Glycopeptide Antibiotic Pregnancy: Use only if clearly necessary — potential ototoxicity and nephrotoxicity in fetus; neonatal monitoring required

Vancomycin (Orthopaedic Bone and Joint Infections)

Brand names: Vancomycin, Vancocin

Adult dose

Dose: 25–30 mg/kg/day IV in divided doses (guided by AUC/MIC monitoring); Bone cement: 1–2 g per 40 g cement packet

Route: Intravenous (systemic); local (bone cement)

Frequency: Every 6–12 hours (systemic); single-use in cement (local)

Max: AUC/MIC guided — target AUC/MIC 400–600 µg·h/mL; typical daily dose 1.5–3 g

Slow infusion over 60–90 minutes per gram to prevent Red Man Syndrome (not allergy). MSSA infections: use flucloxacillin — vancomycin is inferior. MRSA or penicillin allergy: vancomycin first-line. AUC/MIC monitoring preferred over trough-only (ASHP/IDSA 2020 guideline).

Paediatric dose

Dose: 10–15 mg/kg

Route: Intravenous

Frequency: Every 6 hours

Max: 60 mg/kg/day (max 3 g/day)

Paediatric osteomyelitis — MSSA preferably treated with flucloxacillin; vancomycin for MRSA or allergy under specialist guidance

Dose adjustments

Renal

Dose reduction and extended dosing interval essential — vancomycin is renally cleared; serious accumulation in AKI/CKD; AUC/MIC monitoring mandatory in renal impairment

Hepatic

No dose adjustment for hepatic impairment — renally excreted

Paediatric weight-based calculator

Patient weight (kg)

Paediatric osteomyelitis — MSSA preferably treated with flucloxacillin; vancomycin for MRSA or allergy under specialist guidance

Clinical pearls

Red Man Syndrome vs true allergy: Red Man Syndrome (flushing, erythema) is NOT an allergy — it is a rate-dependent mast cell degranulation caused by rapid infusion; slow infusion over ≥60 minutes prevents it; pretreat with antihistamine if previously occurred; true vancomycin allergy is rare
ASHP/IDSA/SIDP 2020 guideline: AUC/MIC monitoring now recommended over trough-only monitoring — target AUC 400–600 µg·h/mL; daily trough-based targets (15–20 mg/L) are now considered outdated and associated with nephrotoxicity
Vancomycin bone cement: locally delivered vancomycin in antibiotic-laden cement (ALC) used in 2-stage revision arthroplasty for PJI — provides high local concentrations without systemic toxicity; standard in infected arthroplasty management
MSSA osteomyelitis: vancomycin is INFERIOR to flucloxacillin for MSSA — always check sensitivities; de-escalate from vancomycin to flucloxacillin when MSSA confirmed; do not continue empirical vancomycin if MSSA
Duration in osteomyelitis: 4–6 weeks IV (or switch to oral highly bioavailable agent — rifampicin + co-trimoxazole or rifampicin + clindamycin for MRSA after initial IV)

Contraindications

Known hypersensitivity to vancomycin
Rapid IV push administration (Red Man Syndrome and haemodynamic collapse)

Side effects

Red Man Syndrome — flushing, erythema, pruritus during infusion; rate-related, NOT allergy; slow infusion prevents it
Nephrotoxicity — especially in combination with aminoglycosides or loop diuretics
Ototoxicity — tinnitus and hearing loss at high trough levels
Thrombophlebitis — peripheral IV site

Interactions

Aminoglycosides (gentamicin, tobramycin) — additive nephrotoxicity; AVOID if possible; monitor closely if unavoidable
Loop diuretics (furosemide) — additive ototoxicity and nephrotoxicity
Neuromuscular blocking agents — enhanced neuromuscular blockade

Monitoring

Renal function and eGFR daily in acute settings
Vancomycin AUC/MIC (or trough 15–20 mg/L if AUC unavailable)
Audiometry if prolonged use or high levels
Signs of phlebitis at IV site

Reference: BNFc; BNF 90; ASHP/IDSA/SIDP Vancomycin Guideline 2020; IDSA Osteomyelitis Guidelines 2012; NICE NG15 (Antimicrobials); SPC Vancomycin. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways