Vancomycin

ED / ICU / Transport

• Sepsis or septic shock with high MRSA risk: empiric anti-MRSA coverage, added to an antipseudomonal beta-lactam such as piperacillin-tazobactam or cefepime. The Surviving Sepsis Campaign 2026 suggests empiric coverage for a specific multidrug-resistant pathogen like MRSA when the patient is at high risk (prior colonization or infection, for example) and suggests against it when risk is low. Once cultures and susceptibilities are back, de-escalate.
• MRSA bacteremia and infective endocarditis: FDA-labeled for septicemia and endocarditis. If the isolate is MSSA, switch to a beta-lactam.
• Pneumonia with MRSA risk: hospital-acquired and ventilator-associated pneumonia, plus severe community-acquired pneumonia with MRSA risk factors. In nonsevere community-acquired pneumonia, a negative MRSA nasal PCR generally supports holding MRSA coverage.
• Skin and soft-tissue infection: severe, purulent or necrotizing infection when MRSA is suspected
• Bone and joint infection: osteomyelitis and septic arthritis with MRSA risk
• Other serious gram-positive infection (FDA-labeled): coagulase-negative staphylococci (often from central lines or prosthetic devices); methicillin-susceptible staphylococci when penicillins or cephalosporins cannot be used (severe allergy or treatment failure); endocarditis from viridans group streptococci, Streptococcus gallolyticus, enterococci (with an aminoglycoside) or Corynebacterium; early prosthetic valve endocarditis from Staphylococcus epidermidis (with rifampin and an aminoglycoside)
• Bacterial meningitis: empiric therapy with ceftriaxone where resistant pneumococcus is possible; post-neurosurgical meningitis and shunt infection (off-label)

Other Uses

• Clostridioides difficile infection (oral, NG or rectal only): alternative to fidaxomicin for an initial episode; tapered and pulsed course for recurrence; high-dose therapy with IV metronidazole for fulminant disease
• Staphylococcal enterocolitis: oral therapy (FDA-labeled)

The usual regimen follows the label (section 2.2). AUC or trough adjustments? Those happen with pharmacy.

Available Forms

• Vials (powder): 500 mg, 750 mg, 1 g, 1.25 g and 1.5 g single-dose; reconstitute to 50 mg/mL with sterile water, then dilute
• Frozen premixed bags: 5 mg/mL (500 mg in 100 mL to 1.5 g in 300 mL) in D5W or 0.9% sodium chloride; once thawed, 72 hr at room temperature or 30 days refrigerated; do not refreeze
• Room-temperature ready-to-use bags: 5 mg/mL, 500 mg in 100 mL to 2 g in 400 mL; contain excipients (N-acetyl-D-alanine; one product also PEG 400, which carries the boxed warning)
• Oral: capsules 125 mg and 250 mg; oral solution kit 25 mg/mL or 50 mg/mL after reconstitution (refrigerate, discard after 14 days); IV powder may be compounded for oral or NG use

Adult Dosing

Pediatric Dosing

For the weight math, see weight-based dosing. Renal, dialysis, CRRT and obesity dosing are covered in Special Populations.

Preparation & Administration

• Dilution: keep the final concentration at 5 mg/mL or less. Go up to 10 mg/mL only for fluid restriction, and expect more infusion reactions if you do.
• Infusion rate: at least 60 min (label). Many protocols run about 1 g per hr (about 17 mg/min) or slower. Premix labels tie 10 mg/min or less (about 1 g over 100 min) to fewer infusion reactions. A 2 g dose takes 2 hr or more.
• Never IV push: a fast push can send the patient into shock and cardiac arrest.
• Line: peripheral or central. It irritates tissue, so use a secure, well-running IV and check the site. IV only, never IM.
• Anesthesia: finish the infusion before induction when feasible. Reactions are worse with anesthetic agents.
• Pump: infusion pump with the dose, volume and duration programmed

Contraindications

• Known hypersensitivity to vancomycin or to a product's excipients (for example, polysorbate 80 in some vials; PEG 400, N-acetyl-D-alanine or L-lysine in some premixes); check the specific product label
• Prior SJS/TEN, DRESS, AGEP or linear IgA bullous dermatosis attributed to vancomycin

Precautions

• Renal impairment, age over 65, critical illness: AKI risk is higher. Dose by levels.
• Concurrent nephrotoxins: piperacillin-tazobactam, aminoglycosides, loop diuretics, amphotericin B, IV contrast, vasopressors
• Hearing loss or other ototoxic drugs: higher ototoxicity risk
• Pregnancy, first or second trimester: avoid the PEG 400/N-acetyl-D-alanine (NADA) premix (boxed warning). The PEG-free premix with NADA and L-lysine (Tyzavan) has no boxed warning. Its label still reports fetal malformations with NADA in animal studies, and human data are insufficient. Vials are the conservative choice.
• Use without a proven or strongly suspected bacterial infection: no benefit, and it selects for drug-resistant bacteria such as VRE. Stop it when cultures do not support it.
• Unapproved routes: intraperitoneal use during CAPD can cause chemical peritonitis. Intracameral or intravitreal use has caused hemorrhagic occlusive retinal vasculitis.

