What Nurses Need to Know About Vancomycin

• Vancomycin gained popularity in treating staph infections after methicillin-resistant bacteria evolved. 
• It is important to be mindful of the general information of Vancomycin regarding the following: uses, side effects, adverse reactions, drug interactions, IV compatibilities/incompatibilities of Vancomycin treatment, and parenteral uses of Vancomycin. 
• The nursing process for Vancomycin therapy must be considered – types, dosages, storage, and patient response. 

Vancomycin is a tricyclic glycopeptide antibiotic whose use has become more common after the emergence of methicillin-resistant staph aureus which has led to the emergence of vancomycin-resistant enterococci.  Due to this, vancomycin should be used sensibly, only when the culture and sensitivity tests indicate its use.  Otherwise, more and more resistant strains will emerge, making it even more difficult to treat the infection.  

As a nurse, you should not confuse vancomycin with clindamycin, gentamicin, tobramycin, or vibramycin. 

Vancomycin is absorbed poorly from the gastrointestinal tract; therefore, it is given intravenously to treat systemic infections.  It is only used orally to treat pseudomembranous colitis.  It is important to keep in mind that oral vancomycin cannot be used for the systemic one and vice versa.  Both forms are separate and are not interchangeable.  

Vancomycin is widely distributed in the body except for the cerebrospinal fluid.  Its protein binding is 10 – 50% and primarily excreted unchanged in the urine and not removed by hemodialysis.  The half-life of vancomycin is 4 to 11 hours, which can be increased in renal impairment.  

Vancomycin diffuses well into the pericardial, pleural, synovial, and ascitic fluid.  The metabolism of vancomycin is unknown.  Around 85% of the dose is excreted unchanged in the urine within 24 hours, and a small fraction may be eliminated through the liver and biliary tract. 

Vancomycin exerts bactericidal actions by binding to the bacterial cell walls, altering cell membrane permeability, and inhibiting RNA synthesis.  When the bacterial cell wall gets damaged, the body can attack the organism through its natural defense mechanism.   

General Information Regarding Vancomycin 

Uses of Vancomycin

Vancomycin is used in the following conditions: 

• To treat infections caused by staphylococcal and streptococcal bacteria.  It is active against gram-positive organisms, such as Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Enterococcus, and Streptococcus pneumoniae. 
• Orally, it is given to treat Clostridium difficile–associated diarrhea and enterocolitis caused by Staphylococcus aureus, including MRSA, and those who do not respond to metronidazole.  
• The IV form is often reserved for patients having serious resistant staphylococcal infections and hypersensitive to penicillin’s. 
• In patients allergic to penicillin’s, vancomycin is a drug of choice, given in combination with an aminoglycoside for the treatment of choice for Enterococcus faecalis endocarditis. 

The off-label uses of vancomycin are as follows: 

• Treatment of infections caused by gram-positive organisms in patients with serious allergies to beta-lactam antibiotics 
• Treatment of beta-lactam–resistant gram-positive infections 
• Surgical prophylaxis 
• Treatment of prosthetic joint infection 

Side Effects of Vancomycin

Side effects of vancomycin, when given through the oral route, are as follows: 

• Bitter and unpleasant taste 
• Nausea  
• Vomiting  
• Mouth irritation, especially with oral solution 

Side effects of vancomycin, when given through the parenteral route, are as follows: 

• Phlebitis 
• Thrombophlebitis 
• Pain at the peripheral IV site 
• Dizziness 
• Vertigo 
• Tinnitus 
• Chills 
• Fever 
• Rash 
• Necrosis with extravasation 

Adverse Reactions of Vancomycin

The adverse reactions of vancomycin are as follows:  

• Eosinophilia 
• Drug fever 
• Neutropenia  
• Hearing loss – can be transient or permanent.  The risk increases even more when it is combined with other ototoxic drugs.  
• Hypersensitivity and anaphylactic reactions  
• Red man syndrome – with rapid IV administration of vancomycin, severe hypotension may occur accompanied by a red rash with flat and raised lesions on the face, neck, chest, and arms.  It is characterized by pruritus, urticaria, erythema, angioedema, and tachycardia; therefore, doses of less than or equal to 1 gram should be given over 1 hour, and doses greater than 1 gram should be given over 1 and a half to 2 hours. 
• Nephrotoxicity such as acute kidney injury, acute tubular necrosis, and renal failure 
• Ototoxicity may occur that can be temporary or permanent hearing loss 
• Hypotension 
• Myalgia 
• Maculopapular rash that usually appears on the face, neck, and upper torso 
• Cardiovascular toxicity, such as cardiac depression or arrest, occurs rarely.  Onset usually occurs within 30 minutes of the start of the infusion and resolves within hours following infusion.  It may result from a too-rapid rate of infusion. 

