Abstract
The use of vancomycin continues to be prevalent in all clinical settings. However, many questions persist about infusion techniques. According to the Infusion Nursing Standards of Practice, peripheral catheters are not the best choice for infusing this drug because of its pH. The key to reducing risk of peripheral phlebitis and extravasation injury is choosing a more appropriate vascular access device. Many healthcare providers correlate systemic side effects with the infusion rate and concentration, although many reports cannot support this correlation. New technologies of vascular access and infusion controlling devices are changing old, established practices. This update provides an examination of the current literature on all aspects of infusing vancomycin and monitoring patients.
Vancomycin was derived in 1956 from the bacterium Streptomyces orientalis found in soil of India and Indonesia. 1 This potent glycopeptide antibiotic kills gram-positive organisms, especially staphylococci and enterococci by hindering cell-wall synthesis.
During the last decade, several factors converged to increase the use of vancomycin. First, Staphylococcus aureus is a major cause of both community-acquired and nosocomial infections. In the United States, S aureus accounts for about 20% of all bacteremias. Additionally, several S aureus strains have become resistant to penicillin, semi-synthetic pencillins (eg, methicillin, nafcillin and oxacillin), macrolides, tetracycline, and aminoglycosides. Because of growing concerns over methicillin-resistant S aureus (MRSA), coagulase-negative staphylococcus, and Clostridium difficile, vancomycin became the preferred therapy for staphylococcal infections, especially nosocomial infections. 2
The incidence of vancomycin-resistant enterococci rose dramatically during the early 1990s. 3 Strains of S aureus with reduced susceptibility to vancomycin have been reported in the United States and Japan and it is labeled by the Centers for Disease Control and Prevention (CDC) as an emerging infectious disease threat. 4 In July 2002, the CDC released a report of the first case of S aureus fully resistant to vancomycin from a culture of the exit site and catheter tip of a temporary dialysis catheter. 5 Guidelines for prudent use of vancomycin have been established, including reducing its use and preventing the spread of organisms between patients. Alternative antibiotics include linezolid and quinupristin/dalfopristin. However, these drugs have additional risk and costs that are beyond the scope of this discussion.
The infusion of vancomycin continues to increase and present challenges. The infusion nurse must be aware of these challenges and prepared to collaborate with the physician and pharmacist to ensure positive patient outcomes from its use.