjustments may be available.
Sources
Regulatory (PI / SmPC)
- Vancomycin Hydrochloride for Injection — Full Prescribing Information. Hikma Pharmaceuticals USA Inc. Revised June 2024. FDA Label Primary regulatory source for FDA-approved indications, dosing, contraindications, and adverse reactions for the lyophilised powder formulation.
- Vancomycin Injection (premixed) — Full Prescribing Information. Baxter Healthcare Corporation. Revised January 2024. Baxter PI Regulatory source for the premixed ready-to-use formulation including administration and compatibility information.
- Vancomycin Injection — Full Prescribing Information. FDA. Revised 2025. FDA Label (2025) Most recent FDA label update for premixed flexible bag formulation including pediatric dosing and HORV warning.
Key Clinical Trials & Consensus Guidelines
- Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by ASHP, IDSA, PIDS, and SIDP. Am J Health-Syst Pharm. 2020;77(11):835–864. doi:10.1093/ajhp/zxaa036 Landmark 2020 consensus guideline establishing AUC/MIC-guided dosing (target 400–600 mg·h/L) and replacing trough-based monitoring for serious MRSA infections.
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18–e55. doi:10.1093/cid/ciq146 IDSA guideline providing infection-specific treatment recommendations for MRSA, including vancomycin dosing by clinical syndrome.
- Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications. Circulation. 2015;132(15):1435–1486. doi:10.1161/CIR.0000000000000296 AHA/IDSA guideline for infective endocarditis treatment including vancomycin-based regimens for MRSA and enterococcal endocarditis.
- Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by IDSA and ATS. Clin Infect Dis. 2016;63(5):e61–e111. doi:10.1093/cid/ciw353 Provides guidance on empiric vancomycin use for suspected MRSA hospital-acquired and ventilator-associated pneumonia.
Guidelines — Surgical Prophylaxis & Special Populations
- Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70(3):195–283. doi:10.2146/ajhp120568 ASHP/IDSA/SHEA/SIS guideline establishing vancomycin as an alternative prophylactic agent for patients with beta-lactam allergy or high MRSA risk.
- Li PK, Chow KM, Cho Y, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022;42(2):110–153. doi:10.1177/08968608221080586 International Society for Peritoneal Dialysis guideline supporting intraperitoneal vancomycin for Gram-positive PD-related peritonitis.
Mechanistic / Basic Science
- Levine DP. Vancomycin: a history. Clin Infect Dis. 2006;42(Suppl 1):S5–S12. doi:10.1086/491709 Comprehensive historical review of vancomycin from discovery through modern clinical use, including evolution of understanding of its mechanism and toxicity.
- Bruniera FR, Ferreira FM, Saviolli LRM, et al. The use of vancomycin with its therapeutic and adverse effects: a review. Eur Rev Med Pharmacol Sci. 2015;19(4):694–700. PMID: 25753888 Review covering vancomycin pharmacodynamics, clinical uses, and the spectrum of adverse effects including infusion reactions and nephrotoxicity.
Pharmacokinetics / Special Populations
- Finch NA, Zasowski EJ, Murray KP, et al. A quasi-experiment to study the impact of vancomycin area under the concentration-time curve-guided dosing on vancomycin-associated nephrotoxicity. Antimicrob Agents Chemother. 2017;61(12):e01293-17. doi:10.1128/AAC.01293-17 Key study demonstrating that AUC-guided dosing reduced nephrotoxicity compared to trough-based approaches, supporting the 2020 guideline shift.
- Lodise TP, Drusano GL, Zasowski E, et al. Vancomycin exposure in patients with methicillin-resistant Staphylococcus aureus bloodstream infections: how much is enough? Clin Infect Dis. 2014;59(5):666–675. doi:10.1093/cid/ciu398 Pharmacokinetic study establishing AUC/MIC thresholds for efficacy in MRSA bloodstream infections and defining the upper bound of safe exposure.
- Luther MK, Timbrook TT, Caffrey AR, et al. Vancomycin plus piperacillin-tazobactam and acute kidney injury in adults: a systematic review and meta-analysis. Crit Care Med. 2018;46(1):12–20. doi:10.1097/CCM.0000000000002769 Meta-analysis confirming elevated AKI risk with vancomycin plus piperacillin-tazobactam versus vancomycin combined with other beta-lactams.