Vancocin, Firvanq, and generics
Antibiotic, glycopeptide

C/B	1	Yes	No	No
Key

• Injection: 0.5, 0.75, 1, 1.5, 5, 10 g
• Premixed injection:
  • In D₅W or NS: 500 mg/100 mL, 750 mg/150 mL, 1000 mg/200 mL
  • In NS: 1250 mg/300 mL, 1500 mg/300 mL
• Caps (Vancocin and generics): 125, 250 mg
• Oral solution: 25 mg/mL
  • Firvanq and generics: 25 mg/mL (80, 150, 300 mL); may contain sodium benzoate
  • Firvanq: 50 mg/mL (150, 210, 300 mL); may contain sodium benzoate

Dosing

• Initial empiric dosage; patient-specific dosage defined by therapeutic drug monitoring (see remarks)
• Neonate, IV (see following table for dosage interval):
  • Bacteremia: 10 mg/kg/dose
  • Meningitis, pneumonia: 15 mg/kg/dose

a Postmenstrual age = gestational age + postnatal age.

• Infant, child, adolescent, and adult, IV:

a Use Q8 hr dosing interval for older adolescent.

• Clostridium difficile colitis (PR route of administration may be preferable for complete ileus):
  • Child: 40–50 mg/kg/24 hr ÷ Q6 hr PO × 7–10 days
    • Max dose: 500 mg/24 hr; higher maximum of 2 g/24 hr have also been used for severe/fulminant disease
  • Adult: 125 mg/dose PO Q6 hr × 7–10 days; dosages as high as 2 g/24 hr ÷ Q6–8 hr have also been used for severe/fulminant disease
• Endocarditis prophylaxis for GU or GI (excluding esophageal) procedures (complete all antibiotic dose infusion[s] within 30 min of starting procedure):
  • Moderate-risk patients allergic to ampicillin or amoxicillin:
    • Child: 20 mg/kg/dose ( max. 1 g/dose) IV over 1–2 hr × 1
    • Adult: 1 g/dose IV over 1–2 hr × 1
  • High-risk patients allergic to ampicillin or amoxicillin:
    • Child and adult: Same vancomycin IV dose as moderate-risk patients plus gentamicin 1.5 mg/kg/dose ( max. dose: 120 mg/dose) IV/IM ×1

Notes

• Ototoxicity and nephrotoxicity may occur and may be exacerbated with concurrent aminoglycoside use. Greater nephrotoxicity risk has been associated with higher therapeutic serum trough concentrations (≥15 mg/mL), concurrent piperacillin/tazobactam therapy, and receiving furosemide in the intensive care unit. Adjust dose in renal failure (see Chapter 31 ). Use total body weight for obese patients when calculating dosages. Low concentrations of the drug may appear in CSF with inflamed meninges. Nausea, vomiting, and drug-induced erythroderma are common with IV use. Vancomycin infusion reaction is associated with rapid IV infusion. Infuse over 60 min (may infuse over 120 min if 60-min infusion is not tolerated). NOTE: Diphenhydramine is used to reverse the infusion reaction. Allergic reactions (including drug rash with eosinophilia and systemic symptoms [DRESS]), neutropenia, and immune-mediated thrombocytopenia have been reported. Serious skin reactions (e.g., SJS, TEN) have been reported in association with use of both IV and oral routes of administration.
• Although current extrapolated adult guidelines suggest measuring only trough levels, an additional post-distributional level may be useful in characterizing enhanced/altered drug clearance for quicker dosage modification to attain target levels; this may be useful for infants with known faster clearance and patients in renal compromise. Consult a pharmacist.
• The following therapeutic trough level recommendations are based on the assumption that the pathogen's vancomycin MIC is ≤1 mg/L.

• Peak level measurement (20–50 mg/L) has also been recommended for patients with burns, clinically nonresponsiveness in 72 hr of therapy, persistent positive cultures, and CNS infections (≥30 mg/L).
• Recommended serum sampling time at steady state: Trough within 30 min prior to the fourth consecutive dose and peak 60 min after the administration of the fourth consecutive dose. Infants with faster elimination (shorter T_1/2) may be sampled around the third consecutive dose.
• Recent evidence strongly suggests moving away from serum trough vancomycin monitoring to a pharmacokinetic/pharmacodynamics (PK/PD) target of area under the curve (AUC) to MIC ratio. An AUC_{24} of 400–600 mg*h/L is associated with clinical efficacy and reduced risk for AKI. Vancomycin therapeutic monitoring guidelines were revised in 2020 by the IDSA in collaboration with PIDS, SIDP, and ASHP. Consult with an ID specialist and pharmacist to see how this monitoring method is best operationalized at your institution.
• ORAL USE for C. difficile: Vancomycin (PO) or metronidazole (PO) is currently the recommended first-line therapy for children, whereas vancomycin (PO) or fidaxomicin is recommended for adults. See Clinical Infectious Diseases 66(7):e1–e48 for the 2017 IDSA/SHEA Clinical Practice Guidelines. Common adverse effects with oral vancomycin capsules in adults include nausea, abdominal pain, and hypokalemia.
• Pregnancy category “C” for the intravenous route and “B” for the oral route of administration.