Vancomycin
Glycopeptide antibiotic
Inhibits cell wall synthesis (binds D-Ala-D-Ala). Active against MRSA + gram-positives.
Indications
- •MRSA prophylaxis (cardiac, ortho implants, β-lactam allergy)
- •C. diff (PO)
Dosing
| Context | Adult | Pediatric |
|---|---|---|
| Surgical prophylaxis | 15 mg/kg IV over ≥ 60 min (max 2 g) | 15 mg/kg IV over ≥ 60 min |
Pharmacokinetics
Onset 30 min. Half-life 4–6 h. Renal excretion (dose-adjust in CKD).
Side effects
- !Vancomycin-induced flushing (formerly 'Red Man Syndrome') — histamine release from rapid infusion (slow it down)
- !Nephrotoxicity (especially with NSAIDs, contrast, gentamicin)
- !Ototoxicity (high serum levels)
- !Linear IgA bullous dermatosis (rare)
Contraindications
- ×Documented vancomycin anaphylaxis (rare)
Clinical pearls
- ★Slow infusion (≥ 60 min) prevents most flushing reactions.
- ★Start at incision − 60 min so full dose in by skin opening.
- ★Trough monitoring not relevant for surgical prophylaxis.
Other drugs in Antibiotics
- Cefazolin
β-lactam — inhibits bacterial cell wall PBPs.
- Clindamycin
Binds 50S ribosomal subunit, blocks peptide-bond formation. Bacteriostatic against most organisms; bactericidal against susceptible streptococci. Excellent activity against anaerobes and gram-positive cocci including community-acquired MRSA.
- Gentamicin
Binds 30S ribosomal subunit, causes misreading of mRNA → defective bacterial protein synthesis. Bactericidal, concentration-dependent killing. Synergy with cell-wall agents (β-lactams, vancomycin) for gram-positive endocarditis.
- Cefuroxime
β-lactam — inhibits cell-wall synthesis (PBP binding). 2nd-gen: gram-positive + expanded gram-negative.
- Cefepime
β-lactam cell-wall inhibitor. Broad gram-negative (incl. Pseudomonas) + gram-positive coverage.
- Cefotetan
β-lactam; adds anaerobic (B. fragilis) coverage → colorectal/gynecologic prophylaxis.
- Cefotaxime
β-lactam cell-wall inhibitor. Broad gram-negative + CNS penetration.
Suggested reading
- •Miller's Anesthesia, 9e
- •FDA package insert
