Vancomycin

Dose & administration
10-15 mg/kg/dose given intravenously per the following interval recommendations, and directed/adjusted by serum concentration measurements:

Postmenstrual age (PMA)

• ≤29 weeks PMA: 0-14 days postnatal age, dosing interval = 18 hours; >14 days postnatal age, dosing interval = 12 hours
• 30 to 36 weeks PMA: 0-14 days postnatal age, dosing interval = 12 hours; >14 days postnatal age, dosing interval = 8 hours
• 37 to 44 weeks PMA: 0-7 days postnatal age, dosing interval = 12 hours; >7 days, dosing interval = 8 hours
• ≥45 weeks PMA: all postnatal ages, dosing interval = 6 hours

Indications

• Beta-lactam resistant coagulase negative staphylococci
• Whenever Methicillin-Resistant Staphylococcus aureus (MRSA) coverage is needed in suspected neonatal bacterial infections
• Serious infections due to staphylococci or streptococci in a patient with a severe B-lactam allergy

Contraindications and special considerations (incl incompatibilities)
Contraindications: hypersensitivity to vancomycin or any component of the formulation

Special considerations: Prolongation of the dosing interval should be considered in neonates also receiving ibuprofen or indomethacin.
Additionally, because infusion reactions such as red man syndrome are commonly associated with administration, the recommended infusion time is 60-120 minutes with a maximum of 10 mg/minute

Incompatibilities, terminal site: Cefazolin, cefepime, cefotaxime, cefoxitin, ceftazidime, ceftriaxone, chloramphenicol, dexamethasone, heparin (concentrations greater than 1 unit/mL), nafcillin, pentobarbital, phenobarbital, piperacillin/tazobactam, and ticarcillin/clavulanate

Adverse effects
Nephrotoxicity, ototoxicity, red man syndrome (rash and hypotension), neutropenia, phlebitis

Pharmacological aspects
Mechanism of action: Vancomycin exhibits time-dependent killing and is bacteriocidal for most gram positive organisms, except for enterococci, for which it is bacteriostatic. Sensitive MICs are generally regarded as those ≤1 milligram/liter. Vancomycin disrupts bacterial cell wall synthesis, RNA synthesis, and plasma membrane function.

Half-Life: highly dependent on renal function; Newborns: 6 – 10 hours; Infants and children 3 months – 4 years: 4 hours

Excretion: Primarily excreted unchanged in the urine by glomerular filtration

Monitoring: Goal trough level is between 15-20 milligram/liter. Although there are recommendations for dosing in the neonatal population, individual needs and renal function vary greatly. Adjust dosing to optimize antibiotic therapy and minimize toxicity. It is generally recommended to draw a trough level before the fourth dose as the drug is approaching steady-state and will give the clinician a more accurate pharmacokinetic picture and dosing can be adjusted accordingly. However, a level can be obtained earlier if renal function declines during treatment. If long-term therapy is indicated, a level may be checked every 5 days once the patient is stabilized within therapeutic range.

References (incl URLs to PubMed)

• 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. Feb1, 2011; 52(3): e18-e55. PMID: 21208910.
• Elyasi S, Khalili H. Vancomycin dosing nomograms targeting high serum trough levels in different populations: pros and cons. Eur J Clin Pharmacol. 2016 Jul;72(7):777-88. PMID: 27117446.
• Pharmacokinetic comparison of nomogram-based and individualized vancomycin regimens in neonates. Am J Health Syst Pharm. 2009 Jan 15;66(2):149-53. PMID: 19139479.
• Trissel LA, Gilbert DL, Martinez JF: Concentration dependency of vancomycin hydrochloride compatibility with beta-lactam antibiotics during simulated y-site administration. Hosp Pharm 1998;33:1515-1520. PMID: 24421422
• Reiter PD, Doron MW: Vancomycin cerebrospinal fluid concentrations after intravenous administration in premature infants. J Perinatol 1996;16:331-335.  PMID: 8915929
• Levy M, Koren G, Dupuis L, Read SE. Vancomycin-induced red man syndrome. Pediatrics. 199086(4):572-80. PMID: 2216623

Document version history
Created 2016/09/02 / Laurie Rollins