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Vancomycin (Vancocin)

Glycopeptide antibiotic (high-alert)

Mechanism of action

Binds the D-alanyl-D-alanine terminus of bacterial cell wall precursors, blocking cell wall synthesis. Bactericidal against gram-positive organisms, including MRSA. IV for systemic gram-positive infections; ORAL for C. difficile colitis (oral vancomycin is not absorbed, so it stays in the gut where it's needed).

Adverse effects

Life-threatening / NCLEX-tested

  • Vancomycin infusion reaction ("red man syndrome") — flushing, pruritus, hypotension from rapid infusion; histamine release, NOT a true allergy; slow the rate, premedicate with antihistamine
  • Nephrotoxicity — risk rises with high troughs and concurrent nephrotoxins
  • Ototoxicity (less than aminoglycosides, but real with high levels)
  • Severe thrombocytopenia (rare)
  • DRESS syndrome / Stevens-Johnson (rare)
  • True anaphylaxis (rare and distinct from red man syndrome)

Side effects

Common — what to teach

  • Phlebitis at peripheral IV site
  • Mild rash
  • Fever (drug fever)
  • Nausea, taste disturbance with oral form
  • Mild dizziness

Food & drug interactions

Aminoglycosides, loop diuretics, cisplatin, and amphotericin B compound nephrotoxicity AND ototoxicity. Concurrent piperacillin-tazobactam may raise AKI risk in some studies — monitor closely. Most drug-drug interactions are pharmacodynamic, not enzymatic.

Nursing implications

Assessment, monitoring, patient teaching

  • Infuse IV slowly: at least 60 minutes for 1 g, longer for larger doses (10 mg/min max) — rapid infusion is the #1 cause of red man syndrome
  • If red man syndrome occurs: STOP the infusion, give IV diphenhydramine, restart at half rate after symptoms resolve
  • Monitor TROUGH levels (just before next dose) — target depends on infection (typically 15–20 mcg/mL for serious MRSA, AUC-based dosing increasingly preferred)
  • Baseline and every 2–3 days BUN, creatinine, and consider drug level
  • Use a central line for long courses or high concentrations — phlebitis is severe through peripheral
  • Distinguish red man syndrome (rate-related, no IgE) from anaphylaxis (any rate, hypotension + airway, IgE) — only anaphylaxis is a permanent contraindication
  • Oral vancomycin is for C. diff ONLY — has no systemic effect

When to hold / contraindications

  • Trough level above target — extend interval or hold next dose
  • Acute kidney injury or rising creatinine
  • New severe rash, fever, eosinophilia (DRESS) or mucosal involvement (SJS)
  • True anaphylaxis (not red man syndrome) — permanent contraindication
  • Severe thrombocytopenia

Memory anchor

"Vanco infused fast = red man, slow it down." Trough just before next dose. Oral is for C. diff (stays in gut); IV is for MRSA. Don't stack with gentamicin or loop diuretics if you can help it.

Reminder: Drug cards are study aids, not clinical guidance. Always cross-check doses, holds, and contraindications with your facility's formulary and your clinical instructors before patient care.

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