Vancomycin Question!

Heres a very good question that I recieved about Vancomycin (AKA Mississippi Mud) from Ingrid. I actually had this question a few months ago.

So here’s my question: Can IV vancomycin be given orally? Once upon a time a couple of jobs ago, maybe 15 years ago I worked on a peri-op floor of a fairly small hospital. We all know that PO vanco is really expensive and IV vanco is pretty cheap. The pharmacist at our hospital told us that it was perfectly okay, and it was cheaper for the patient (and probably the hospital if we got stuck with reimbursement stuff, I’m thinking). We would draw up whatever the dose, squirt it into a med cup, and the patient would drink it.

Actually, I had this same question about 9 months ago. I actually called up my old coworker at the hospital that I used to work at and asked him. Yes, you can. Vanco is vanco and the capsules aren’t anything special or extended release. Considering that Vancocin Caps are kilo-bucks and Vancomycin IV is dirty cheap, its a good way to save the patient a whole lot of money if they are competent enough to reconstitute and administer it.

NO ONE I have ever worked with since has ever heard of such a thing. MDs don’t believe me, and I don’t know whether or not to believe them. I’m asking because 1. it’s interesting, whether it’s true or not, for lots of reasons, which I’m sure you get.
2. my dad has mrsa (wound) and has been taking some pretty expensive p.o. alternatives at home (&%### medicare D and its wonderful “donut hole”).

Oral Vanco isn’t bioavailable. Meaning that if you take vanco caps, all it will do is just kill everything in the gut and not get absorbed into the rest of the body. Thats a /very/ common mistake that doctors make is they have the patient on IV vanco, then send them home with caps and wonder why its not working. Vancomycin is not like Levaquin or any other IV/Oral antibiotic. Like Neomycin (though Neomycin isn’t given IV anymore. Well, not if the doctor likes your kidneys), the physical molecule is too large for the body to absorb, so its really just GI topical. If he’s taking oral Vancocin for a MRSA wound, then you’re just wasting money and your doctor is a fucking idiot. Oral Vanco is only indicated for C. Diff pseudomembraneous colitis after failure of Flagyl.
People tend to freak out when the word MRSA is thrown around, however when the doctors get off of their butt and do a C&S report, they find that sometimes its not resistant to some really common antibiotics like clindamycin, doxy/tetracycline, or cipro.
But to answer your question, no, there is not any difference between oral/IV chemically. There is a difference between absorption on oral vs IV, and the biggest problem is having the patient be competent enough to reconstitute the proper IV dose to give it to themselves orally.
Wow, I actually impressed myself with how smart I sound.. :) Pretty good for a retail chump.

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42 Comments

  1. MrHunnybun says:

    Great idea. We had a similar situation with Midazolam buccal liquid. The branded product had to be imported and was $100 per 5ml. 1x5ml Midazolam ampoule was pennies and in stock. We just needed to make sure patient could break ampoule without amputating fingers!

  2. tim says:

    i work in a hospital and we use IV vanco for oral use all the time as opposed to the caps. with every one we dispense, we give a sheet that states “oral vanco is used in treating antiotic associated pseudomembranous colitis caused by C. difficile and for staphylococcal enterocolitis. vancomycin is not effective by the oral route for other types of infections. the usual adult total daily dosage is 500mg to 2g given in 3 or 4 divided doses for 7 to 10 days……… the appropriate dose may be diluted in 1oz of h2o abd given to the patient to drink. common flavoring syrups may be added to the solution to improve taste.
    there is more, but that is most of it.

  3. Ingrid says:

    Hey, cool, I got a Gold Star for my question! Thanks for the wicked smart answer.
    Now that we’ve confirmed the rumor we need to get all of the health care professionals together and put this out there. These poor old people dealing with Linezolid at two-thousand dollars a course need some relief.

  4. At my hospital, we prepare vancomycin oral solution by dissolving 8 g of I.V. vancomycin in sterile water for injection, then qs ad 240 mL with Syrpalta.This yields a palatable oral solution with a concentration of 500 mg vancomycin/15 mL solution.

  5. kabob says:

    off topic question? i go to a pharmacy school and your site is really popular among us, the students. yesterday, i tried to get on to your website and i was banned from it. was that your doing or the doing of the IT peeps?