Drug Interactions of Vancomycin

• Vancomycin, when administered with drugs that can cause nephrotoxicity or ototoxicity, such as aminoglycosides, amphotericin B, cisplatin, bacitracin, colistin, and polymyxin B, can increase the risk of toxicity.  
• Bile acid sequestrates such as cholestyramine may decrease the therapeutic effects of oral vancomycin.  

Caution to be exercised with Vancomycin

Exercise caution in administering vancomycin in the following conditions: 

• Renal impairment 
• Concurrent therapy with other ototoxic and nephrotoxic medications 
• Elderly patients  
• Dehydration 

IV Compatibilities/Incompatibilities of Vancomycin

Vancomycin IV is compatible with the following drugs: 

• Amiodarone (Cordarone) 
• Calcium gluconate 
• Dexmedetomidine (Precedex) 
• Diltiazem (Cardizem) 
• Hydromorphone (Dilaudid) 
• Insulin 
• Lorazepam (Ativan) 
• Magnesium sulfate 
• Midazolam (Versed) 
• Morphine 
• Nicardipine (Cardene) 
• Potassium chloride 
• Propofol (Diprivan) 

Vancomycin IV is incompatible with the following drugs: 

• Albumin 
• Amphotericin B complex (Abelcet, AmBisome, Amphotec) 
• Aztreonam (Azactam) 
• Cefazolin (Ancef) 
• Cefotaxime (Claforan) 
• Cefoxitin (Mefoxin) 
• Ceftazidime (Fortaz) 
• Ceftriaxone (Rocephin) 
• Cefuroxime (Zinacef) 
• Foscarnet (Foscavir) 
• Heparin 
• Nafcillin (Nafcil) 
• Piperacillin and tazobactam (Zosyn) 

Parenteral Dose of Vancomycin

The usual parenteral dose of vancomycin is as follows: 

• IV for adults and elderly: 15–20 mg/kg/dose (rounded to the nearest 250 mg) q8–12h. 
• Dosage requires adjustment in renal impairment.  The usual maximum dose is 2 g. 
• Children older than 1 month: 10–15 mg/kg/ dose q6h. Maximum: 2,000 mg/dose. 
• For neonates, the loading dose is 20 mg/kg, then 15 mg/kg q48h up to 10–15 mg/kg/dose q6–8h. 

The oral dose of vancomycin for staphylococcal enter colitis, antibiotic-associated pseudomembranous colitis caused by Clostridium Difficile, is: 

• For adults and elderly: 125–500 mg 4 times/day for 10–14 days.  
• For children: 40 mg/kg/day in 3 to 4 divided doses for 7–10 days.  Maximum: 2 g/day 

For patients with renal impairment after the loading dose, subsequent doses and frequency are modified based on creatinine clearance, the severity of infection, and the serum concentration of the drug. 

Nursing Process for Vancomycin Usage 

For patients undergoing vancomycin therapy, the following nursing processes are appropriate: 

Assessment

• Assess the patient’s infection before and regularly after therapy.  
• Before giving the first dose of vancomycin, obtain culture and sensitivity tests of the specimen.  Do this before initiating the therapy, despite pending results.  
• Before beginning the therapy and throughout, obtain hearing and kidney function tests.  
• In elderly patients, premature neonates, and those with decreased renal function monitor, serum creatinine levels must be checked regularly.  
• Assess for adverse drug reactions and drug interactions.  
• Assess the patient and family’s knowledge of drug therapy. 

