Dose:    10 mg/kg/dose IV
              Oral dose: 10 mg/kg Q 6 hours
               

Frequency:   Q 8 hours > 28 weeks PCA
                       Q 12 hours < 28 weeks PCA
                       Q 12 hours if receiving indomethacin (we'll also adjust for ibuprofen) or if suspect significant renal injury
                                             

Comments: Vancomycin is bacteriocidal against most staphylococci, non-enterococcal streptococci, and most other gram positive bacteria including C. difficile. Staphylococcal organisms have higher minimum inhibitory concentrations (MICs) to vancomycin.  The MIC for coagulase negative Staphylococci is usually 2 mcg/mL and may be higher.   In order to have effective antimicrobial therapy the trough concentration of vancomycin should be 5 to 10 times the MIC. Because of these recent changes, the recommendation for trough levels have been increased to 10-20 mcg/ml. The trough level should be obtained before the 5th or 6th dose. The suggested dosage regimen used to achieve these trough levels is based on an report by de Hoog (Clin Pharmacol Ther 2000; 67:360-367).  Although routine peak levels may not be necessary, infants with severe asphyxia may have prolonged serum half-lives of vancomycin; the interval between doses should be increased and serum levels obtained during the first 24 to 48 hours. Alternatively, if the measured trough levels are less than 10, the dose interval should be increased (to 6 hours if using an eight hour dosing interval and to 8 hours if using a 12 hour dosing interval). Vancomycin concentrations in the CSF have ranged from 7% to 21% of serum levels. The drug is extremely irritating and may cause necrosis if the iv infiltrates. Several adverse reactions have followed the administration of vancomycin through UAC's so that this should be avoided if at all possible. Further comments vancomycin.
Although vancomycin is superior in treating methicillin-resistant Staph aureus (MRSA), it is a less-effective agent than are the beta-lactams against susceptible strains. This appears to be due to its relatively slow bactericidal effect. As a result, isolates that are methicillin- or penicillin-susceptible should be treated with beta-lactams. In addition, vancomycin is less effective in treating MRSA infections with MICs of 1 to 2 microgram/mL. In these situations, addition of another antimicrobial agent such as rifampin, clindamycin, linezolid, aminoglycocides, or trimethaprim-sulfamethoxazole may improve treatment outcomes.

Preparation:
IV: Vancomycin (Vancocin) will be prepared by the pharmacy in a 5 mg/ml concentration.  It can be prepared using D5W or D10W.  Vancomycin will ordinarily be prepared in batches. For a single dose (usually seen when ordered in D10W) add 10 ml SWFI to 500 mg vial. Stability is 96 hours after time of initial reconstitution if refrigerated. Using the 50 mg/cc concentration, draw up 10 ml and add to "piggy-back" iv bag. Inject an additional 90 ml of D5W or D10W to make a final concentration for infusion of 5 mg/ml. Stable at room temperature for 24 hours, though should be refrigerated after entering IV bag. Infuse over 60 minutes per infusion policy.

PO: Add 20 ml of distilled or deionized water to 1 gram bottle of vancomycin for oral solution. Mix thoroughly. This 50 mg/ml concentration is stable for 2 weeks if refrigerated. The dose may be diluted in water for ease of administration. It should be given between feedings on an empty stomach.

Compatibility: Compatible with TPN and TPN containing heparin if the concentration of heparin is 1 unit/ml or less (Martins. JPEN 1991; 15:536). There is no information about compatibility with lipids. [Vancomycin has been shown to be compatible with a TPN solution containing 20% dextrose, 3% amino acids, and 1 unit/ml heparin, with standard electrolytes and minerals for up to 8 hours at room temperature.] It was recommended to be infused below inline filters though it can be infused through 0.22-um cellulose filter. It is also compatible with sterile water for injection, D5W, D10W, D5W with sodium chloride, LR, NS, acyclovir, allopurinol, amikacin, amiodarone, atracurium, calcium gluconate, enalaprilat, erythromycin, esmolol, fentanyl, filgrastim, fluconazole, hydrocortisone, insulin, labetalol, lorazepam, magnesium sulfate, meropenem, midazolam, morphine,  pancuronium, potassium chloride, propofol, ranitidine, ticarcillin, tolazoline, vecuronium,  and zidovudine.  Incompatible with aminophylline, aztreonam, ceftazidime, cefotaxime, chloramphenicol, chlorothiazide, dexamethasone, hydrocortisone, methicillin, penicillin G potassium, phenobarbital, phenytoin, and piperacillin-tazobactam. It has equivocal stability with heparin [low concentrations (1 unit/ml or less) are compatible while high concentrations (50-12,000 units/ml) cause immediate precipitation] and sodium bicarbonate.