Supportive care is advised, with maintenance of glomerular filtration.
Vancomycin is poorly removed by dialysis. Haemofiltration and haemoperfusion with Amberlite resin XAD-4 have been reported to be of limited benefit.
Summary of the safety profile
The absorption of vancomycin from the gastrointestinal tract is negligible. However, in severe inflammation of the intestinal mucosa, especially in combination with renal insufficiency, side effects that occur when vancomycin is administered parenterally may appear. Therefore, the below mentioned adverse reactions and frequencies related to parenteral vancomycin administration are included.
When vancomycin is administered parenterally, the most common adverse reactions are phlebitis, pseudo-allergic reactions and flushing of the upper body (“red-neck syndromeâ€) in connection with too rapid intravenous infusion of vancomycin.
Tabulated List of Adverse reactions
Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
The adverse reactions listed below are defined using the following MedDRA convention and system organ class database:
Very common (> 1/10); common (> 1/100 to < 1/10); uncommon (> 1/1,000 to < 1/100); rare (> 1/10,000 to < 1/1,000); very rare (< 1/10,000), not known (cannot be estimated from the available data).
| System organ class | |
| Frequency | Adverse reaction |
| Blood and the lymphatic system disorders: | |
| Rare | Reversible neutropenia, agranulocytosis, eosinophilia, thrombocytopenia, pancytopenia. |
| Immune system disorders: | |
| Rare | Hypersensitivity reactions, anaphylactic reactions |
| Ear and labyrinth disorders: | |
| Uncommon | Transient or permanent loss of hearing |
| Rare | Vertigo, tinnitus, dizziness |
| Cardiac disorders | |
| Very rare | Cardiac arrest |
| Vascular disorders: | |
| Common | Decrease in blood pressure |
| Rare | Vasculitis |
| Respiratory, thoracic and mediastinal disorders: | |
| Common | Dyspnoea, stridor |
| Gastrointestinal disorders: | |
| Rare | Nausea |
| Very rare | Pseudomembranous enterocolitis |
| Not known | Vomiting, diarrhoea |
| Skin and subcutaneous tissue disorders: | |
| Common | Flushing of the upper body (“red man syndromeâ€), exanthema and mucosal inflammation, pruritus, urticaria |
| Very rare | Exfoliative dermatitis, Stevens-Johnson syndrome, Lyell's syndrome, Linear IgA bullous dermatosis |
| Not known | Eosinophilia and systemic symptoms (DRESS syndrome), AGEP (Acute Generalized Exanthematous Pustulosis) |
| Renal and urinary disorders: | |
| Common | Renal insufficiency manifested primarily by increased serum creatinine and serum urea |
| Rare | Interstitial nephritis, acute renal failure |
| Not known | Acute tubular necrosis |
| General disorders and administration site conditions: | |
| Common | Phlebitis, redness of the upper body and face |
| Rare | Drug fever, shivering, pain and muscle spasm of the chest and back muscles |
Description of selected adverse drug reactions
Reversible neutropenia usually starting one week or more after onset of intravenous therapy or after total dose of more than 25 g.
Intravenous vancomycin should be infused slowly. During or shortly after rapid infusion anaphylactic/anaphylactoid reactions including wheezing may occur. The reactions abate when administration is stopped, generally between 20 minutes and 2 hours. Necrosis may occur after intramuscular injection.
Tinnitus, possibly preceding onset of deafness, should be regarded as an indication to discontinue treatment.
Ototoxicity has primarily been reported in patients given high doses, or in those on concomitant treatment with other ototoxic medicinal product like aminoglycoside, or in those who had a pre-existing reduction in kidney function or hearing.
If a bullous disorder is suspected, the drug should be discontinued and specialised dermatological assessment should be carried out.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
There are no preclinical data of relevance to the prescriber in addition to that summarised in other sections of the Summary of Product Characteristics
Vancomycin capsules are indicated in patients 12 years and older for the treatment of Clostridium difficile infection (CDI).
Consideration should be given to official guidance on the appropriate use of antibacterial agents.
Pharmacotherapeutic group: Antibiotics, ATC Code: A07 AA09.
Mechanism of action
Vancomycin is a tricyclic glycopeptide antibiotic that inhibits the synthesis of the cell wall in sensitive bacteria by binding with high affinity to the D-alanyl-D-alanine terminus of cell wall precursor units. The drug is bactericidal for dividing microorganisms. In addition, it impairs the permeability of the bacterial cell membrane and RNA synthesis.
Mechanism of resistance
Acquired resistance to glycopeptides is most common in enterococci and is based on acquisition of various van gene complexes which modifies the D-alanyl-D-alanine target to D-alanyl-D-lactate or D-alanyl-D-serine which bind vancomycin poorly. In some countries, increasing cases of resistance are observed particularly in enterococci; multi-resistant strains of Enterococcus faecium are especially alarming.
Van genes have rarely been found in Staphylococcus aureus, where changes in cell wall structure result in “intermediate†susceptibility, which is most commonly heterogeneous. Also, methicillin-resistant staphylococcus strains (MRSA) with reduced susceptibility for vancomycin were reported. The reduced susceptibility or resistance to vancomycin in Staphylococcus is not well understood. Several genetic elements and multiple mutations are required.
There is no cross-resistance between vancomycin and other classes of antibiotics. Cross-resistance with other glycopeptide antibiotics, such as teicoplanin, does occur. Secondary development of resistance during therapy is rare.
Susceptibility testing breakpoints
The prevalence of acquired resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some types of infections is questionable. This information only provides approximate guidance on the chance whether micro-organisms are susceptible to vancomycin.
Minimum inhibitory concentration breakpoints established by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) are as follows:
|
Clostridium difficile1 | Susceptible ≤ 2 mg/L | Resistant > 2 mg/L |
1The breakpoints are based on epidemiological cut-off values (ECOFFs), which distinguish wild-type isolates from those with reduced susceptibility.
Absorption
Vancomycin is not usually absorbed into the blood after oral administration. However, absorption may be enhanced in patients with inflammatory disorders of the intestinal mucosa or with Clostridium difficile-induced pseudomembranous colitis. This may lead to vancomycin accumulation in patients with co-existing renal impairment.
Elimination
An oral dose is excreted almost exclusively in the faeces. During multiple dosing of 250 mg every 8 hours for 7 doses, faecal concentrations of vancomycin, in volunteers, exceeded 100 mg/kg in the majority of samples. No blood concentrations were detected and urinary recovery did not exceed 0.76%.
Oral use only
This preparation is for oral use only and is not systemically absorbed. Orally administered Vancomycin capsules are not effective for other types of infections.
Potential for systemic absorption
Absorption may be enhanced in patients with inflammatory disorders of the intestinal mucosa or Clostridium difficile-induced pseudomembranous colitis. These patients may be at risk for the development of adverse reactions, especially if there is a concomitant renal impairment. The greater the renal impairment, the greater the risk of developing the adverse reactions associated with the parenteral administration of vancomycin. Monitoring of serum vancomycin concentrations of patients with inflammatory disorders of the intestinal mucosa should be performed.
Nephrotoxicity
Serial monitoring of renal function should be performed when treating patients with underlying renal dysfunction or patients receiving concomitant therapy with an aminoglycoside or other nephrotoxic drugs.
Ototoxicity
Serial tests of auditory function may be helpful in order to minimise the risk of ototoxicity in patients with an underlying hearing loss, or who are receiving concomitant therapy with an ototoxic agent such as an aminoglycoside.
Drug interactions with anti-motility agents and proton pump inhibitors
Anti-motility agents should be avoided and proton pump inhibitor use should be reconsidered.
Development of Drug-Resistant Bacteria
Prolonged use of vancomycin may result in the overgrowth of non-susceptible organisms. Careful observation of the patient is essential. If superinfection occurs during therapy, appropriate measures should be taken.
Not relevant.
Posology:
Adults and adolescents aged 12 to less than 18 years old
The recommended vancomycin dose is 125 mg every 6 hours for 10 days for the first episode of non-severe CDI. This dose can be increased to 500 mg every 6 hours for 10 days in case of severe or complicated disease. The maximum daily dose should not exceed 2 g.
In patients with multiple recurrences, consideration may be given to treat the current episode of CDI with vancomycin, 125 mg four times daily for 10 days followed by either tapering the dose, i.e., gradually decreasing it until 125 mg per day or a pulse regimen, i.e., 125-500 mg/day every 2-3 days for at least 3 weeks.
Treatment duration with vancomycin may need to be tailored to the clinical course of individual patients. Whenever possible the antibacterial suspected to have caused CDI should be discontinued. Adequate replacement of fluid and electrolytes should be instituted.
Monitoring vancomycin serum concentrations after oral administration in patients with inflammatory intestinal disorders should be performed.
Special populations
Renal impairment
Due to the very low systemic absorption, dose adjustment is unlikely, unless substantial oral absorption may occur in case of inflammatory intestinal disorders or Clostridium difficile-induced pseudomembranous colitis.
Paediatric population
Vancomycin capsules are not appropriate for the treatment of children under the age of 12 years or for adolescents unable to swallow them. Below 12 years, age-appropriate formulation should be used.
Method of administration
For oral use.
The capsule should not be open and should be taken with plenty of water.
No special requirements for disposal.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