  6. AngryNatalie says:

    that was a really interesting article, thanks. i have never heard of such a tale; i work mostly in retail, but i did do a short stint at a cancer hospital.
    the bioavailability of certain antibiotics/infectives etc was gone over in my micro class years ago; you’d hope doctors retain information like that…
    unfortunately, the patients at my pharmacy are..well..for about 80-85% the lights are on, and no one’s really home. i mean, to try and explain taking an oral dose of vanco to people who don’t understand how refills work would cause and aneurysm in any sane healthcare worker. oh well.

  7. Pharmacist Dick says:

    I work in a large hospital, and we use IV Vanco for oral all the time. It works just the as well, and a lot cheaper to boot. The one good thing about hospital is that we can figure out if the doctor has fucked up pretty quickly and fix the problem, usually within the same day.
    Anyway, love the rants! I worked retail for 14 years before giving up to live the life of a rock star at the big badass hospital.My worst day here is still better than my best day in Retail. Good luck, and keep ranting!

  8. RXJOE says:

    AG, ro you really think it’s a good idea to have the patient do the reconstituting?? Trust no one! Mix it up for them and slap on a 14 day expiration date, and if they need it for longer than that, they’ll just have to come back for more! Reconstituted Vanco IV vials for oral use are OK for that long (different story if you plan on injecting!). There is one catch though.. doesn’t taste so hot.. might wanna add a little sweetener and some flavoring.

  9. Alex says:

    In the hopsital I used to work at in New Jersey, we would do this all the time. Even in a compounding pharmacy I worked for few months were using this method when MD requested Vancomycin oral liquid… So I guess at least in NJ, it’s a widely accepted method of making cheaper or rather “cost-effective” oral vancomycin.

  10. DrRx says:

    You are CORRECT for every single reason you mention about vanco…. Most ‘seasoned’ physicians know the deal with IV/PO vanco and the treatment of anything BESIDES C.diff… But I get residents who think they can convert from IV to PO ALL OF THE TIME! They must ‘gloss’ over this in pharmacology during med school….WAIT!!!… Physicians hardly get any pharmacology teaching in school! So who is the person you really want prescribing your drug to you? The physician with almost no teaching…beyond the salesrep schpeel or the pharmacist who spent at least 2.5 years doing mostly just that! Not to offend any physicians out there, but it’s the reality… MD/DO’s do the diagnosing…that’s their niche… Pharmacists have the treatment side of that paradigm…. Just my honest opinion….

  11. Beth Briand says:

    Yes, we do this at my practice site. We make a “vancomycin oral solution” which is basically 1 gram reconsituted with fluid. the patient gets 250 mg qid to treat their ailment. it works. its cheap. doesnt take much time to make up! i dont know about the taste but hey, cant be much worse than cleocin suspension!

  12. Jeff, CPhT says:

    I have worked in the hospital for almost 8 years now and we’ve always used the IV Vanco for oral use. We mix ours with cherry syrup to make it a little easier on the patient.

  13. Joanna says:

    Hey, they teach us that in school. We use IV vanco orally only to treat C. dif infections. It stays in the gut and that is how it has no systemic effects but acts on that raging, bloody infection. sounds good to me.

  14. Jerry Cherzick says:

    I work at the University of Michigan Hospital, and we use injectable Vanco for PO Vanco.

  15. Shalom (R.Ph.) says:

    Ah, oral Vanco. I had one Medicaid patient who had been taking the stuff, and he asked me to get him a refill. Knowing the co$t of these, and as it’s MedNJ it’s coming out of my damn pocket thank you very much, and also knowing that last-resort antibiotics like these should be used sparingly if at all to minimize resistance, I asked the patient what he was using it for.
    He said, “I like it because I can have a real good bowel movement when I’m taking it.”
    I told him nothing doing, the state isn’t paying $1300 a week for you to have a good bowel movement.

  16. Kelli says:

    I work at a VA hospital and we use IV vanco solution in oral vanco compounds whenever an oral solution is required.

  17. jennerator says:

    we make vanco oral solution by the boatload in my hospital. good stuff!

  18. Shyam says:

    i love your blog, all the way from Singapore, where i’m a hospital-based drug information pharmacist :)
    BTW, at my hospital we do use IV vanco for PO use where the pt has failed PO metronidazole, but only for inpatients. i hear from nursing colleagues that it tastes truly awful, tho…

  19. Voyles says:

    Not bad at all, retail guy. Speaking of alternate administration routes for IV Vanco, don’t forget the Vanco retention enema for those particularly hard to kill C. Diff. infestations… a gram in a liter q8h for a few days usually does it. Just remember everyone has a different colonic capacity, so don’t force it too much.

