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Part III: Guidelines for selected antimicrobial use

3.1 Vancomycin

3.1.1 Situations in which the use of vancomycin is appropriate

  1. Treatment of serious infections caused by ß-lactam resistant Gram-positive bacteria (e.g. MRSA, coagulase-negative staphylococci) (135–136).
  2. Treatment of CA-MRSA in severe and extensive skin and soft tissue infection (multiple sites), rapid progression of cellulitis, immunosuppression, extremes of age, site of infection difficult to drain (11).
  3. Treatment of infections caused by Gram-positive bacteria in patients who have serious allergies to ß-lactam antibiotics (e.g. anaphylactic reaction, Stevens-Johnson syndrome).
  4. When Clostridium difficile colitis fails to respond to metronidazole therapy or is severe and life-threatening (137–138).
  5. As prophylaxis for endocarditis before dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth, or perforation of the oral mucosa in inpatients at high risk for endocarditis; according to recommendation from the American Heart Association (139–140).
  6. As prophylaxis for major surgical procedures involving the implantation of prosthetic material or devices in known carriers of MRSA in addition to the routine regimen. For elective procedures, daily washing of skin and hair with a suitable antiseptic soap (e.g. 4% chlorhexidine liquid soap) and topical treatment of the anterior nares with nasal mupirocin ointment (for 3 to 5 days) are recommended before the procedures. Vancomycin may be less effective in preventing surgical wound infection due to methicillin-sensitive staphylococci (141).


3.1.2 Situations in which the use of vancomycin is not advised

  1. Treatment of MRSA nasal carriage or colonisation at other sites such as the isolation of MRSA from:
    • Surface swab of superficial wounds
    • Surface swab of chronic ulcers
    • Surface swab of pressure ulcers
  2. Routine surgical prophylaxis other than in a patient who has serious allergy to ß-lactam antibiotics.
  3. Vancomycin is not a standard part of empirical antibiotic therapy for neutropenic fever, except in known MRSA carriers, haemodynamically unstable neutropenic patients or in presence of severe oral mucositis (142).
  4. Treatment in response to a single blood culture positive for coagulase-negative staphylococci, if other blood cultures taken during the same time frame are negative.
  5. Continued empirical use for presumed infections in patients whose cultures (blood, joint fluid, peritoneal fluid, pus, etc.) are negative for ß-lactam-resistant Gram-positive bacteria (e.g. MRSA).
  6. Systemic or local (e.g. antibiotic lock) prophylaxis against infection (or colonisation) of indwelling (central or peripheral) intravascular catheters.
  7. As routine prophylaxis, before insertion of Hickman/Broviac catheter or Tenckhoff catheter.
  8. Primary treatment of Clostridium difficile colitis, except when it is severe and life-threatening.
  9. Routine prophylaxis for patients on continuous ambulatory peritoneal dialysis or haemodialysis.
  10. Treatment (e.g. chosen for dosing convenience) of infection caused by ß-lactam-sensitive Gram-positive bacteria in patients who have renal failure.
  11. Use of vancomycin solution for topical application (e.g. to burn wound, ulcers) or irrigation (e.g. of T-tube, drains).


3.1.3 Vancomycin dosing

  1. In adults, the standard recommended dose of vancomycin is 30 mg/kg/day (I.V. 1 g q12h or I.V. 0.5 g q6h in a normal 70 kg person).
  2. In seriously ill patients with suspected MRSA infection, a loading dose of 25–30 mg/kg of actual body weight may be considered.
  3. For individual doses over 1g, infuse over 1.5–2 hours (143).


3.1.4 Dosing in patients with impaired renal function

  1. For daily dosing based on creatinine clearance when it can be accurately measured or estimated, see Table 3.1 (this table is not suitable for functionally anephric patients).
  2. An initial single dose of 15mg/kg should be given.
  3. For anuric patient, 1g every 7–10 days.


Table 3.1 Dosage table for vancomycin using creatinine clearance (144)

Creatinine clearance Dosing
>50 mL/min 500 mg I.V. every 6–12 hours
10–50 mL/min 500 mg I.V. every 24–48 hours
<10 mL/min 500 mg I.V. every 48–96 hours


3.1.5 Therapeutic drug monitoring

  • Usage of vancomycin therapeutic drug monitoring as a guide to treat MRSA infections is controversial (145–147).
  • Vancomycin therapeutic drug monitoring can be considered in patients with impaired renal function (147), in order to avoid vancomycin-related nephrotoxicity.