Key Nursing Diagnoses

• Risk for infection related to altered immune status 
• Risk for deficient fluid volume related to adverse GI reactions 
• Knowledge deficit of the patient and the caregivers related to drug therapy 

Planning Outcome Goals

• The patient’s infection will resolve, evidenced by culture reports, temperature, and WBC counts. 
• The patient’s daily fluid intake and output will be monitored and the patient’s fluid volume will remain within normal limits.  
• The patient and his caregivers will have an understanding of the drug therapy.  

Implementation

• For patients with renal dysfunction, adjust the vancomycin dose accordingly.  
• If refrigerated, the oral dosage form is stable for 2 weeks.  
• To administer IV infusions, dilute in 200 mL of D5W and infuse over 60 minutes. 
• Obtain vancomycin peak/trough level as ordered by the physician or pharmacist.  The therapeutic peak serum level of vancomycin, which is not routinely obtained, is 20–40 mcg/ml.  The therapeutic trough serum level is 10–20 mcg/ml.  The toxic peak serum level is greater than 40 mcg/mL and the toxic trough serum level is greater than 20 mcg/ml. 
• During the infusion, monitor the patient’s blood pressure closely.   
• Check the infusion site daily for irritation or phlebitis.  If the patient has pain at the infusion site, report it to the physician.  Also, monitor for irritation and infiltration, as extravasation can cause tissue damage and necrosis.  
• Do not administer the drug through the intramuscular route.  
• If the patient gets redneck or red man syndrome during the infusion because it is administered too rapidly, stop it immediately and inform the physician.  
• After reconstitution, refrigerate the vial and use it within 96 hours.  
• When giving vancomycin to treat staphylococcal endocarditis, do not stop it before 4 weeks.  

Evaluation

• The patient is free from the infection. 
• The patient drinks enough water and remains well-hydrated.  
• The patient and his family members verbalize and have an understanding of the drug therapy.  

Patient Understanding

• Ensure that the patient continues the therapy for the full length of treatment.  However, if there are any adverse effects, report them to the physician soon.  
• Doses should be evenly spaced, and infusions should not be given too fast.  
• Ask the patient to report as soon as possible if they have any complaints such as ringing in the ears, hearing loss, or changes in urinary frequency or consistency. 
• Tell the patient that the lab tests are an essential part of total therapy.  

Availability

Vancomycin is available under the brand name Vancocin in the following dosage forms and strengths.  

• Capsules as 125 mg and 250 mg 
• Infusion premix in the strengths 500 mg/100 ml, 750 mg/150 ml, and 1g/200 ml 
• Injection, powder for reconstitution as 500 mg, 750 mg, and 1g 
• Oral solution in concentrations of 25 mg/ml and 50 mg/ml 
• Oral suspension in the concentration of 50 mg/mL 

Administration and Handling of Vancomycin

• Administer vancomycin IV infusion through a piggyback or continuous intravenous line.  Do not give it as an IV push, as it may result in exaggerated hypotension or red man syndrome.  
• To reconstitute for intermittent IV infusion, reconstitute each 500 mg vial with 10 ml sterile water for injection (20 ml for 1g vial) to provide a concentration of 50 mg/ml. Further, dilute with D5W or 0.9% NaCl to a final concentration not to exceed 5 mg/ml.  
• For the rate of administration, administer over 60 min or longer.  Make sure to keep it for 30 minutes for each recommended 500 mg. 
• During infusion, monitor the patient’s blood pressure closely.  

Storage of Vancomycin Vials

• Reconstituted vials are stable for 14 days at room temperature or if refrigerated. 
• Diluted solutions are stable for 14 days if refrigerated or 7 days at room temperature. However, discard any that has precipitated in form.  
• For oral administration, vancomycin can be given with food.  The powder form for injection may be reconstituted and diluted for oral administration.  

The Bottom Line

With vancomycin therapy, it is imperative to understand the reasoning as to why the therapy is being used and to be aware of symptoms and adverse reactions that may indicate a reaction is taking place. While vancomycin is a great treatment for many individuals, there are some who may experience serious side effects and life-threatening issues that need to be attended to immediately. 

It is important to keep a close check on the patient’s kidney and auditory functions as they pose a risk of nephrotoxicity and ototoxicity, as well as to check for hypotensive events. Encourage the patient to obtain lab tests when taking vancomycin therapy and to report any unusual symptoms immediately.   

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