Vancomycin IV

Vancomycin IV

C difficile risk
Oral Bioavailability


This antimicrobial is currently protected in the Saskatoon and Athabasca areas. Therapy is UNRESTRICTED for the first 72 hours of therapy after which Infectious Diseases approval is required for continuation of therapy (see below for exceptions/rules).

Approval may be granted via phone conversation or formal consult and must be reflected in the patient orders section.

The following conditions are also in place:

  •  Nephrologists are authorized to prescribe without ID approval for renal diseases

  •  Vancomycin may be used for surgical prophylaxis for up to 24 hours post-operatively in patients with documented penicillin allergy (anaphylaxis) or patients who are known to be MRSA carriers/colonized (ID approval is required for continuation of therapy beyond 24 hours)

General Information

Suspected or proven MRSA, coagulase-negative Staphylococcal infections, Enterococcal spp. infections.


  • Inpatients: at baseline then twice weekly

  • Outpatients: at baseline then once weekly

  • More frequent monitoring may be required if fluctuating renal status or multiple risk factors for nephrotoxicity (e.g. target trough 15-20 mg/L, baseline SCr greater than 100 micromol/L, BMI greater than or equal to 40 kg/m², concurrent nephrotoxins, daily dose greater than 4000 mg, when SCr is a poor indicator of renal function)

Hydration status

VANCOMYCIN TROUGH CONCENTRATION MONITORING To be drawn 30 minutes prior to the next dose once at steady state Repeat concentrations every 5-7 days if hemodynamically stable, concentrations may be required earlier if hemodynamically unstable or BMI greater than 40 kg/m² when total daily dose greater than 4000 mg

Therapeutic drug monitoring NOT required for:

  • Anticipated short course of therapy (less than 5 days) AND hemodynamically stable

  • Treating non-Staphylococcal aureus indications EXCEPT in cases of anticipated prolonged therapy (e.g. Enterococcal spp. endocarditis)

Goal Trough 10-20 mg/L if treating:

  • skin and soft tissue infection

  • urinary tract infection

  • bloodstream or line infections due to Coagulase Negative Staphylococci (CoNS)

  • Other infections due to Enterococci spp.

  • any other infection not specified in goal 15-20 mg/L category

Goal Trough 15-20 mg/L if treating:

  • any patient on renal replacement therapy or dialysis

  • deep-seated or sequestered infections (e.g. abscess) and/or invasive infections where antibiotic penetration may be compromised/decreased (e.g. CNS infections, osteomyelitis, empyema etc.)

  • pneumonia due to MRSA or HAP/VAP (where MRSA suspected or confirmed)

  • other infections due to S. aureus with vancomycin MIC greater than or equal to 1 mg/L

  •  Nephrotoxicity

  •  Cytopenias

  •  Rash including Stevens-Johnson Syndrome

  •  Red man syndrome (histamine release- slow down infusion)

Aminoglycosides may potentiate nephrotoxicity.

May enhance neuromuscular blockade of NM blocking agents.

Careful with concomitant nephrotoxins.

Antimicrobial class: Glycopeptide

Pregnancy category: C

Average serum half life: 8 hours

Biliary penetration: Moderate

CSF penetration: Moderate

Lung penetration: Therapeutic

Urine penetration: Therapeutic

Route of Elimination: Renal

Target concentrations vary widely based upon site of infection and organism.

Consult Infectious Diseases or Pharmacy for target recommendations and dosing assistance.