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Vancomycin

Glycopeptide antibacterial agent · Antibiotic

Also known as Vancomycin hydrochloride, Vancocin, Vancor

START
Obtain baseline SCr, CBC. Load with 20-35mg/kg (actual body weight, max 3g) in critically ill. Obtain levels (2 levels for AUC or trough) to guide dosing. Infuse over ≥1 hour (≥10mg/min to prevent red man syndrome).
TYPICAL MAX
No fixed max—driven by AUC/MIC target. Single doses >3g not recommended due to infusion reactions.
STOP IF
Severe nephrotoxicity (SCr doubling), severe ototoxicity, anaphylaxis, profound myelosuppression.
WATCH
Therapeutic drug monitoring (TDM) essential—target AUC/MIC 400-600 (preferred) or trough 10-15 mcg/mL (uncomplicated) / 15-20 mcg/mL (serious infections). Nephrotoxicity risk increased with concurrent piperacillin-tazobactam, aminoglycosides. Infuse over ≥1 hour. Oral vancomycin only for C. difficile (IV does not reach colonic lumen).
CDSCO approvedSchedule HATC J01XA01
Dose laddermg/d
125start500titrate1ktitrate1.5ktitrate3kceiling
Renal dose adjustmenteGFR mL/min/1.73m²
FULL15-20mg/kg q8-12h50REDUCE15-20mg/kg q24h20REDUCE15-20mg/kg…10REDUCEHD: 7.5-10…≥90

KDIGO 2024 + manufacturer label

Pharmacokineticsplasma · t hours
1hONSET2hPEAK5ht½8hDURATION
ONSET
1h · Onset ~1 hour
PEAK
2h · Post-infusion peak
t½
5h · t½ 4-6h (normal); 150-250h (anuric)
DURATION
8h · q8-12h dosing interval
EXCRETION
Renal unchanged (~85%)
route + CYP
INTERACTIONS
12 major
SEVERE in our sources
PREGNANCY
Crosses placenta; no teratogenic effects documented. Oral vancomycin for C. difficile is minimally absorbed and safe. Use when clinically indicated.
FDA category + note
Top interactionssee all 12 →
  • AmikacinSevereDatabaseKimi deep-research + Cla
  • AminoglycosidesSevereDatabaseKimi deep-research + Cla
  • CidofovirSevereDatabaseDDInter
  • ColistinSevereDatabaseKimi deep-research + Cla
Available in India

128 branded formulations. Look up specific brands in the Drugs workspace.

Mechanism

Inhibits bacterial cell wall synthesis by binding to D-alanyl-D-alanine termini of peptidoglycan precursors, preventing cross-linking and causing cell lysis. Bactericidal against dividing organisms.

Indications

Severe MRSA infections (bacteremia, endocarditis, pneumonia, skin/soft tissue)C. difficile colitis (oral only—IV does not achieve colonic lumen concentrations)Severe infections due to methicillin-resistant Staphylococcus epidermidisEndocarditis prophylaxis in penicillin-allergic patientsMeningitis (shunt-related, MRSA; intrathecal/IV)

Dosing

Adult
Loading dose: 20-35mg/kg IV (actual body weight, max 3g). Maintenance: 15-20mg/kg IV q8-12h (adjust for renal function). Target AUC/MIC 400-600. C. difficile: 125mg PO QID x 10 days (first recurrence: tapered/pulsed regimen; fidaxomicin preferred for recurrence).
Pediatric
Neonates: 10-15mg/kg IV q8-24h (age-dependent). Children: 40-60mg/kg/day divided q6h. Target AUC/MIC 400-600.
Renal adjustment
Extend interval based on CrCl or use Bayesian dosing. Loading dose unchanged. q24h if CrCl 20-50; q48-96h if CrCl <20; hemodialysis: redose post-HD (7.5-10mg/kg).
Hepatic adjustment
No adjustment needed (renally eliminated).
Geriatric
Use adjusted body weight; higher risk of nephrotoxicity and ototoxicity; monitor levels closely.
Max dose
No absolute max; usual max single dose 3g (loading). Dose based on AUC/MIC target.

