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Medication Safety Issues
Sound-alike/look-alike issues:
I.V. vancomycin may be confused with Invanz®
Vancomycin may be confused with clindamycin, gentamicin, tobramycin, valACYclovir, vecuronium, Vibramycin®
High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication (intrathecal administration) among its list of drug classes which have a heightened risk of causing significant patient harm when used in error.
Pronunciation
(van koe MYE sin)
U.S. Brand Names
Index Terms
Generic Available
Yes: Injection
Canadian Brand Names
Pharmacologic Category
Use: Labeled Indications
Treatment of patients with infections caused by staphylococcal species and streptococcal species; used orally for staphylococcal enterocolitis or for antibiotic-associated pseudomembranous colitis produced by C. difficile
Use: Unlabeled/Investigational
Bacterial endophthalmitis; treatment of infections caused by gram-positive organisms in patients who have serious allergies to beta-lactam agents; treatment of beta-lactam resistant gram-positive infections
Pregnancy Risk Factor
B (oral); C (injection)
Pregnancy Considerations
Adverse effects have not been observed in animal studies and there are no controlled studies in pregnant women; however, oral vancomycin is not systemically absorbed. Therefore, I.V. vancomycin has been classified pregnancy category C and oral vancomycin has been classified pregnancy category B. Vancomycin crosses the placenta. In vivo studies and human case reports have documented placental transfer of vancomycin in the second and third trimesters of pregnancy resulting in therapeutic fetal concentrations. Vancomycin has not caused adverse fetal effects, including hearing loss or nephrotoxicity, when administered during pregnancy. A case report has been published of a vancomycin dose rapidly administered over 3 minutes leading to maternal hypotension and fetal bradycardia.The pharmacokinetics of vancomycin may be altered during pregnancy and pregnant patients may need a higher dose of vancomycin. Maternal half-life is unchanged, but the volume of distribution and the total plasma clearance are increased. Individualization of therapy through serum concentration monitoring may be warranted. Vancomycin is recommended for use in pregnant women for prevention of early-onset group B streptococcal (GBS) disease in newborns.
Lactation
Enters breast milk/not recommended
Breast-Feeding Considerations
Small amounts of vancomycin are excreted in human milk and use during breast-feeding is not recommended by the manufacturer. If given orally to the mother, the minimal systemic absorption of the dose would limit the amount available to pass into the milk. If given intravenously, the small amount that distributes to the milk would not be expected to cause systemic toxicity due to the lack of GI absorption. Nondose-related effects could include modification of bowel flora.
Contraindications
Hypersensitivity to vancomycin or any component of the formulation; avoid in patients with previous severe hearing loss
Warnings/Precautions
Concerns related to adverse effects:
• Nephrotoxicity: May cause nephrotoxicity although limited data suggest direct causal relationship; usual risk factors include pre-existing renal impairment, concomitant nephrotoxic medications, advanced age, and dehydration. If multiple sequential (?2) serum creatinine concentrations demonstrate an increase of 0.5 mg/dL or ?50% increase from baseline (whichever is greater) in the absence of an alternative explanation, the patient should be identified as having vancomycin-induced nephrotoxicity (Rybak, 2009). Discontinue treatment if signs of nephrotoxicity occur; renal damage is usually reversible.
• Neurotoxicity: May cause neurotoxicity; usual risk factors include pre-existing renal impairment, concomitant neuro-/nephrotoxic medications, advanced age, and dehydration. Ototoxicity, although rarely associated with monotherapy, is proportional to the amount of drug given and the duration of treatment. Tinnitus or vertigo may be indications of vestibular injury and impending bilateral irreversible damage. Discontinue treatment if signs of ototoxicity occur.
• Neutropenia: Prolonged therapy (>1 week) or total doses exceeding 25 g may increase the risk of neutropenia; prompt reversal of neutropenia is expected after discontinuation of therapy.
• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.
Disease-related concerns:
• Renal impairment: Use with caution in patients with renal impairment or those receiving other nephrotoxic or ototoxic drugs; dosage modification required (especially elderly).
