Vancomycin (Glycopeptide)

Vancomycin is what "severe" means pharmacologically on this page. It is the intravenous start when MRSA risk factors are present — "start with intravenous vancomycin and later transition to oral trimethoprim-sulfamethoxazole" — so the drug follows a defined trigger rather than a hunch. The chapter names who gets MRSA cover: "purulent cellulitis, MRSA colonization, cellulitis associated with an abscess or extensive puncture wounds, or a history of intravenous drug use." In necrotizing infection it is the usual anti-MRSA agent — "vancomycin or linezolid given the high prevalence of methicillin-resistant Staphylococcus aureus (MRSA)" — alongside piperacillin-tazobactam or a carbapenem. For the immunocompromised patient with cellulitis the sourced combination is "vancomycin with piperacillin-tazobactam or using a carbapenem." The nursing item the source itself names is monitoring: pharmacists "monitor medications with renal toxicity (vancomycin)." Level monitoring, renal dosing and infusion-reaction management belong to the class page.

Oral vancomycin is standard of care (CDC: an "appropriate course (about 10 days) of treatment, including oral vancomycin or fidaxomicin"). SHEA/IDSA 2021 (adults) suggests fidaxomicin over a standard vancomycin course for a first episode because of lower recurrence — "Vancomycin remains an acceptable alternative." For fulminant CDI, vancomycin by mouth or nasogastric tube. Label: "Parenteral administration of vancomycin is not effective for the above infections; therefore, vancomycin must be given orally for these infections." Nephrotoxicity has occurred with oral therapy, especially in older adults — "Monitor renal function." Take the whole course even after feeling better. Fidaxomicin (DIFICID, a macrolide with minimal systemic absorption, approved from 6 months of age) is the other first-line option; stop it for a severe hypersensitivity reaction.

Two different drugs share one name here, and the route is the whole distinction. Intravenous vancomycin remains the standard for serious MRSA infection — trough goals of 15 to 20 µg/mL for complicated infections, with optimal therapy targeting an AUC/MIC of 400 to 600 mg·h/L; alternatives are linezolid, daptomycin (never for pneumonia — it is "inactivated by surfactant"), ceftaroline and tedizolid. Oral vancomycin is for C. difficile, and it works precisely because it is not absorbed — it stays in the gut lumen where the organism is, at 125 mg every 6 hours for 10 days when fidaxomicin is unavailable, in a tapered or pulsed regimen for recurrence, and as a rectal enema alongside IV metronidazole in fulminant disease. Oral and IV forms are not interchangeable for this indication. Vancomycin also has its own surgical-prophylaxis timing rule: 120 minutes before incision, versus 30 to 60 minutes for other agents. The disorder-side caution is that using it drives VRE: previous antimicrobial therapy is the commonest VRE risk factor, and the sourced stewardship rule is to "only use vancomycin when absolutely needed," with infectious-disease approval.

The usual empiric agent while cultures are pending (started promptly after the cultures are drawn) and first-line for MRSA IE — 6 weeks, with daptomycin the alternative — and the backbone of methicillin-resistant prosthetic-valve regimens with gentamicin and rifampin; penicillin-resistant enterococci get vancomycin plus gentamicin. Two cautions: it is inferior to a beta-lactam for MSSA, so de-escalate once susceptibilities return; and it is nephrotoxic, so levels are monitored (weekly on OPAT) in a kidney already threatened by emboli and immune complexes.

Empiric and MRSA treatment of choice. Empiric therapy pairs IV vancomycin with a third-generation cephalosporin or a beta-lactam/beta-lactamase inhibitor, then narrows once susceptibilities are known. The FDA label requires a diluted infusion over at least 60 minutes — rapid bolus can cause exaggerated hypotension and, rarely, cardiac arrest; monitor renal function (AKI risk rises with exposure), hearing, and the leukocyte count on prolonged therapy.

The MRSA arm of empiric coverage: when MRSA is a likely pathogen, empiric therapy includes MRSA coverage — and vancomycin is one of the few drugs still reliably effective against it. Giving it without a proven or strongly suspected bacterial infection breeds resistance.

The original β-lactams — bactericidal cell-wall inhibitors. The defining nursing job is screening for and recognizing allergy, from rash to anaphylaxis.

β-lactam cousins of penicillin, organized by generation — each generation trades some gram-positive reach for broader gram-negative coverage.

Powerful, broad-spectrum DNA-synthesis blockers — but a boxed warning for disabling tendon, nerve, and CNS effects means they’re reserved when alternatives exist.

Suppress viral replication rather than kill viruses outright. The nursing essentials: hydrate with acyclovir, start early (flu within 48 h), and remember most antivirals suppress — they don’t cure.

Powerful IV drugs for serious Gram-negative infection — but nephrotoxic and ototoxic. Levels matter.

Broad, generally safe protein-synthesis inhibitors — a penicillin-allergy alternative. Watch QT and CYP3A4.