Glycopeptide Antibiotic — MRSA / Severe Gram-Positive Infections in Children Pregnancy: Teratology studies in rats and rabbits revealed no evidence of harm to the foetus; vancomycin was found in cord blood in a controlled clinical study, in which no sensorineural hearing loss or nephrotoxicity attributable to vancomycin was noted. Because vancomycin was administered only in the second and third trimesters, it is not known whether it causes foetal harm. Vancomycin should be given in pregnancy only if clearly needed and blood levels should be monitored carefully to minimise the risk of foetal toxicity; pregnant patients may require significantly increased doses to achieve therapeutic serum concentrations. Breast-feeding: vancomycin hydrochloride is excreted in human milk — caution should be exercised in nursing women (eMC §4.6).

Vancomycin (Paediatric)

Brand names: Vancocin, Vancomycin Hydrochloride

Vancomycin is a glycopeptide antibiotic used in children for serious Gram-positive infections including MRSA, and given orally for Clostridioides difficile 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: Patients aged 12 years and older: 15 to 20 mg/kg of body weight every 8 to 12 hours (not to exceed 2 g per dose). In seriously ill patients, a loading dose of 25-30 mg/kg of body weight can be used to facilitate rapid attainment of target trough serum vancomycin concentration.

Route: Intravenous infusion. Vancomycin should be infused slowly in a dilute solution (2.5 to 5.0 mg/mL) at a rate no greater than 10 mg/min and over a period not less than 60 minutes to avoid rapid infusion-related reactions (eMC §4.4). Vancomycin must NOT be administered intramuscularly due to the risk of necrosis at the site of administration (§4.3).

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

Max: Not to exceed 2 g per dose (patients aged 12 years and older). Administration ceiling (§4.4): infuse in a dilute solution of 2.5 to 5.0 mg/mL, at a rate no greater than 10 mg/min, over not less than 60 minutes — rapid bolus administration (i.e. over several minutes) may be associated with exaggerated hypotension (including shock and, rarely, cardiac arrest), histamine-like responses, and maculopapular or erythematous rash.

Source: eMC SPC for Vancomycin 1000 mg powder for concentrate for solution for infusion (§4.2). Where appropriate, vancomycin should be administered in combination with other antibacterial agents. The initial dose should be based on total body weight; subsequent dose adjustments should be based on serum concentrations to achieve targeted therapeutic concentrations, and renal function must be taken into consideration for subsequent doses and interval of administration. Peri-operative prophylaxis of bacterial endocarditis in ALL age groups: an initial dose of 15 mg/kg prior to induction of anaesthesia; depending on the duration of surgery, a second vancomycin dose may be required. Suggested treatment durations (tailor to type and severity of infection and individual clinical response): complicated skin and soft tissue infections — non-necrotizing 7 to 14 days, necrotizing 4 to 6 weeks (continue until further debridement is not necessary, the patient has clinically improved and is afebrile for 48 to 72 hours); bone and joint infections 4 to 6 weeks (longer courses of oral suppression treatment should be considered for prosthetic joint infections); community-acquired pneumonia 7 to 14 days; hospital-acquired pneumonia including ventilator-associated pneumonia 7 to 14 days; infective endocarditis 4 to 6 weeks (duration and need for combination therapy is based on valve type and organism). Elderly: lower maintenance doses may be required due to the age-related reduction in renal function. Obese patients: the initial dose should be individually adapted according to total body weight as in non-obese patients. Pregnancy: significantly increased doses may be required to achieve therapeutic serum concentrations. Hepatic impairment: no dose adjustment needed. CAPTURE CAVEATS for the clinician verifier: (1) the ORAL administration posology was truncated in the fetched text ('Oral administration Patients aged 12 years and ...') and is therefore NOT reproduced here — source the oral (e.g. Clostridioides difficile) regimen separately; (2) eMC §4.5 (interactions) was not included in the fetched bundle — the interactions listed below are drawn from eMC §4.4 and from the US label as tagged, and must be verified against SPC §4.5; (3) less-than / greater-than comparator symbols were stripped from the neonatal PMA table and the paediatric renal table when the SPC text was captured — verify those thresholds against the source SPC.