Other warnings/precautions:
• Appropriate use: Oral vancomycin is only indicated for the treatment of pseudomembranous colitis due to C. difficile and enterocolitis due to S. aureus and is not effective for systemic infections; parenteral vancomycin is not effective for the treatment of colitis due to C. difficile and enterocolitis due to S. aureus.
• Infusion reactions: Rapid I.V. administration may result in hypotension, flushing, erythema, urticaria, and/or pruritus.
Adverse Reactions
Oral:
>10%: Gastrointestinal: Bitter taste, nausea, vomiting
1% to 10%:
Central nervous system: Chills, drug fever
Hematologic: Eosinophilia
<1%: Interstitial nephritis, ototoxicity, renal failure, thrombocytopenia, vasculitis
Parenteral:
>10%:
Cardiovascular: Hypotension accompanied by flushing
Dermatologic: Erythematous rash on face and upper body (red neck or red man syndrome - infusion rate related)
1% to 10%:
Central nervous system: Chills, drug fever
Dermatologic: Rash
Hematologic: Eosinophilia, reversible neutropenia
Local: Phlebitis
<1%, postmarketing, and/or case reports: Drug rash with eosinophilia and systemic symptoms (DRESS), ototoxicity (rare; use of other ototoxic agents may increase risk), renal failure (limited data suggesting direct relationship), Stevens-Johnson syndrome, thrombocytopenia, vasculitis
Drug Interactions
Aminoglycosides: Vancomycin may enhance the nephrotoxic effect of Aminoglycosides. Risk C: Monitor therapy
BCG: Antibiotics may diminish the therapeutic effect of BCG. Risk X: Avoid combination
Colistimethate: Vancomycin may enhance the nephrotoxic effect of Colistimethate. Risk D: Consider therapy modification
Gallium Nitrate: Vancomycin may enhance the nephrotoxic effect of Gallium Nitrate. Risk X: Avoid combination
Neuromuscular-Blocking Agents: Vancomycin may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Nonsteroidal Anti-Inflammatory Agents: May decrease the excretion of Vancomycin. Risk C: Monitor therapy
Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Risk D: Consider therapy modification
Storage
Reconstituted 500 mg and 1 g vials are stable for at either room temperature or under refrigeration for 14 days. Note: Vials contain no bacteriostatic agent. Solutions diluted for administration in either D5W or NS are stable under refrigeration for 14 days or at room temperature for 7 days.
Reconstitution
Reconstitute vials with 20 mL of SWFI for each 1 g of vancomycin (10 mL/500 mg vial; 20 mL/1 g vial; 100 mL/5 g vial; 200 mL/10 g vial). The reconstituted solution must be further diluted with at least 100 mL of a compatible diluent per 500 mg of vancomycin prior to parenteral administration.
Intrathecal: Vancomycin is available as a powder for injection and may be diluted to 1-5 mg/mL concentration in preservative free 0.9% sodium chloride for administration into the CSF.
Compatibility
Stable in dextran 6% in NS, D5NS, D5W, D10W, LR, NS; variable stability (consult detailed reference) in peritoneal dialysis solutions, TPN.
Y-site administration: Compatible: Acyclovir, aldesleukin, allopurinol, amifostine, amiodarone, amsacrine, anidulafungin, atracurium, cisatracurium, clarithromycin, cyclophosphamide, dexmedetomidine, diltiazem, docetaxel, doxapram, doxorubicin liposome, enalaprilat, esmolol, etoposide phosphate, fenoldopam, filgrastim, fluconazole, fludarabine, gallium nitrate, gemcitabine, granisetron, hetastarch, hydromorphone, insulin (regular), labetalol, levofloxacin, linezolid, lorazepam, magnesium sulfate, melphalan, meperidine, meropenem, midazolam, milrinone, morphine, nicardipine, ondansetron, paclitaxel, pancuronium, pemetrexed, perphenazine, remifentanil, sodium bicarbonate, tacrolimus, teniposide, theophylline, thiotepa, tigecycline, tolazoline, vecuronium, vinorelbine, zidovudine. Incompatible: Albumin, amphotericin B cholesteryl sulfate complex, bivalirudin, drotrecogin alfa, idarubicin, omeprazole. Variable (consult detailed reference): Ampicillin, ampicillin/sulbactam, aztreonam, cefazolin, cefepime, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftizoxime, ceftriaxone, cefuroxime, foscarnet, heparin, methotrexate, nafcillin, piperacillin, piperacillin/tazobactam, propofol, sargramostim, ticarcillin/clavulanate, TPN, warfarin.