  20. Cathy Lane RPh says:

    I don’t believe oral vanco is always an acceptable alternative to oral linezolid (Zyvox), as perhaps misstated by Ingrid? Depending on sensitivities, C. diff can be tx with metronidazole or oral vanc et al; MRSA can be tx with IV vanco or IV/PO linezolid, etc.?
    However, in cost savings and potential cross-contamination…PO linezolid (if + C/S), is definitely more cost-effective than IV vanco?
    Correct me if I’m wrong.
    Sorry, speaking as pharmacist, not as a microbiologist –not into the particulars too much in e-mail communication; as am going for sound-(info) bites!
    Cathy

    • Jaime says:

      though I’m not a pharmacist, I have been a CPhT for 3 and a half years at an extremely busy retail pharmacy. I also spent many many hours doing clinical rotations in several different hospitals for nursing school. In all the patients I’ve seen, and all the times I’ve seen Zyvox and Vancomycin written; surprising a lot for retail, vancomycin is always a lot cheaper almost 3 times cheaper. we filled a prescription for a patient today for Zyvox, 20 capsules, retail cost was $2600.00. it just so happens we compounded oral vancomycin solution today for a patient, retail cost was $200.00. that being said, in retail, I have never seen Zyvox go through on anyone’s insurance without a long PA process, and I’ve seen Vancomycin capsules and compounded oral solution go through without a PA 85% of the time. To me, from a cost point of view oral vancomycin solution that we compound is the way to go in my experience.

  21. Sarah says:

    It’s amazing how difficult it can be to get some doctors and patients to understand that sometimes a drug can be taken orally but won’t be absorbed – in a similar situation to the vanc story, I explained to a patient that taking oral nystatin wouldn’t work to prevent vaginal candidiasis, although her GP had told her that it would. I explained it to the junior doctor and she crossed it off the drug chart, but the next day I found that the registrar had prescribed it again, on the patient’s request. So annoying!
    By the way, I’ve only just discovered your site and I think it’s great – we have so many of the same problems in the UK, although thankfully we don’t have to deal with medical insurance companies! I’ll start telling my pharmacist friends about this site.

  22. Hey, Pharmacist Dick, I have the same time frame for retail vs. hospital. Badass rock star here in Texas! Why is it we can’t help our retail brethren over their fear of switching to hospital? Then again, maybe we don’t want to flood the market (grin).

  23. Kim says:

    Can anyone tell me how long it takes before IV Vancomycin helps with pain relieve from a Staph infection (knee)?
    Thanks

  24. Misty says:

    We made the switch to using IV vanco to compound oral solutions as well. The only problem we are facing now is a physician that is very adamant that this solution doesn’t work as well as the caps and that he is seeing recurrent infections because of this practice. Does anyone have any specific data on this or that the vanco in the caps is exactly the same as the IV formulation? He doesn’t want to back down and is writting orders as do not substitute and insits that we purchase the caps for his patients.

  25. Gabrielle says:

    Hi! Vancomycin given orally is NOT absorbed systemically. Therefore, the vancomycin (whether IV formulation OR oral capsules) will work for the treatment of C.diff. It will not work for any other infection other than those found locally. To treat systemic infections (ie: cellulitis, etc) IV vanco has to be given. So it doesn’t matter what the formulation is if it is given po, b/c it doesn’t have any barriers to cross (so long as it is acid labile, which vancomycin is). 125 mg of IV vanco is the same as 125 mg of oral capsule vanco b/c it is only going to the GI tract, nowhere else.

  26. gary says:

    what is the cost difference between Iv vanc and the capsules? Specify part of world also.
    Thanks

    • Siobhan says:

      I spoke to a Medicare Advantage member who would have been charged $7000 for an oral course of Vancomycin. He went to several large retail chain pharmacies to price shop and couldn’t get it lower than that. He told them he didn’t have that kind of money, so his PCP admitted him to hospital for IV 3-day course of Vancomycin and that’s all that was approved so he had to be d/c’d. Upon discharge was told he needed to continue with oral form. Still couldn’t afford it and said he’d have to take his chances so a social worker stepped in and got something approved for a reduced cost.

  27. Jenessa says:

    My question is for those of you who mix a large vial of vanco for oral use, what is the expiration date you use on the vial?
    For those of you who do not send a bulk reconstituted vial, do you send the doses in oral syringes or do you let the nurses mix the vanco themselves on the floors?

