Vancomycin Indications
Post-neurosurgical procedure meningitis
Posttraumatic meningitis
Brain abscess
Unknown pathogen and suspected Staphylococcus aureus:
Vancomycin: covers MRSA.15 mg/kg IV q8-12 hours to achieve through 15-20 mg/dl.
Shunt infection
1. Vancomycin (adult) 15 mg/kg IV q 8–12 hours to achieve trough 15–20 mg/dl for MRSA cover- age + cefepime 2 g IV q 8h or meropenem 2 g q 8h to cover gram-negative pathogens. Streamline therapy based on culture and sensitivity results
S. aureus and S. epidermidis
a) if methicillin-sensitive:nafcillin or oxacillin±ITvancomycin
b) if methicillin-resistant:continue IV vancomycin+POrifampin±ITvancomycin
2. Enterococcus: IV ampicillin ± IT gent
3. other streptococci: either antistreptococcal or above enterococcal regimen
4. aerobic GNR: base on susceptibilities. Both IV beta-lactam & IT aminoglycoside indicated
5. Serratia marcescens: a rare cause of VP shunt infection15 but the high morbidity may warrant aggressive antibiotic therapy (IV ceftriaxone + IT aminoglycoside) and surgical therapy
6. Corynebacterium spp. & Proprionibacterium spp. (diphtheroids)
a) if PCN sensitive:use enterococcal regimen above b) if PCN resistant:IV+ITvancomycin
External ventricular drain (EVD)-related infection
Management: remove EVD when clinically acceptable. Empiric coverage with IV vancomycin (for gram-positives) + IV ceftazidime or cefepime (for gram-negatives). Consider intraventricular/intrathecal antimicrobial for resistant organisms or non-responsiveness to IV antimicrobials.
If no penicillin allergy:
– vancomycin as a continuous infusion or divided doses (2–3) of 60 mg per kg of body weight per day after a loading dose of 15 mg per kg of body weight, aiming for trough (15–25 mcg/ ml) PLUS
– ceftazidime 2g IV q 8 hrs or cefepime 2g IV q 8 hrs
○ For penicillin allergy:
– vancomycin as a continuous infusion or divided doses (2–3) of 60 mg per kg of body weight per day after a loading dose of 15 mg per kg of body weight PLUS
– meropenem2gIVq8hrsoraztreonam2gIVq6hrs
Superficial wound infection
Start the patient empirically on vancomycin plus cefepime or meropenem
Postoperative discitis
most start with anti-staphylococcal antibiotics(initial empiric therapy:vancomycin±PO rifampin) and cefepime or meropenem. Modify based on sensitivities if positive cultures are obtained
Osteomyelitis of the skull
Debridement surgery is followed by at least 6–12 weeks of antibiotics.
Until MRSA is ruled out: vancomycin + cefepime or meropenem. Culture results guide the choice of antibiotics. Once MRSA is ruled out, vancomycin may be changed to penicillinase-resistant synthetic penicillin (e.g. nafcillin). Most treatment failures occurred in patients treated with < 4 weeks of antibiotics following surgery.
Spinal epidural abscess
If the organism and source are unknown, S. aureus is most likely.
Empiric antibiotics:
● Ceftriaxone or cefepime (use when pseudomonas is a concern) PLUS ● metronidazole PLUS ● vancomycin:
○ until methicillin resistant S. aureus (MRSA) can be ruled out
○ once MRSA is ruled out switch to synthetic penicillin (e.g. nafcillin or oxacillin)
● ± rifampin PO
Craniotomy
prophylactic antibiotics: (optional) ideally 30–60 minutes before incision. Most antibiotics, it is given in the O.R. before the skin incision. For antibiotics that take a long time to infuse (e.g. vancomycin) it may help to order it to be given “on call to O.R.”
Vancomycin is also taken by mouth as a treatment for severe Clostridium difficile colitis.
It is recommended intravenously as a treatment for complicated skin infections, bloodstream infections, endocarditis, bone and joint infections, and meningitis caused by methicillin-resistant Staphylococcus aureus.
Data suggest that the use of vancomycin as a prophylactic agent for cerebrospinal fluid shunt placement reduces the rate of shunt infections in the context of the high prevalence of Methicillin resistant Staphylococcus aureus. 1).
The local application of powdered vancomycin was not associated with a significant difference in the rate of deep surgical site infection SSI after spinal deformity surgery, and other treatment modalities are necessary to limit infection for this high-risk group. This study is in contrary to prior studies, which have reported a decrease in SSI with vancomycin powder.Level of Evidence: 2 2)
Dombrowski et al. found a high rate of treatment failure in an urban population among patients who completed recommended therapy, largely with vancomycin alone. Failure in osteomyelitis was particularly common. High quality comparative studies of antibiotic regimens for MRSA infections, particularly osteomyelitis, are needed 3).