Vancomycin Hydrochloride (Vancocin, Firvanq)

Red Man Syndrome - Rapid infusion causes flushing, hypotension, and pruritus (not IgE-mediated). Slow to minimum 60 min (1g over 60 min, 1.5-2g over 90 min); pretreat with diphenhydramine if history of reaction.

Hemodynamic Effects - Significant hypotension can occur intraoperatively, especially with concurrent volatile agents; have vasopressors available.

Prophylaxis Timing - Complete infusion at least 60 min before incision.

Nephrotoxicity - Avoid concurrent nephrotoxins (aminoglycosides, NSAIDs, contrast); monitor renal function with repeated dosing. Single prophylactic dose is generally safe even in AKI/CKD; repeat dosing requires interval adjustment.

Drug Interactions - Additive nephrotoxicity with aminoglycosides, amphotericin B, and loop diuretics. Additive ototoxicity with loop diuretics.

Renal Impairment - Dose interval significantly extended in AKI/CKD; consult pharmacy for dosing in severe renal impairment or dialysis-dependent patients.

Line Compatibility - Incompatible with alkaline solutions and beta-lactams in the same line; flush between drugs. Central line preferred for prolonged infusions; peripheral access acceptable for single perioperative doses.

Excessive Dose/Toxicity - Stop infusion, provide supportive hemodynamic care; if continued dosing required, restart at a slower rate. Hemodialysis partially removes vancomycin.

Pediatric Implications:

Higher weight-based doses required (15 mg/kg/dose q6h in neonates/infants). AUC-guided monitoring preferred over trough-only. Neonates require individualized dosing based on gestational age and renal function.

Obstetric Implications:

Crosses the placenta; fetal serum levels approximate maternal levels. Used for GBS prophylaxis in penicillin-allergic patients and MRSA coverage. No evidence of teratogenicity. Compatible with breastfeeding.

ABSOLUTE:

- Known hypersensitivity to vancomycin

RELATIVE:

- Concurrent nephrotoxic agents

- Pre-existing severe renal impairment (requires dose adjustment)

CAUTION:

- Pre-existing hearing loss or cochlear impairment

- Concurrent ototoxic drugs (loop diuretics, aminoglycosides)

- Elderly patients

- Obesity (use adjusted body weight for dosing)

Surgical prophylaxis: 15-20 mg/kg (max 3g); infuse over 60-120 min

Treatment (severe MRSA infection): 25-30 mg/kg loading dose

15-20 mg/kg q8-12h (renally adjusted); target AUC/MIC 400-600 mg·h/L

Maximum infusion rate: 10 mg/min (500mg over 30 min minimum; 1g over 60 min preferred)

Binds D-alanyl-D-alanine terminus of peptidoglycan precursors, inhibiting cell wall synthesis; bactericidal against gram-positive organisms including MRSA

Hepatic

Renal