Compatibility in syringe: Compatible: Caffeine citrate, pantoprazole. Incompatible: Dimenhydrinate, heparin.
Compatibility when admixed: Compatible: Amikacin, atracurium, calcium gluconate, cefepime, cimetidine, corticotropin, dimenhydrinate, famotidine, fusidate sodium, hydrocortisone sodium succinate, meropenem, ofloxacin, potassium chloride, ranitidine, verapamil, vitamin B complex with C. Incompatible: Amobarbital, chloramphenicol, chlorothiazide, dexamethasone sodium phosphate, penicillin G potassium, pentobarbital, phenobarbital. Variable (consult detailed reference): Aminophylline, aztreonam, heparin, sodium bicarbonate.
Mechanism of Action
Inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding tightly to D-alanyl-D-alanine portion of cell wall precursor
Pharmacodynamics/Kinetics
Absorption: Oral: Poor; I.M.: Erratic; Intraperitoneal: ~38%
Distribution: Vd: 0.4-1 L/kg; Distributes widely in body tissue and fluids, except for CSF
Relative diffusion from blood into CSF: Good only with inflammation (exceeds usual MICs)
Uninflamed meninges: 0-4 mcg/mL; serum concentration dependent
Inflamed meninges: 6-11 mcg/mL; serum concentration dependent
CSF:blood level ratio: Normal meninges: Nil; Inflamed meninges: 20% to 30%
Protein binding: ~50%
Half-life elimination: Biphasic: Terminal:
Newborns: 6-10 hours
Infants and Children 3 months to 4 years: 4 hours
Children >3 years: 2.2-3 hours
Adults: 5-11 hours; significantly prolonged with renal impairment
End-stage renal disease: 200-250 hours
Time to peak, serum: I.V.: Immediately after completion of infusion
Excretion: I.V.: Urine (80% to 90% as unchanged drug); Oral: Primarily feces
Dosage
Usual dosage range:
Infants >1 month and Children: I.V.: 10-15 mg/kg every 6 hours
Adults:
I.V.: 2-3 g/day (or 30-60 mg/kg/day) in divided doses every 8-12 hours (Rybak, 2009); Note: Dose requires adjustment in renal impairment
Oral: 500-1000 mg/day in divided doses every 6 hours
Indication-specific dosing:
Infants >1 month and Children:
Colitis
(C. difficile)
, enterocolitis
(S. aureus)
: Oral: 40 mg/kg/day in 3-4 divided doses added to fluids for 7-10 days (maximum: 2000 mg/day)
Meningitis/CNS infection:
I.V.: 15 mg/kg every 6 hours
Intrathecal: 5-20 mg/day
Prophylaxis against infective endocarditis: I.V.:
Dental, oral, or upper respiratory tract surgery: 20 mg/kg 1 hour prior to the procedure. Note: American Heart Association (AHA) guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur.
GI/GU procedure: 20 mg/kg plus gentamicin 2 mg/kg 1 hour prior to surgery. Note: As of April 2007, routine prophylaxis no longer recommended by the AHA.
Susceptible gram-positive infections: I.V.: 10 mg/kg every 6 hours
Adults: Initial intravenous dosing should be based on actual body weight; subsequent dosing adjusted based on serum trough vancomycin concentrations.
Complicated infections in seriously-ill patients (Rybak, 2009): I.V.: Loading dose: 25-30 mg/kg (based on actual body weight) may be used to rapidly achieve target concentration; then 15-20 mg/kg/dose every 8-12 hours.