Pharmacokinetics

Onset
Bactericidal effect within hours; clinical improvement 48-72 hours
Peak effect
Post-infusion peak; AUC drives efficacy (AUC/MIC 400-600 target)
Duration
Dose-dependent; trough concentrations maintained between doses
Half-life
4-6 hours (normal renal function); 150-250 hours (anuric patients)
Bioavailability
Poor oral absorption (<5%); IV bioavailability 100%
Protein binding
10-50% (average ~30%)
Metabolism
Not metabolized (no hepatic metabolism)
Excretion
~80-90% unchanged in urine via glomerular filtration

Contraindications

  • Hypersensitivity to vancomycin
  • Severe hearing loss (relative—ototoxicity risk)

Side effects

Common
Nephrotoxicity (dose-dependent, reversible)Infusion-related reaction (red man syndrome—histamine release, not allergy)Phlebitis at infusion siteNausea (oral)Hypokalemia
Serious
  • Nephrotoxicity (acute kidney injury—especially with aminoglycosides, piperacillin-tazobactam)
  • Ototoxicity (irreversible hearing loss—rare, usually with high troughs or concurrent aminoglycosides)
  • Severe hypersensitivity/anaphylaxis (rare)
  • Neutropenia / thrombocytopenia
  • Myositis
  • DRESS syndrome

Pregnancy & lactation

Pregnancy

Crosses placenta; no teratogenic effects documented. Oral vancomycin for C. difficile is minimally absorbed and safe. Use when clinically indicated.

Lactation

Excreted in breast milk in low concentrations; oral absorption in infant minimal. Compatible with breastfeeding for oral use; monitor infant for GI upset.

Drug interactions

Amikacin
Severe
Database

Additive nephrotoxicity. Both drugs are independently nephrotoxic; combined use significantly increases risk of acute kidney injury.

Monitor renal function closely (daily creatinine). Consider TDM for both drugs. Limit duration of combination. If creatinine rises >0.5 mg/dL, discontinue one or both.

Source: Kimi deep-research + Cla

Aminoglycosides
Severe
Database

Synergistic nephrotoxicity and ototoxicity; additive kidney damage.

Avoid if possible; if essential, monitor renal function and drug levels closely. Space doses apart.

Source: Kimi deep-research + Cla

Cidofovir
Severe
Database

Drug interaction classified as: synergy

Source: DDInter

Colistin
Severe
Database

Additive nephrotoxicity; both are renally cleared and nephrotoxic

Monitor renal function daily; consider alternatives

Source: Kimi deep-research + Cla

Deferasirox
Severe
Database

.

Source: DDInter

Diatrizoate
Severe
Database

Clinical effect not specified

Source: DDInter

Everolimus
Severe
Database

Clinical effect not specified

Source: DDInter

Gentamicin
Severe
Database

Additive nephrotoxicity. Both drugs are independently nephrotoxic; combined use significantly increases risk of acute kidney injury.

Monitor renal function closely (daily creatinine). Limit duration of combination. If creatinine rises >0.5 mg/dL, discontinue one or both.

Source: Kimi deep-research + Cla

Human Cytomegalovirus Immune Globulin
Severe
Database

Clinical effect not specified

Source: DDInter

Inotersen
Severe
Database

Clinical effect not specified

Source: DDInter

Iodipamide
Severe
Database

Clinical effect not specified

Source: DDInter

Iodixanol
Severe
Database

.

Source: DDInter

Related guidelines

Infective endocarditis prevention
NICE · Cardiology / Dentistry · 2008
Infective endocarditis prevention
AHA · Cardiology / Dentistry · 2007
Skin and soft tissue infections
IDSA · Infectious Diseases · 2010
Community-acquired pneumonia
ICMR · Pulmonology · 2022
Infective endocarditis prevention
ADA_DENTAL · Dentistry · 2015

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Sources: KD Tripathi 7e, Goodman & Gilman 14e, Harrison 22e, Katzung·Verified: 2026-05-19 · House clinical team·Cockpit curated: 2026-05-19