  28. chemoqueenrph says:

    We mix a 5gm vial with 100 ml SWFI and transfer it into a bulk bottle. All doses are drawn up in an oral syringe. Refrigerated, it’s good 14 days. We deliver all doses to the refrigerator in the med room so we can recycle them if they aren’t used. We go through it like water.
    The oral caps will never dissolve if you need a liquid. It’s like rock sugar inside, without the solubility.

  29. vancomycin says:

    how do calc the amount needed from 1 gm vanco with 20 ml SWFI to make 750mg of vanco in a 250 nss? I’m racking my brain off and the calc i keep getting is 15 ml of the of 1 gm vanco with 20 ml SWFI into 250 NSS. But i was told u take 7.5 ml, why?

  30. WOLVERINE says:

    Vancomycin,

    Your calculations are correct.

    1gm/20ml=0.75gm/x ml
    1x=15ml

    Add 15ml vancomycin to 250ml NS

  31. drjillb says:

    can anyone provide a published ref on the non-absorption issue? Thanks!

  32. Christina says:

    Wow, this is great. About 2 years ago, I was on a rotation at a Coumadin clinic, outpatient, where other problems tended to come up. My fellow classmate told the physician about IV for PO use, and physician was amazed. Since leaving school and my placement at my retail home out in North East Ohio, I spoke up to the GI doc out here about the compounding. Incredible response. Kept a ton of patients out of the donut hole. 5 bucks for a 1 g vial, MUCH CHEAPER. I compound each 1 g vial with 10 ml sterile water. For every 10 ml of water, I use 10 ml cherry syrup, making 1 g per 20 ml, good 250 mg/1 tea. Stability 14 days in the fridge. Process the script for “bill for only approved ingredients.” We make barely anything off of the compounds, but we are doing about 1 each week and winning over patients left and right.

  33. johnny says:

    Okay, nice discussion. I am aware of the iv/po substition. My question now is, can I use both iv and po concurrently. Pt on po therapy for c.diff also presents with severe UTI. Don’t want to use other broad spectrum abx so is vanco an appropriate choice? Since po isn’t absorbed I’m guessing this is okay.

  34. Kay says:

    Can the same principle be applied to a similar drug in IV form like gentamicin?

  35. bobbinsy says:

    I need an answer ASAP: I’ve had many health problems (spreading and worsening all the time) following hernia repair surgery months ago – reading the surg. report, I see that the (huge piece of) abdominal mesh was soaked in Vancomycin just prior to inserting it in my abdomen. Is this an established use of Vancomycin, or could this be causing me problems throughout my body? I’m getting scared about some of the symptoms and have been unable to work for months. Internet research hasn’t helped me find an answer. If this vanco-soaked mesh might be a problem, what can I do about it?
    Thanks for any info.

  36. Neil says:

    I just got a request to make po vancomycin solution but dont really know how. Could someone please write appropriate directions for any dosage? i spoke with a comkpounding pharmacist and he mentioned it has to be done under sterile conditions? Please let me know. Thanks!

  37. Jared says:

    Usually it is reconstituted just like it requests on the vial. 20mL’s per 1 gram of vanco, and then the dose is 250mg/5mLs or 125mg’s per 2.5 mL’s(100 mls for 5 gram vial)

    I just bust out the rubber stopper and pour the water in(why waste a syringe?), shake it up and pour it out into a bottle.

    I usually mix up a 10-14 day supply that the patient can refrigerate. No need for sterile conditions, it is just like amoxicillin suspension when used this way. I use distilled water.

    It just tastes… not so good, but most patients think it is worth the 500-1000.00 price difference. Patient can mix it in some juice and it not so bad

  38. Brandy says:

    So, here is my question…
    How/who do you bill for it?
    Our ID docs prescribe oral vanco, and we now compound it at our infusion pharmacy as well. However, I can’t find anywhere that explains how we bill the patient’s insurance for it!
    We decided not to use outside pharmacies due to the outrageous costs, but if we only get paid for the J3370 we use as IV, we can’t afford to make it at all…..

  39. Dogmatrix says:

    Hi there, I am a hospital pharmacist also.

    We get a 500mg amp and add 10ml of sterile water this will give you a 50mg/ml solution. The capsules available here are a 125mg capsule this is given 4 times a day so likewise the oral is given as 125mg (2.5ml) qid.

    The made up amp can be refrigerated for 24 hours (gives you 1 days worth of dose… after which its dumped.

    Hope that helps

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