Catheter-related infections: Antibiotic lock technique (Mermel, 2009): 2 mg/mL ± 10 units heparin/mL or 2.5 mg/mL ± 2500 or 5000 units heparin/mL or 5 mg/mL ± 5000 units heparin/mL (preferred regimen); instill into catheter port with a volume sufficient to fill the catheter (2-5 mL). Note: May use SWFI/NS or D5W as diluents. Do not mix with any other solutions. Dwell times generally should not exceed 48 hours before renewal of lock solution. Remove lock solution prior to catheter use then replace.
Colitis
(C. difficile)
, enterocolitis
(S. aureus)
: Oral: 500-2000 mg/day in 3-4 divided doses for 7-10 days (usual dose: 125-250 mg every 6 hours)
Endophthalmitis (unlabeled use): Intravitreal: Usual dose: 1 mg/0.1 mL NS instilled into vitreum; may repeat administration if necessary in 3-4 days, usually in combination with ceftazidime or an aminoglycoside
Note: Some clinicians have recommended using a lower dose of 0.2 mg/0.1 mL, based on concerns for retinotoxicity.
Hospital-acquired pneumonia (HAP): I.V.: 15 mg/kg/dose every 12 hours (American Thoracic Society [ATS] 2005 guidelines)
Meningitis
(Pneumococcus
or
Staphylococcus)
:
I.V.: 30-60 mg/kg/day in divided doses every 8-12 hours (Rybak, 2009) or 500-750 mg every 6 hours (with third-generation cephalosporin for PCN-resistant Streptococcus pneumoniae)
Intrathecal: 5-20 mg/day
Prophylaxis against infective endocarditis: I.V.:
Dental, oral, or upper respiratory tract surgery: 1 g 1 hour before surgery. Note: AHA guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur
GI/GU procedure: 1 g plus 1.5 mg/kg gentamicin 1 hour prior to surgery. Note: As of April 2007, routine prophylaxis no longer recommended by the AHA.
Susceptible (MIC ?1 mcg/mL; Rybak, 2009) gram-positive infections: I.V.: 15-20 mg/kg/dose (usual: 750-1500 mg) every 8-12 hours
Note: If MIC ?2 mcg/mL, alternative therapies are recommended.
Dosing interval in renal impairment (vancomycin levels should be monitored in patients with any renal impairment):
Clcr >50 mL/minute: Start with 15-20 mg/kg/dose (usual: 750-1500 mg) every 8-12 hours
Clcr 20-49 mL/minute: Start with 15-20 mg/kg/dose (usual: 750-1500 mg) every 24 hours
Clcr <20 mL/minute: Will need longer intervals; determine by serum concentration monitoring
Note: In the critically-ill patient with renal insufficiency, the initial loading dose (25-30 mg/kg) should not be reduced. However, subsequent dosage adjustments should be made based on renal function and trough serum concentrations.
Dialysis: Variable, depending on method; poorly dialyzable by conventional hemodialysis (0% to 5%). Use of high-flux membranes and continuous renal replacement therapy (CRRT) increases vancomycin clearance, and generally requires replacement dosing.
Hemodialysis (HD): Following loading dose of 15-20 mg/kg, give 500 mg to 1 g after each dialysis session, depending on factors such as HD membrane type and flow rate; monitor levels closely.
Continuous ambulatory peritoneal dialysis (CAPD):
Administration via CAPD fluid: 15-30 mg/L (15-30 mcg/mL) of CAPD fluid
Systemic: 1 g loading dose, followed by 500 mg to 1 g every 48-72 hours with close monitoring of levels
Continuous renal replacement therapy (CRRT): Removal of vancomycin is highly dependent on the method of replacement, filter type, and flow rate. Appropriate dosing requires close monitoring of levels in relation to target trough. The following are general recommendations only (Trotman, 2005), and require consideration of the aforementioned parameters.
CVVH: Following loading dose of 15-20 mg/kg, give 1 g every 48 hours
CVVHD or CVVHDF: Following loading dose of 15-20 mg/kg, give 1 g every 24 hours
Trotman RL, Williamson JC, Shoemaker DM, et al, "Antibiotic Dosing in Critically Ill Adult Patients Receiving Continuous Renal Replacement Therapy," Clin Infect Dis, 2005, 41:1159-66.
