Glycopeptide Antibiotic Pregnancy: Give in pregnancy only if clearly needed; monitor blood levels carefully (significantly increased doses may be required). Excreted in human milk - caution in nursing women.

Vancomycin (Orthopaedic Bone and Joint Infections)

Brand names: Vancomycin, Vancocin

Intravenous vancomycin is a glycopeptide antibacterial for serious Gram-positive infection such as MRSA, including bone and joint infection.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: 15-20 mg/kg

Route: Intravenous infusion

Frequency: Every 8 to 12 hours (patients aged 12 years and older)

Max: 2 g per dose

Orthopaedic bone and joint infection context: same IV dosing as general vancomycin. Suggested treatment duration for bone and joint infections is 4-6 weeks; longer courses of oral suppression treatment should be considered for prosthetic joint infections. Initial dose based on total body weight; subsequent doses adjusted to serum trough concentrations and renal function. Seriously ill patients: a loading dose of 25-30 mg/kg may be used. Peri-operative prophylaxis of bacterial endocarditis (all ages): initial 15 mg/kg prior to induction of anaesthesia; a second dose may be required depending on duration of surgery. Infuse slowly in a dilute solution (2.5-5.0 mg/mL) at no more than 10 mg/min over not less than 60 minutes. Must not be given intramuscularly. Where appropriate, use in combination with other antibacterials.

Paediatric dose

Route: Intravenous infusion

Frequency: Every 6 hours (infants and children from 1 month to less than 12 years)

Infants and children 1 month to <12 years: 10-15 mg/kg every 6 hours (range stated, not a single per-kg value). Term and preterm neonates: seek specialist advice; one possible regimen is 15 mg/kg with interval set by post-menstrual age (24-hourly if <29 weeks; 12-hourly 29-35 weeks; 8-hourly >35 weeks). Doses adjusted to serum trough levels and renal function. Verify against a children's formulary before prescribing.

Dose adjustments

Renal

In renal impairment prefer an initial starting dose followed by serum trough levels. Mild/moderate impairment: starting dose must not be reduced. Adults: usual start 15-20 mg/kg, which could be given every 24 hours for creatinine clearance 20-49 mL/min. Severe impairment (CrCl <20 mL/min) or on renal replacement therapy: prolong the dosing interval, base doses on trough levels. Critically ill with renal insufficiency: initial loading dose 25-30 mg/kg should not be reduced. No adjustment for hepatic impairment.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

US labelling (FDA)

Reference — US labelling, may differ from UK

DOSAGE AND ADMINISTRATION Infusion-related events are related to both the concentration and the rate of administration of vancomycin. Concentrations of no more than 5 mg/mL and rates of no more than 10 mg/min, are recommended in adults (see also age-specific recommendations). In selected patients in need of fluid restriction, a concentration up to 10 mg/mL may be used; use of such higher concentrations may increase the risk of infusion-related events. An infusion rate of 10 mg/min or less is associated with fewer infusion-related events (see ADVERSE REACTIONS ). Infusion-related events may occur, however, at any rate or concentration. Patients with Normal Renal Function Adults The usual …

Source: US FDA prescribing information (openFDA / DailyMed), label dated 2026-01-30. Accessed 2026-06-12. US dosing and indications can differ from UK practice — use UK sources for prescribing decisions.

Contraindications

Hypersensitivity to vancomycin
Must not be administered intramuscularly (risk of necrosis at the injection site)

Side effects

Flushing of the upper body ('vancomycin infusion reaction'), phlebitis, redness of upper body and face (common)
Renal insufficiency - increased serum creatinine and urea (common)
Decrease in blood pressure (common)
Dyspnoea, stridor (common); increased ALT/AST (common)
Transient or permanent hearing loss (uncommon); hypersensitivity/anaphylactic reactions (rare)

Interactions

Concurrent or sequential nephrotoxic/neurotoxic drugs (e.g. amphotericin B, aminoglycosides, bacitracin, polymyxin B, colistin, viomycin, cisplatin) - monitor renal function (US labelling)
Anaesthetic agents - associated with erythema and histamine-like flushing and anaphylactoid reactions
Other ototoxic substances (e.g. aminoglycosides) - increased risk of ototoxicity; concurrent/sequential use should be avoided

Clinical monograph

How it works

It inhibits bacterial cell-wall synthesis by binding cell-wall precursors, an action distinct from beta-lactams and active against many resistant Gram-positive organisms.

Prescribing in practice

It requires therapeutic drug monitoring (trough or AUC-guided) to balance efficacy against nephrotoxicity.
It is renally cleared and can cause nephrotoxicity and ototoxicity, with greater risk alongside other nephrotoxic or ototoxic drugs.
Infusing too rapidly can cause an infusion-related reaction (vancomycin flushing, formerly 'red-man' syndrome), so it is given as a slow infusion.

Monitoring

Monitor vancomycin levels (trough or AUC-guided), renal function and, with prolonged therapy, hearing; adjust dosing to the monitoring results.

Counselling the patient

Report flushing, rash or itching during the infusion, which may mean it is running too quickly.
Report any change in hearing, ringing in the ears or reduced urine output.

Evidence & guidelines

A mainstay for serious MRSA infection including bone and joint infection; monitored dosing is standard to optimise outcomes and limit toxicity.

Reference: ASHP/IDSA/SIDP Vancomycin Guideline 2020; IDSA Osteomyelitis Guidelines 2012; NICE NG15 (Antimicrobials); SPC Vancomycin; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

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