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Glycopeptide Antibiotic — MRSA / Severe Gram-Positive Infections in Children Pregnancy: Use with caution — limited data; crosses placenta; fetal ototoxicity theoretical; use only for serious MRSA infections

Vancomycin (Paediatric)

Brand names: Vancocin, Vancomycin Hydrochloride

Adult dose

Dose: 15–20 mg/kg IV every 8–12 hours (AUC-guided dosing now preferred)
Route: IV infusion over 60 minutes (min) — rate-dependent red man syndrome
Frequency: Every 8–12 hours
Max: Guided by TDM (AUC/MIC target 400–600)
Adult reference — see paediatric dose section

Paediatric dose

Dose: Neonates: 15 mg/kg every 12–24 hours (gestational-age dependent); Children 1 month–18 years: 15 mg/kg every 6 hours (up to 60 mg/kg/day) mg/kg
Route: IV infusion — minimum 60 minutes (rate max 10 mg/min to prevent red man syndrome)
Frequency: Every 6–24 hours (age and renal function dependent)
Max: 60 mg/kg/day (children); guided by AUC/MIC TDM
BNFc: neonates — TDM essential; check trough before 3rd dose (target trough 10–15 mg/L for most indications; 15–20 mg/L for CNS/endocarditis). UK moving toward AUC-guided TDM (target AUC/MIC 400–600 mg·h/L) — Bayesian TDM software recommended. Red man syndrome (flushing, erythema, hypotension): not allergy — histamine release from rapid infusion; slow infusion rate and/or pre-treat with antihistamine.

Dose adjustments

Renal

Extend interval based on renal function and TDM; CrCl <30: every 24–48 hours with TDM

Hepatic

No dose adjustment required

Paediatric weight-based calculator

BNFc: neonates — TDM essential; check trough before 3rd dose (target trough 10–15 mg/L for most indications; 15–20 mg/L for CNS/endocarditis). UK moving toward AUC-guided TDM (target AUC/MIC 400–600 mg·h/L) — Bayesian TDM software recommended. Red man syndrome (flushing, erythema, hypotension): not allergy — histamine release from rapid infusion; slow infusion rate and/or pre-treat with antihistamine.

Clinical pearls

  • Red man syndrome vs anaphylaxis: red man syndrome is rate-related histamine release — occurs during infusion, flush pattern on face/neck/trunk, not IgE-mediated; slow infusion to 90 minutes or add chlorphenamine pretreatment; true vancomycin allergy (anaphylaxis with urticaria, bronchospasm) is much rarer
  • AUC-guided TDM is now preferred over trough-only monitoring — trough alone is poor surrogate for AUC; Bayesian software (DoseMeRx, InsightRx) calculates individualised AUC from 2 levels (peak and trough)
  • MRSA meningitis/ventriculitis: vancomycin has limited CNS penetration — consider adding rifampicin or intrathecal vancomycin (specialist decision)
  • Neonates: vancomycin + gentamicin combination is standard empirical therapy for late-onset neonatal sepsis (MRSA, CONS cover + gram-negative cover)

Contraindications

  • Hypersensitivity to vancomycin

Side effects

  • Red man syndrome (histamine-mediated, infusion rate-dependent)
  • Nephrotoxicity (especially with aminoglycosides)
  • Ototoxicity (with high levels or concurrent aminoglycosides)
  • Thrombophlebitis (peripheral IV)
  • Neutropenia (prolonged courses)
  • DRESS syndrome (rare)

Interactions

  • Aminoglycosides — additive nephrotoxicity and ototoxicity (frequent combination in neonates — requires close TDM)
  • Loop diuretics — additive ototoxicity
  • Anaesthetic agents — enhanced hypotension if given rapidly
  • Neuromuscular blocking agents — enhanced blockade

Monitoring

  • Trough levels (target 10–15 mg/L standard; 15–20 mg/L CNS/endocarditis) OR AUC/MIC (Bayesian)
  • Renal function (daily in acute setting)
  • FBC (neutropenia — weekly if prolonged)
  • Audiometry (prolonged courses)
  • Infusion site inspection

Reference: BNF for Children; BSAC Vancomycin TDM Guidelines 2020 (AUC-based); NICE NG195 (Neonatal Infection); IDSA MRSA Guidelines 2011. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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