Vancomycin (Vancocin) Risks, Warnings, and Complications

ORAL USE FOR ENTEROCOLITIS ONLY: Vancomycin hydrochloride capsules and oral solution (for use by mouth) are only for the treatment of enterocolitis (infection and inflammation in the intestines). The drug is not absorbed systemically from the digestive tract and cannot treat infections in other parts of the body. Oral vancomycin is used to treat staphylococcal enterocolitis and Clostridioides difficile-associated diarrhea (CDAD). Intravenous vancomycin is not effective for these infections. 

POTENTIAL SYSTEMIC ABSORPTION: Taking multiple oral doses of vancomycin can result in clinically significant serum concentrations in some patients. This risk is especially high in people with inflammatory bowel disease. Systemic absorption of vancomycin can lead to adverse reactions. Doctors may monitor serum concentrations of vancomycin in some patients, for example, those with renal impairment (decreased kidney function), colitis, or concomitant treatment with aminoglycoside antibiotics.

NEPHROTOXICITY: There are reports of an increase in blood creatinine, decreased renal function, and kidney failure in patients who received oral vancomycin hydrochloride. This can occur during or after completing treatment. The risk of nephrotoxicity is higher in elderly patients (age 65 and above). Your doctor will monitor kidney function if you are at a high risk of kidney damage from this antibiotic. 

Vancomycin injection can also cause acute kidney injury (AKI) and acute kidney failure. This is primarily due to interstitial nephritis, but can also sometimes occur due to acute tubular necrosis. The risk is greater with higher doses and serum concentrations of vancomycin, prolonged exposure to the antibiotic, receiving concomitant therapy with piperacillin-tazobactam, concomitant therapy with other nephrotoxic drugs, volume depletion, pre-existing kidney problems, and critically ill patients or those with health conditions that predispose them to kidney dysfunction. Your doctor will monitor vancomycin serum concentrations and test kidney function if you are receiving vancomycin injection. 

OTOTOXICITY: Damage to the ear has been reported in patients receiving vancomycin. Drug-induced hearing problems (ringing in the ears, hearing loss, dizziness, vertigo) can be temporary or permanent. Risk factors include high intravenous doses, underlying hearing loss, concomitant treatment with other ototoxic drugs such as aminoglycoside antibiotics, and older age. Your doctor may do serial testing of auditory function to lower the risk of ototoxicity.

SEVERE SKIN REACTIONS: Rarely, treatment with vancomycin can cause severe dermatologic reactions such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), linear IgA bullous dermatosis (LABD), and acute generalized exanthematous pustulosis (AGEP). Stop taking vancomycin and seek emergency medical attention if you develop signs and symptoms such as skin rashes or blistering and peeling skin. 

DRUG-RESISTANT BACTERIA: Vancomycin should only be used for a known or strongly suspected bacterial infection or for prevention of bacterial infections. Using this drug when it’s not needed can lead to the development of drug resistant bacteria.

INFUSION REACTIONS: Vancomycin intravenous infusion should be done slowly over a period of 60 minutes or more. Rapid infusion can result in an infusion reaction with signs and symptoms such as hives, itching, low blood pressure, wheezing, difficulty breathing, shock, and cardiac arrest. The reaction can be more severe in pediatric patients. 

Another vancomycin infusion reaction that can occur is rash and itching on the face, neck and upper body and muscle spasms or muscle pain in the back and chest. 

CLOSTRIDIOIDES DIFFICILE-ASSOCIATED DIARRHEA (CDAD): Vancomycin injection and other antibacterial agents can cause Clostridioides difficile-associated diarrhea (CDAD). This can range in severity from mild diarrhea to life-threatening or fatal colitis. Overgrowth of Clostridioides difficile results primarily from treatment with antibiotics due to changes in the gut microbiome. This bacterium produces toxins that cause CDAD. CDAD may not respond to antimicrobial therapy, and some patients may require colectomy (surgical removal of the large intestine). This complication can occur even two months after the use of antibiotics. 

If you develop CDAD (suspected or confirmed), you may need to stop any antibiotics that are not effective against C. difficile. Treatment for CDAD consists of fluids and electrolytes, protein supplementation, and antibacterial treatment for C. difficile. Notably, oral vancomycin is used to treat this serious infection. 

Prolonged use of IV vancomycin can result in the overgrowth of bacteria that are not susceptible to this antibiotic, leading to superinfection. There are rare reports of pseudomembranous colitis due to C. difficile.

HEMORRHAGIC OCCLUSIVE RETINAL VASCULITIS: The safety and efficacy of vancomycin administration in the eye through the intracameral or intravitreal routes is not established by well-controlled clinical trials. Hemorrhagic occlusive retinal vasculitis (HORV) is an eye complication that can cause permanent vision loss. It has been reported in patients who received vancomycin injection in the eye during or after cataract surgery. 

NEUTROPENIA: Drug fever and neutropenia (low levels of neutrophils, a type of white blood cell) have been reported in people with healthy immune systems who received vancomycin. This is usually promptly reversed when vancomycin is discontinued. Risk factors include prolonged treatment with vancomycin or the concomitant use of other drugs that can also cause neutropenia. Your doctor will monitor your leukocyte count during treatment.

INJECTION SITE REACTIONS: Vancomycin infusion can cause Inflammation at the injection site due to irritation of the tissues (thrombophlebitis). Slow infusion of the drug and rotating between infusion sites can lower this risk. Note: Vancomycin is only given intravenously. Administration of this drug by other routes (intramuscular, intraperitoneal, intravitreal, intraventricular, or intrathecal) is not approved or recommended. 

HIGH SODIUM LOAD: Vancomycin injection solution contains 354 mg of sodium per 100 mL, 531 mg of sodium per 150 mL, and 708 mg of sodium per 200 mL solution. Use of this drug should therefore be avoided in people who require sodium restriction, including elderly patients and those with congestive heart failure