Vancomycin shortage

You read that correctly, folks. As you may already know, there is a nation-wide shortage of vancomycin, in part due to increasing demand. Before starting the medication empirically, it may be important to review the indications, spectrum, dosing, and  pharmacokinetics of this antibiotic titan.

Vancomycin

– Indications:
  • Documented methicillin-resistant staphylococcus aureus infections
  • Treatment of gram-positive infections in patients with serious B-lactam allergies
  • Empiric treatment for patients at risk for MRSA (prior documented infection, prior antibiotic therapy, indwelling catheter, prolonged hospitalization/nursing home, high prevalence of community-acquired MRSA)
  • Treatment of ampicillin-resistant enterococcal infections (if vancomycin susceptible)
  • Treatment of community-acquired meningitis (in addition to ceftriaxone) and post-neurosurgical meningitis (in addition to cefepime or meropenem)
  • Surgical prophylaxis for procedures involving implantation of prostheses in patients allergic to B-lactams
– Spectrum:
  • Aerobic gram-positive cocci: bactericidal against staphylococcal and non-enterococcal streptococci
  • Enterococcal infections, if systemic, may require synergistic treatment with gentamicin
  • Gram-positive bacilli: diptheroids, Clostridium spp, Bacillus spp
– MIC and Resistance patterns
  • Resistant gram-positives: some Lactobacillus spp, Erysipelothrix spp, Pediococcus spp
  • MRSA: MIC ≤ 2 = sensitive; MIC ≥ 16 = resistant
  • Streptococci: MIC ≤ 1 = sensitive
  • Other: MIC ≤ 4 = sensitive; MIC ≥ 32 = resistant
– Dosing:
  • CrCl > 60 ml/min: 10-15 mg/kg q12h
  • 40-60 ml/min: 10-15 mg/kg q12-24h
  • 20-40 ml/min: 5-10 mg/kg q24h
  • 10-120 ml/min: 5-10 mg/kg load, then 500mg IV post HD only
  • Single dose should not exceed 2 grams
– Pharmacokinetics
  • Half-life 6-8 hours in adults with normal renal function
  • For renal insufficiency, see dosing recommendations above
  • Trough levels:
    • goal 10-15 for most cases
    • goal 15-20 for for CNS infections, endocarditis, VAP, or osteomyelitis
    • Patients at risk for nephrotoxicity at higher trough levels
  • To reduce the risk of the Red Man Syndrome (a histamine response that causes flushing, tachycardia, and hypotension), doses should be infused slowly

For more about the vancomycin shortage, check out the links below: