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Vancomycin Nursing Considerations & Implications | Bioavailable

Compound database
Glycopeptide antibiotics
Vancomycin

VancomycinNursing considerations

Known brand names include Vancocin.

A glycopeptide antibiotic given IV for serious gram-positive infections such as MRSA bloodstream, heart valve, bone, skin, and lung infections. Taken by mouth, it stays in the gut and treats C. difficile diarrhea. Kidney function, hearing, and blood levels need watching.

Nursing implications

Hold parameters

Do not give with hypersensitivity to vancomycin or polysorbate 80
Acute kidney injury: stop vancomycin or reduce the dose
Tinnitus, hearing loss, or vertigo: stop vancomycin
First sign of rash, mucosal lesions, or blisters: stop vancomycin
Infusion reaction (flushing, hypotension, wheezing): stop the infusion
Evaluate any diarrhea for C. difficile

Sources: [1][2][3][4][5][6]

Administration

IV: always dilute and infuse over 60 minutes or longer; never give by IV push
Dilute to 5 mg/mL or less in adults; up to 10 mg/mL only with fluid restriction, which raises reaction risk
Give before IV anesthetic agents when feasible
Use a secure IV line and rotate sites; never give IM, which causes pain and necrosis
Do not add other drugs to the bag; flush the line between vancomycin and beta-lactams
Oral: the reconstituted vial can be given by mouth or nasogastric tube, with a sweetener added if desired

Sources: [1][2][3][4][5][6]

Assess and report

Side effects by what to assess

GI

Oral use: nausea (17%), abdominal pain (15%), hypokalemia (13%), vomiting, diarrhea
C. difficile diarrhea with IV use (serious)

Skin and allergy

Vancomycin infusion reaction with rapid infusion: itching and flushing of the face, neck, and upper body
Severe skin reactions: SJS, TEN, DRESS, AGEP, linear IgA bullous dermatosis (serious)

IV site

Phlebitis and pain at the infusion site

Labs

Acute kidney injury (interstitial nephritis), rising BUN and creatinine (serious)
Reversible neutropenia, usually after a week or more of IV therapy (serious)

Hearing and balance

Ototoxicity: tinnitus, hearing loss, vertigo; may be permanent (serious)

Vital signs

Hypotension, shock, or cardiac arrest with rapid infusion; wheezing, chest and muscle pain (serious)

Sources: [1][2][3][4][5][6][7][8][9]

Labs and vitals

BUN (blood urea nitrogen)

Why: Acute kidney injury
When: With creatinine during therapy
Normal: 6 to 20 mg/dL.

Sources: [1][2]

Serum creatinine

Why: Acute kidney injury
When: During all IV therapy; during and after oral therapy in patients over 65
Act on: If acute kidney injury occurs, stop vancomycin or reduce the dose
Normal: 0.7 to 1.3 mg/dL in men and 0.5 to 0.95 mg/dL in women.

Sources: [1][2]

Vancomycin level (trough or AUC)

Why: Guide IV dosing and limit toxicity
When: During IV therapy, especially in seriously ill patients or with changing renal function
Act on: Adjust the dose based on trough levels

Sources: [1][2]

White blood cell count

Why: Neutropenia
When: Periodically during prolonged therapy or with other drugs that cause neutropenia
Normal: 4,500 to 11,000 per microliter.

Sources: [1][2]

Safety

High-alert status

Vancomycin is not on the ISMP acute care high-alert list.

Sources: [1]

Narrow therapeutic index

Narrow therapeutic index. The label directs measuring trough serum vancomycin levels to guide IV dosing, especially when kidney function is changing.

Sources: [1][2]

Boxed warning

None on the current label.

Sources: [1]

Antidote or reversal

No antidote. Give supportive care and protect kidney function. Standard dialysis removes little vancomycin; hemofiltration and hemoperfusion with polysulfone resin have increased clearance.

Sources: [1]

Patient teaching

Blood tests are needed to check vancomycin levels and kidney function
Report hearing loss, ringing in the ears, or balance problems
Flushing, itching, rash, chest or muscle pain, wheezing, or dizziness can happen during the infusion; tell the nurse right away
Stop and seek care at the first sign of rash, mouth sores, or blisters
Watery or bloody stools, even 2 or more months later, need prompt medical attention
Take every dose as directed and finish the course; antibiotics do not treat viral infections

Sources: [1]

Sound-alike and look-alike names

None listed in the ISMP list of confused drug names.

Sources: [1]

Dosing

Doses come from the FDA label. Study tool, not for clinical decisions.

Adult dose

Systemic infections, IV, normal renal function: 2 g per day, given as 500 mg every 6 hours, or alternatively 1 g every 12 hours; infuse each dose over at least 60 minutes. Age or obesity may call for changes.
C. difficile-associated diarrhea, oral: 125 mg by mouth 4 times daily for 10 days.
Staphylococcal enterocolitis, oral: 500 mg to 2 g per day by mouth, split into 3 or 4 doses, for 7 to 10 days.

Sources: [1][2]

Renal adjustment

Required. Give an initial IV dose of at least 15 mg/kg in any degree of renal impairment, then adjust using trough levels, especially in seriously ill patients with changing renal function. Functionally anephric: 15 mg/kg, then 1.9 mg/kg every 24 hours.

Sources: [1][2]

Hepatic adjustment

The label gives no hepatic dose adjustment.

Sources: [1]

How it works

Mechanism

Bactericidal. It mainly blocks bacterial cell wall synthesis, and it also changes cell membrane permeability and RNA synthesis. It is not active against gram-negative bacilli, mycobacteria, or fungi. It is poorly absorbed by mouth, so oral doses act only in the gut, and IV doses are needed for systemic infections.

Sources: [1][2][3]