Vancomycin is bactericidal for most gram-positive organisms, particularly staphylococci and streptococci; it is, however, bacteriostatic for most enterococci. While active against staphylococci, vancomycin kills more slowly when compared with nafcillin or cefazolin, and these agents are preferred in the treatment of serious infection associated with methicillin-resistant S aureus. Although vancomycin has retained activity against staphylococci and streptococci, vancomycin-resistant strains of enterococci (particularly E faecium) are common. S aureus both intermediately sensitive and highly vancomycin-resistant has been observed in patients receiving long-term vancomycin therapy. Vancomycin is not absorbed from the gastrointestinal tract and thus useful orally only for the treatment of antibiotic-associated enterocolitis. For systemic effect, the medication must be administered intravenously (30 mg/kg/day in two or three divided doses). Vancomycin is excreted mainly via the kidneys. In end-stage kidney disease, the half-life may extend to 8 days. Vancomycin is cleared via high-flux hemodialysis and continuous renal replacement therapy (CRRT), resulting in the need for increased dosing. In patients with impaired kidney function, the dosing interval is determined by measuring trough serum levels. When trough serum levels decline to 10–15 mcg/mL, repeat dosing is required, primarily in the treatment of severe infection. As an example, more aggressive dosing with associated troughs of greater than 15 mcg/mL has been recommended in the treatment of methicillin-resistant S aureus ventilator-associated pneumonia. However, the association of attainment of these elevated trough levels and efficacy has not been proven. Large doses (4 g daily or more) and concomitant use of piperacillin-tazobactam have been associated with mild reversible nephrotoxicity. Vancomycin likely increases the risk of aminoglycoside-associated nephrotoxicity. Vancomycin efficacy is closely correlated with pharmacokinetics/pharmacodynamics. Specifically, an area under the curve (AUC) divided by the minimum inhibitory concentration (MIC) of greater than 400 (AUC/MIC greater than 400) has been associated with favorable outcomes in serious infection due to S aureus. Attainment of this ratio appears to be particularly important during the first 2 days of therapy of methicillin-resistant S aureus bloodstream infections. Considering this relationship, the MIC is critical regarding the decision to use vancomycin; when the MIC is greater than or equal to 2 mcg/mL (or greater than or equal to 1.5 mcg/mL by E-test), alternatives to vancomycin (including daptomycin, linezolid, and other agents, depending on the site of infection) should be considered.
Indications for parenteral vancomycin include the following: (1) severe staphylococcal infections in patients with type 1 allergy to penicillin; (2) methicillin-resistant S aureus and methicillin-resistant S epidermidis infections; (3) serious infections (pneumonia, meningitis) due to resistant S pneumoniae; (4) severe enterococcal infections in the penicillin-allergic patient or ampicillin-resistant Enterococcus; (5) other gram-positive infections in penicillin-allergic patients, eg, viridans streptococcal endocarditis; (6) surgical prophylaxis in penicillin-allergic patients in clean surgical procedures; (7) for gram-positive infections due to organisms that are multidrug-resistant, ie, Corynebacterium jeikeium; and (8) endocarditis prophylaxis in the penicillin-allergic patient. In C difficile–associated disease, vancomycin, 0.125 g, is given orally four times daily. Oral vancomycin is preferred over oral metronidazole in the treatment of severe C difficile disease. Oral doses in excess of 0.125 g are not associated with improved outcomes in the treatment of this disease, although it is recommended in severe recurrent disease.
Thrombophlebitis sometimes follows intravenous injection. The medication is infrequently reversibly ototoxic when given concomitantly with aminoglycosides or high-dose intravenous erythromycins; it increases aminoglycoside-induced nephrotoxicity with coadministration. Concomitant administration of vancomycin with piperacillin-tazobactam increases the risk for nephrotoxicity; this association has not been observed for other beta-lactams. Vancomycin doses of 4 g or greater daily and elevated trough levels are also associated with an increased incidence of mild nephrotoxicity. Rapid infusion or high doses (1 g or more) may induce diffuse hyperemia (“red man syndrome”) and can be avoided by extending infusions over 1–2 hours, by reducing the dose, or by pretreating with a histamine antagonist such as hydroxyzine.