Hold / Reassess If

• Serum creatinine rises 0.3 mg/dL or more within 48 hr, or 50% from baseline: reassess dose, levels and other nephrotoxins
• Estimated AUC above 600 mg·hr/L (adults or children), or in children a trough above 15 mg/L: reassess the dose with pharmacy; hold if AKI is developing
• Flushing, pruritus or hypotension during infusion: stop the infusion
• New tinnitus, hearing loss, rash with mucosal involvement or fever: stop and notify

Common

• Infusion reaction with rapid or concentrated infusions
• Phlebitis at peripheral IV sites
• Rise in serum creatinine, more often with high exposure and other nephrotoxins
• Oral capsules: nausea (17%), abdominal pain (15%), hypokalemia (13%)

Serious / Life-Threatening

Overdose & Toxicity Management

• Signs: very high levels with AKI; ototoxicity
• Management: stop vancomycin. Give supportive care that protects glomerular filtration: keep up the volume and avoid nephrotoxins.
• Antidote: none
• Extracorporeal removal: conventional dialysis removes little. High-permeability hemodialysis, hemofiltration and hemoperfusion increase clearance. That is a nephrology decision.

Clinically Significant Interactions

IV Compatibility

• Diluents: 0.9% sodium chloride, D5W, lactated Ringer's, D5 with lactated Ringer's, D5 with 0.9% sodium chloride
• Incompatible: beta-lactams in mixed solution, including ceftriaxone. The acidic solution can destabilize other drugs, so keep anything else out of the bag.
• Verify with an institutional compatibility resource.

• Pediatrics: children clear vancomycin faster than adults, so they need higher mg/kg/day doses. Infusion reactions may be more severe. Watch levels and renal function. See the Pediatric Dosing table.
• Neonates and Infants Younger Than 3 Months: label: 15 mg/kg first dose, then 10 mg/kg every 12 hr in week 1 and every 8 hr up to 1 month (section 2.2). Premature infants need longer intervals. Check levels. Use Bayesian AUC-guided dosing where it is available.
• Pregnancy: published second- and third-trimester data show no link to adverse outcomes. First-trimester data are lacking. Avoid the PEG 400/N-acetyl-D-alanine premix in the first and second trimesters (boxed warning). The PEG-free premix with N-acetyl-D-alanine and L-lysine (Tyzavan) lacks pregnancy data, so vials are a reasonable choice. Use it when serious infection calls for it.
• Lactation: it passes into human milk after IV dosing. Oral absorption by the infant is low. Effects on the infant are not well studied.
• Older Adults: clearance is lower. AKI and ototoxicity risk are higher, and the clinical response is slower. Dose by levels and check creatinine often.
• Renal Impairment: give a full first dose, at least 15 mg/kg, or a 20–35 mg/kg load if critically ill. Then extend the interval by levels, with pharmacy dosing. Anephric half-life is about 7.5 days.
• Intermittent Hemodialysis: conventional dialysis removes vancomycin poorly (label). Give the first load as in Dosing & Administration. Then redose from pre-dialysis levels with pharmacy.
• CRRT: hemofiltration increases vancomycin clearance (label section 10). Give the first load as in Dosing & Administration. Then dose by levels checked within 24 hr, with pharmacy (CRRT).
• Hepatic Impairment: No adjustment. Vancomycin is not metabolized.
• Obesity / Dosing Weight: dose on actual body weight. Load at 20–25 mg/kg (max 3,000 mg). Empiric maintenance rarely goes above 4,500 mg/day. Start early AUC monitoring, especially above 4,000 mg/day. Label section 2.2: age or obesity may call for a dose modification of the usual dose.

• Scope: rarely started in the field. RN and critical-care transport teams (Paramedic/RN/CCT) continue a running infusion on interfacility transfer, depending on state and agency protocol. The Surviving Sepsis Campaign 2026 suggests giving antimicrobials in the ambulance or aircraft for probable or definite septic shock when in-hospital evaluation is more than 60 min away, but only with a structured sepsis screening process. Field protocols that carry an antibiotic typically use a beta-lactam such as ceftriaxone. Vancomycin is seldom part of them.
• Storage & Stability: vials at 20–25°C (68–77°F); frozen premix lasts 72 hr at room temperature once thawed; ready-to-use bags 28 days at room temperature after removal from the overpouch; check the bag's beyond-use time.
• Infusions in Transport: pump with the programmed duration (at least 1 hr per 1 g); do not speed up the infusion to finish before arrival; separate line or flush from beta-lactams.
• Altitude / Environment: No specific effect. Vibration and dim light hide flushing, so watch blood pressure during the infusion.
• Handoff Essentials: dose in mg and mg/kg, start time and volume infused, loading dose given or not, last level with time and next level due, creatinine trend, companion antibiotics and their times, any infusion reaction.

Mechanism of Action

• Binds the D-Ala–D-Ala end of cell-wall precursors. That blocks peptidoglycan polymerization and cross-linking. The result is bactericidal against most gram-positive organisms, including MRSA.
• Too large to cross the gram-negative outer membrane. No gram-negative activity.
• Resistance (VRE, VISA/VRSA) comes from D-Ala–D-Lac precursors or thickened cell walls. Either way, binding drops.
• Efficacy tracks the 24-hr AUC/MIC ratio, which is why dosing is AUC-guided.

Pharmacokinetics

• Half-life: 4–6 hr with normal renal function. About 7.5 days if anephric.
• Metabolism: none
• Elimination: glomerular filtration. About 75% is excreted unchanged in urine within 24 hr.
• Distribution: Vd 0.3–0.43 L/kg. Protein binding is about 55%. It enters CSF only when the meninges are inflamed.

Generic Name

Vancomycin hydrochloride

Brand Names

Vancocin (oral capsules); Firvanq (oral solution kit); Tyzavan (ready-to-use IV bags); generic vials and premixed bags

Pharmacologic Class

Glycopeptide antibiotic

Therapeutic Class

Anti-MRSA, gram-positive antibacterial; oral agent for C. difficile infection

Controlled Substance

Not controlled

ISMP High-Alert

No

Look-Alike / Sound-Alike

No ISMP tall-man pair; the common error is route confusion between oral (C. difficile) and IV (systemic) orders