Dental Usual Dosing
Prophylaxis against infective endocarditis: I.V.:
Infants >1 month and Children:
Dental, oral, or upper respiratory tract surgery: 20 mg/kg 1 hour prior to the procedure. Note: American Heart Association (AHA) guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur.
GI/GU procedure: 20 mg/kg plus gentamicin 2 mg/kg 1 hour prior to surgery. Note: As of April 2007, routine prophylaxis no longer recommended by the AHA.
Adults:
Dental, oral, or upper respiratory tract surgery: 1 g 1 hour before surgery. Note: AHA guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur
GI/GU procedure: 1 g plus 1.5 mg/kg gentamicin 1 hour prior to surgery. Note: As of April 2007, routine prophylaxis no longer recommended by the AHA.
Administration: Oral
May be administered with food. If patient cannot swallow capsules, the powder for injection may be reconstituted and diluted for oral administration.
Administration: I.M.
Do not administer I.M.
Administration: I.V.
Administer vancomycin with a final concentration not to exceed 5 mg/mL by I.V. intermittent infusion over at least 60 minutes (recommended infusion period of ?30 minutes for every 500 mg administered).
Red man syndrome may occur if the infusion is too rapid. It is not an allergic reaction, but may be characterized by hypotension and/or a maculopapular rash appearing on the face, neck, trunk, and/or upper extremities. If this should occur, slow the infusion rate to over 11/2 to 2 hours and increase the dilution volume. Reactions are often treated with antihistamines and steroids.
Extravasation treatment: Monitor I.V. site closely; extravasation will cause serious injury with possible necrosis and tissue sloughing. Rotate infusion site frequently.
Administration: Other
Vancomycin is available as a powder for injection and may be diluted to 1-5 mg/mL concentration in preservative-free 0.9% sodium chloride for intrathecal administration.
May be administered by intravitreal injection (unlabeled use).
Administration: I.V. Detail
pH: 3.9 (in distilled water or sodium chloride 0.9%); 2.5-4.5 (5% solution in water)
Monitoring Parameters
Periodic renal function tests, urinalysis, WBC; serum trough vancomycin concentrations in select patients (eg, aggressive dosing, unstable renal function, concurrent nephrotoxins, prolonged courses)
Suggested frequency of trough vancomycin concentration monitoring (Rybak, 2009):
Hemodynamically stable patients: Draw trough concentrations at least once-weekly.
Hemodynamically unstable patients: Draw trough concentrations more frequently or in some instances daily.
Prolonged courses (>3-5 days): Draw at least one steady-state trough concentration; repeat as clinically appropriate.
Note: Drawing >1 trough concentration prior to the fourth dose for short course (<3 days) or lower intensity dosing (target trough concentrations <15 mcg/mL) is not recommended.
Reference Range
Timing of serum samples: Draw trough just before next dose at steady-state conditions (approximately after the fourth dose). Drawing peak concentrations is no longer recommended.
Therapeutic levels: Trough: ?10 mcg/mL. For pathogens with an MIC ?1 mcg/mL, the minimum trough concentration should be 15 mcg/mL to meet target AUC/MIC of ?400 (see 'Note' below). For complicated infections (eg, bacteremia, endocarditis, osteomyelitis, meningitis, and hospital-acquired pneumonia caused by S. aureus), trough concentrations of 15-20 mcg/mL are recommended to improve penetration and improve clinical outcomes (Rybak, 2009). The American Thoracic Society (ATS) guidelines for hospital-acquired pneumonia and the Infectious Disease Society of America (IDSA) meningitis guidelines also recommend trough concentrations of 15-20 mcg/mL.
Note: Although AUC/MIC is the preferred pharmacokinetic-pharmacodynamic parameter used to determine clinical effectiveness, trough serum concentrations may be used as a surrogate marker for AUC and is recommended as the most accurate and practical method of vancomycin monitoring (Rybak, 2009).
Toxic: >80 mcg/mL (SI: >54 ?mol/L)
Dietary Considerations
May be taken with food.
