warnings and cautions
5 WARNINGS AND PRECAUTIONS Nephrotoxicity : Systemic vancomycin exposure may result in acute kidney injury (AKI) including acute renal failure, mainly due to interstitial nephritis or less commonly acute tubular necrosis. Monitor serum vancomycin concentrations and renal function in patients receiving Vancomycin Hydrochloride for Injection intravenously. Monitor renal function in patients over 65 years of age receiving Vancomycin Hydrochloride for Injection orally. ( 5.1 ) Ototoxicity : Ototoxicity has occurred in patients administered vancomycin intravenously or orally. Monitor for signs and symptoms of ototoxicity during oral or intravenous therapy. Assessment of auditory function may be appropriate in some instances. ( 5.2 ) Severe Dermatologic Reactions: Discontinue Vancomycin Hydrochloride for Injection at the first appearance of skin rashes, mucosal lesions, or blisters ( 5.3 ). Neutropenia: This has been reported in patients administered vancomycin intravenously or orally. Periodically monitor leukocyte count. ( 5.4 ) Infusion Reactions : Hypotension, including shock and cardiac arrest, wheezing, dyspnea, urticaria, muscular, chest pain and vancomycin infusion reaction which manifests as pruritus and erythema that involves the face, neck and upper torso may occur with rapid intravenous administration. To reduce the risk of infusion reactions, administer Vancomycin Hydrochloride for Injection in a diluted solution over a period of 60 minutes or greater and also prior to intravenous anesthetic agents. ( 2.1 , 5.5 ) Phlebitis : To reduce the risk of local irritation and phlebitis administer Vancomycin Hydrochloride for Injection by a secure intravenous route of administration. ( 5.6 ) Clostridioides difficile -Associated Diarrhea : Evaluate patients if diarrhea occurs. ( 5.7 ) Development of Drug-Resistant Bacteria : Prescribing Vancomycin Hydrochloride for Injection in the absence of a proven or strongly suspected bacterial infection is unlikely to provide benefit to the patient and increases the risk of the development of drug resistant bacteria. ( 5.9 ) 5.1 Nephrotoxicity Vancomycin Hydrochloride for Injection administered intravenously or orally can result in acute kidney injury (AKI), including acute renal failure, mainly due to interstitial nephritis or less commonly acute tubular necrosis. AKI is manifested by increasing blood urea nitrogen (BUN) and serum creatinine (Cr). The risk of AKI increases with higher vancomycin serum levels, prolonged exposure, concomitant administration of other nephrotoxic drugs, concomitant administration of piperacillin-tazobactam [see Drug Interactions ( 7.2 )] , volume depletion, pre-existing renal impairment and in critically ill patients and patients with co-morbid conditions that predispose to renal impairment. Monitor serum vancomycin concentrations and renal function in all patients receiving Vancomycin Hydrochloride for Injection intravenously. Nephrotoxicity (e.g., reports of renal failure, renal impairment, blood creatine increased) has occurred following oral vancomycin hydrochloride capsule therapy in randomized controlled clinical studies and can occur either during or after completion of therapy. The risk of nephrotoxicity is increased in patients >65 years of age [see Adverse Reactions ( 6.1 ) and Use in Specific Populations ( 8.5 )] . In patients over 65 years of age, including those with normal renal function prior to treatment, renal function should be monitored during and following treatment with oral Vancomycin Hydrochloride for Injection therapy to detect potential vancomycin induced nephrotoxicity. More frequent monitoring is recommended in patients with comorbidities that predispose to impairment in renal function or are concomitantly receiving other nephrotoxic drugs, in critically ill patients, in patients with changing renal function, and in patients requiring higher therapeutic vancomycin levels. If acute kidney injury occurs, discontinue Vancomycin Hydrochloride for Injection or reduce the dose. 5.2 Ototoxicity Ototoxicity has occurred in patients administered vancomycin intravenously or orally. It may be transient or permanent. Ototoxicity manifests as tinnitus, hearing loss, dizziness or vertigo. The risk is higher in older patients, patients who are receiving higher doses, who have an underlying hearing loss, who are receiving concomitant therapy with another ototoxic agent, such as an aminoglycoside or who have underlying renal impairment. Monitor for signs and symptoms of ototoxicity during oral or intravenous therapy with Vancomycin Hydrochloride for Injection. Discontinue Vancomycin Hydrochloride for Injection if ototoxicity occurs. Serial tests of auditory function may be helpful in order to minimize the risk of ototoxicity. 5.3 Severe Dermatologic Reactions Severe dermatologic reactions such as toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS), drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), and linear IgA bullous dermatosis (LABD) have been reported in association with the use of vancomycin. Cutaneous signs or symptoms reported include skin rashes, mucosal lesions, and blisters. Discontinue Vancomycin Hydrochloride for Injection at the first appearance of signs and symptoms of TEN, SJS, DRESS, AGEP, or LABD. 5.4 Neutropenia Reversible neutropenia has been reported in patients administered vancomycin intravenously or orally. Patients who will undergo prolonged therapy with Vancomycin Hydrochloride for Injection or those who are receiving concomitant drugs which may cause neutropenia should have periodic monitoring of the leukocyte count. 