Paediatric dose

Dose: 10 mg/kg

Route: Intravenous infusion, in a dilute solution (2.5 to 5.0 mg/mL), at a rate no greater than 10 mg/min and over a period not less than 60 minutes. Must NOT be given intramuscularly (risk of necrosis at the site of administration).

Frequency: Every 6 hours — infants and children aged from one month to less than 12 years of age: the recommended dose is 10 to 15 mg/kg body weight every 6 hours (eMC §4.2; dosePerKg records the lower bound of the stated 10-15 mg/kg range)

Max: No per-dose milligram cap is stated by the SPC for the 1 month to under 12 years band (the 'not to exceed 2 g per dose' cap is stated for patients aged 12 years and older, who receive 15 to 20 mg/kg every 8 to 12 hours). MANDATORY ADMINISTRATION CEILING (§4.4): dilute to 2.5 to 5.0 mg/mL and infuse at a rate no greater than 10 mg/min over not less than 60 minutes — rapid bolus administration may cause exaggerated hypotension (including shock and, rarely, cardiac arrest), histamine-like responses and rash.

Exact SPC wording (§4.2): 'Infants and children aged from one month to less than 12 years of age: The recommended dose is 10 to 15 mg/kg body weight every 6 hours.' The initial dose should be based on total body weight; subsequent dose adjustments should be based on serum concentrations to achieve targeted therapeutic concentrations, with renal function taken into account for subsequent doses and dosing interval. AGED 12 YEARS AND OLDER: 15 to 20 mg/kg every 8 to 12 hours (not to exceed 2 g per dose); in seriously ill patients a loading dose of 25-30 mg/kg may be used. NEONATES (term, birth to 27 days of post-natal age; preterm, birth to expected date of delivery plus 27 days): the SPC states that for establishing the dosing regimen in neonates the advice of a physician experienced in the management of neonates should be sought, and gives 'one possible way of dosing' by post-menstrual age (PMA) — PMA 29 weeks: 15 mg/kg every 24 hours; PMA 29-35 weeks: 15 mg/kg every 12 hours; PMA 35 weeks: 15 mg/kg every 8 hours. The comparator symbols on the first and third PMA rows were stripped when the source text was captured — verify against the SPC. PERI-OPERATIVE PROPHYLAXIS OF BACTERIAL ENDOCARDITIS (all age groups): initial dose 15 mg/kg prior to induction of anaesthesia; a second dose may be required depending on the duration of surgery. US labelling (cross-check only, may differ from the UK SPC) states 10 mg/kg per dose every 6 hours for paediatric patients, each dose administered over a period of at least 60 minutes. Concomitant administration of vancomycin and anaesthetic agents has been associated with erythema and histamine-like flushing in paediatric patients (US labelling). Verify against a children's formulary before prescribing in under-18s.

Dose adjustments

Renal

Paediatric patients aged 1 year and older — dose adjustments could be based on eGFR by the revised Schwartz formula (eGFR mL/min/1.73 m2 = height cm x 0.413 / serum creatinine mg/dL, or height cm x 36.2 / serum creatinine micromol/L). Orientative eMC §4.2 paediatric table (comparator symbols stripped in capture — verify against the SPC): GFR 50-30 mL/min/1.73 m2 — 15 mg/kg 12-hourly; GFR 29-10 — 15 mg/kg 24-hourly; GFR 10 — 10-15 mg/kg, re-dose based on levels; intermittent haemodialysis, peritoneal dialysis and continuous renal replacement therapy — 15 mg/kg, re-dose based on levels. For neonates and infants below 1 year of age, expert advice should be sought as the revised Schwartz formula is not applicable to them. In adult and paediatric patients with renal impairment, consideration should be given to an initial starting dose followed by serum vancomycin trough levels rather than a scheduled dosing regimen; in mild or moderate renal failure the starting dose must not be reduced, and in severe renal failure it is preferable to prolong the interval of administration rather than administer lower daily doses. Vancomycin is poorly dialyzable by intermittent haemodialysis, but high-flux membranes and CRRT increase clearance and generally require replacement dosing. In the critically ill patient with renal insufficiency the initial loading dose (25 to 30 mg/kg) should not be reduced. Hepatic impairment: no dose adjustment needed.