Patient Education
Do not take any new prescription or OTC medications or herbal products during therapy without consulting prescriber. If administered by infusion, report immediately any chills; pain, swelling, or redness at infusion site; or respiratory difficulty. Oral medication should be taken as directed. Take all of prescribed medication even if feeling better. Maintain adequate hydration unless instructed to restrict fluid intake. May cause nausea, vomiting, or GI upset (small, frequent meals, frequent mouth care, sucking lozenges, or chewing gum may help). Report rash or hives; chills or fever; persistent GI disturbances; opportunistic infection (sore throat, chills, fever, burning, itching on urination, vaginal discharge, white plaques in mouth); respiratory difficulty; any change in urine output; chest pain or palpitations; changes in hearing or feeling of fullness in ears; other persistent adverse effects or worsening of condition. Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to become pregnant. Consult prescriber if breast-feeding.
Geriatric Considerations
As a result of age-related changes in renal function and volume of distribution, accumulation and toxicity are a risk in the elderly. Careful monitoring and dosing adjustment is necessary.
Additional Information
Because of its long half-life, vancomycin should be dosed on an every 8- to 12-hour basis. Monitoring of trough serum concentrations is advisable in certain situations. “Red man syndrome”, characterized by skin rash and hypotension, is not an allergic reaction but rather is associated with too rapid infusion of the drug. To alleviate or prevent the reaction, infuse vancomycin at a rate of ?30 minutes for each 500 mg of drug being administered (eg, 1 g over ?60 minutes); 1.5 g over ?90 minutes.
Anesthesia and Critical Care Concerns/Other Considerations
Clinical Pearls/Comments: “Red man syndrome” (characterized by skin rash and hypotension) is not an allergic reaction, but rather is associated with infusion administered too rapidly. To alleviate or prevent the reaction, infuse vancomycin at a rate of ?30 minutes for each 500 mg of drug being administered (eg, 1 g over ?60 minutes; 1.5 g over ?90 minutes). CVVHD clears vancomycin from the circulation while conventional hemodialysis does not.
Limitations which may contribute to clinical failure include poor lung penetration, slow bactericidal activity against S. aureus, limited CNS penetration, high-level resistance to enterococci and S. aureus, and limited activity against bacteria that coat prosthetic devices.
Dental Health: Effects on Dental Treatment
Key adverse event(s) related to dental treatment: Bitter taste. “Red man syndrome”, characterized by skin rash and hypotension, is not an allergic reaction but rather is associated with too rapid infusion of the drug. To alleviate or prevent the reaction, infuse vancomycin at a rate of ?30 minutes for each 500 mg of drug being administered (eg, 1 g over ?60 minutes); 1.5 g over ?90 minutes.
Dental Health: Vasoconstrictor/Local Anesthetic Precautions
No information available to require special precautions
Mental Health: Effects on Mental Status
None reported
Mental Health: Effects on Psychiatric Treatment
May cause neutropenia; use caution with clozapine and carbamazepine
Nursing: Physical Assessment/Monitoring
Assess results of culture and sensitivity tests and patient's allergy history prior to first dose. Use caution with renal impairment or previous hearing loss. Assess potential for interactions with other pharmacological agents patient may be taking (eg, concurrent use with anything that is ototoxic or nephrotoxic increases risk of toxicity). See Administration for infusion specifics (premedication with antihistamines may prevent or minimize "red man" reaction). Infusion site must be monitored closely to prevent extravasation. Assess results of laboratory tests, therapeutic effectiveness (resolution of infection), and adverse response (eg, hypotension, rash, neutropenia, nausea, vomiting, auditory changes) on a regular basis during therapy. Teach patient appropriate use (oral), possible side effects/appropriate interventions, and adverse symptoms to report.
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Capsule (Vancocin®): 125 mg, 250 mg
Infusion [premixed in iso-osmotic dextrose] (Vancocin®): 500 mg (100 mL); 1 g (200 mL)
Injection, powder for reconstitution: 500 mg, 1 g, 5 g, 10 g
Pricing: U.S. (www.drugstore.com)
Capsules (Vancocin HCl)
250 mg (20): $698.67
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