5.5 Infusion Reactions Hypotension, including shock and cardiac arrest, wheezing, dyspnea, urticaria, muscular and chest pain may occur with rapid Vancomycin Hydrochloride for Injection intravenous administration. The reactions may be more severe in younger patients, particularly children, and in patients receiving concomitant muscle relaxant anesthetics. Rapid intravenous administration of Vancomycin Hydrochloride for Injection may also be associated with vancomycin infusion reaction, which manifests as pruritus and erythema that involves the face, neck and upper torso. Infusion-related adverse reactions are related to both the concentration and the rate of administration of Vancomycin Hydrochloride for Injection. Infusion-related adverse reactions may occur, however, at any rate or concentration. Administer Vancomycin Hydrochloride for Injection in a diluted solution over a period of 60 minutes or greater to reduce the risk of infusion-related adverse reactions. In selected patients in need of fluid restriction, a concentration up to 10 mg/mL may be used; use of such higher concentrations may increase the risk of infusion-related adverse reactions [see Nonclinical Toxicology ( 13.2 )] . Administer prior to intravenous anesthetic agents when feasible. Stop the infusion if a reaction occurs. 5.6 Phlebitis and Adverse Reactions with Unapproved Routes of Administration Inflammation at the site of injection of vancomycin has been reported. Vancomycin is irritating to tissue and must be given by a secure intravenous route of administration to reduce the risk of local irritation and phlebitis. Thrombophlebitis may occur, the frequency and severity of which can be minimized by slow infusion of the drug and by rotation of venous access sites. Administration of Vancomycin Hydrochloride for Injection by intramuscular (IM), intraperitoneal, intrathecal intraventricular, or intravitreal routes has not been approved and is not recommended. The safety and efficacy of vancomycin administered by these routes of administration have not been established by adequate and well controlled trials. Pain, tenderness, and necrosis occur with IM injection of vancomycin or with inadvertent extravasation. Intraperitoneal administration during continuous ambulatory peritoneal dialysis (CAPD) can result in chemical peritonitis. Manifestations range from cloudy dialysate alone to a cloudy dialysate accompanied by variable degrees of abdominal pain and fever. This syndrome appears to be resolved after discontinuation of intraperitoneal vancomycin. About 60% of an intraperitoneal dose of vancomycin administered during peritoneal dialysis is absorbed systemically in 6 hours. Serum concentrations of about 10 mcg/mL are achieved by intraperitoneal injection of 30 mg/kg of vancomycin. However, the safety and efficacy of the intraperitoneal use of vancomycin has not been established in adequate and well-controlled trials. 5.7 Clostridioides difficile -Associated Diarrhea (CDAD) Clostridioides difficile -associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including with intravenous administration of vancomycin and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile . C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibacterial use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents. If CDAD is suspected or confirmed, ongoing antibacterial use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C. difficile , and surgical evaluation should be instituted as clinically indicated. Clinically significant serum concentrations of vancomycin have been reported in some patients being treated for active C. difficile -induced pseudomembranous colitis after multiple oral doses of vancomycin [see Warnings and Precautions ( 5.10 )] . Prolonged use of Vancomycin Hydrochloride for Injection may result in the overgrowth of non-susceptible microorganisms. Careful observation of the patient is essential. If superinfection occurs during therapy, appropriate measures should be taken. There have been reports of pseudomembranous colitis due to C. difficile developing in patients who received intravenous vancomycin. 5.8 Hemorrhagic Occlusive Retinal Vasculitis (HORV) Hemorrhagic occlusive retinal vasculitis, including permanent loss of vision, occurred in patients receiving intracameral or intravitreal administration of vancomycin during or after cataract surgery. The safety and efficacy of vancomycin administered by the intracameral or the intravitreal route have not been established by adequate and well-controlled trials. Vancomycin Hydrochloride for Injection (intravenously and orally administered) is not indicated for the prophylaxis of endophthalmitis. 5.9 Development of Drug-Resistant Bacteria Prescribing Vancomycin Hydrochloride for Injection (intravenously and orally administered) in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria. 5.10 Potential for Systemic Absorption after Oral Administration Clinically significant serum concentrations have been reported in some patients who have taken multiple oral doses of oral vancomycin for active C. difficile -associated diarrhea. Some patients with inflammatory disorders of the intestinal mucosa also may have significant systemic absorption of vancomycin. These patients may be at risk for the development of adverse reactions associated with higher doses of oral vancomycin; therefore, monitoring of serum concentrations of vancomycin may be appropriate in some instances, e.g., in patients with renal insufficiency and/or colitis or in those receiving concomitant therapy with an aminoglycoside antibacterial drug.