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.

Paediatric weight-based calculator

Patient weight (kg)

Verify in a children's formulary

Contraindications

Hypersensitivity to the active substance
Must not be administered intramuscularly, due to the risk of necrosis at the site of administration

Side effects

Flushing of the upper body ('vancomycin infusion reaction'), exanthema and mucosal inflammation, pruritus, urticaria (common); phlebitis and redness of the upper body and face (common)
Renal insufficiency, manifested primarily by increased serum creatinine and serum urea (common); interstitial nephritis and acute renal failure (rare)
Decrease in blood pressure (common); vasculitis (rare); cardiac arrest (very rare)
Dyspnoea, stridor (common); increased alanine aminotransferase and aspartate aminotransferase (common)
Transient or permanent loss of hearing (uncommon); vertigo, tinnitus, dizziness (rare); hypersensitivity and anaphylactic reactions (rare); severe cutaneous adverse reactions including Stevens-Johnson syndrome, toxic epidermal necrolysis, DRESS and AGEP

Interactions

(eMC §4.4) Other ototoxic active substances such as aminoglycosides — increased risk of ototoxicity; concurrent or sequential use of other ototoxic substances should be avoided, and vancomycin should also be avoided in patients with previous hearing loss
(eMC §4.4) Other medications which may cause neutropenia or agranulocytosis — monitor the leukocyte count at regular intervals during longer-term or concurrent use
(eMC §4.4) Teicoplanin — use vancomycin with caution in patients with allergic reactions to teicoplanin, since cross hypersensitivity including fatal anaphylactic shock may occur
(US labelling) Anaesthetic agents — associated with erythema and histamine-like flushing (reported in paediatric patients) and anaphylactoid reactions
(US labelling) Concurrent and/or sequential systemic or topical use of other potentially neurotoxic and/or nephrotoxic drugs such as amphotericin B, aminoglycosides, bacitracin, polymyxin B, colistin, viomycin or cisplatin — monitor renal function
(eMC §4.2) Medicinal products that may reduce vancomycin clearance and/or potentiate its undesirable effects — give appropriate consideration when co-administered

Clinical monograph

How it works

It inhibits bacterial cell-wall synthesis by binding the D-alanyl-D-alanine terminus of peptidoglycan precursors; oral vancomycin acts locally in the gut lumen and is minimally absorbed.

Prescribing in practice

Intravenous vancomycin is nephrotoxic and ototoxic and requires therapeutic drug monitoring with dose individualisation in children, while rapid infusion can cause an infusion reaction so it must be given slowly.
Renal function strongly influences clearance, so dosing must account for renal impairment and concurrent nephrotoxic drugs.
Intravenous and oral routes are not interchangeable; oral is for gut infection only and intravenous dosing should be confirmed against a children's formulary and local microbiology advice.

Monitoring

Monitor vancomycin levels (target trough or AUC per local policy) together with renal function, and watch for infusion reactions and, with prolonged use, hearing changes.

Counselling the patient

The intravenous medicine is given slowly to avoid a flushing reaction.
Blood tests are needed to keep the dose in the safe and effective range.
Report any change in hearing, balance or urine output during treatment.

Evidence & guidelines

Vancomycin is a standard agent for serious paediatric MRSA and Gram-positive infection and for C. difficile, with therapeutic drug monitoring recommended to balance efficacy and toxicity.

Reference: BSAC Vancomycin TDM Guidelines 2020 (AUC-based); NICE NG195 (Neonatal Infection); IDSA MRSA Guidelines 2011; 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).

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