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Pharmacology · Glycopeptides

Vancomycin !

An intravenous glycopeptide for serious gram-positive infections such as MRSA; given by mouth only for C. difficile colitis.

Updated 2026-11-01

  • Class: Glycopeptides
  • Target: D-Ala–D-Ala terminus of the peptidoglycan precursor
  • ATC code: J01XA01
  • WHO Model List of Essential Medicines

Vancomycin has no protein target. The figure shows vancomycin itself (a small cyclic peptide) holding the diacetyl-Lys-D-Ala-D-Ala peptide that mimics the end of the cell-wall building block.

Target in 3D: D-Ala–D-Ala terminus of the peptidoglycan precursor. PDB structure 1FVM (RCSB PDB, public domain). View the structure at RCSB PDB

Mechanism of action

Vancomycin binds the D-Ala–D-Ala end of the peptidoglycan precursor with several hydrogen bonds. The bulky molecule then blocks the enzymes that link the precursors into chains and cross-link the chains, so the wall cannot be built and the dividing bacterium dies. It is bactericidal against most gram-positive bacteria, including MRSA, and has no activity against gram-negative bacilli.

  1. Binds the D-Ala–D-Ala end of the wall precursor
  2. Blocks chain building and cross-linking
  3. The gram-positive wall weakens
  4. The bacterium lyses

Pharmacokinetics

Absorption
Poorly absorbed by mouth: oral doses stay in the gut, which is why the oral route treats only C. difficile colitis.
Distribution
Reaches most body fluids; it enters the cerebrospinal fluid mainly when the meninges are inflamed.
Elimination
Mostly unchanged in the urine by glomerular filtration; it accumulates when kidney function falls.
Half-life
About 4 to 6 hours with normal kidney function; much longer in kidney failure.

Indications

Adverse effects

Common

  • Infusion reaction with fast infusion: flushing of the face, neck and upper body, itching, rash, chest or back pain, low blood pressure
  • Phlebitis and pain at the infusion site
  • Drug fever, chills, eosinophilia, rash

Contraindications

  • Known hypersensitivity to vancomycin

Key interactions

Aminoglycosides, amphotericin B, polymyxin B, colistin and other nephrotoxic or ototoxic drugs
Added kidney and ear damage: renal function is followed closely.
Anaesthetic agents
More infusion reactions (flushing, hypotension); the infusion is finished before induction where possible.
Some penicillins
May raise the risk of kidney injury when combined.

What is monitored

  • Serum creatinine and urine output before and during treatment
  • Blood levels by the local protocol (trough or area under the curve), timed to the dose schedule
  • Complete blood count in long courses
  • Hearing checks in patients with kidney disease, prior hearing loss or other ototoxic drugs

Administration and safety

  • Intravenous only for systemic infections, always diluted and infused slowly, never as a bolus: fast infusion causes the infusion reaction and hypotension.
  • Never intramuscular: it is irritant and causes pain and tissue necrosis; extravasation can also damage tissue.
  • If flushing or itching appears, the infusion is stopped and restarted more slowly as ordered.
  • The oral form is only for C. difficile colitis: it does not treat infections outside the gut.

Nursing care

  • Before starting: baseline creatinine, urine output and allergy history; ask about hearing problems.
  • During the infusion: blood pressure and skin of the face and chest; flushing points to infusion rate, wheeze or swelling to allergy.
  • Draw level samples exactly at the time the protocol sets and record the dose times.
  • Watch the IV site for phlebitis and extravasation.
  • Teaching: report tinnitus, hearing change, less urine, rash or blisters, and diarrhoea even weeks after the course.

Pregnancy and breastfeeding

Vancomycin reaches the cord blood; a clinical study found no hearing loss or kidney damage attributable to it in the newborns, and it is used in pregnancy when clearly needed.

Test yourself

Think of the answer, then tap the question to see it.

During a fast vancomycin infusion a patient develops flushing of the face and chest with itching. What is happening, and is it an allergy?

A vancomycin infusion reaction from direct histamine release by mast cells. It is not an allergy; stopping and restarting the infusion more slowly usually resolves it.

Why is oral vancomycin used for C. difficile colitis but not for MRSA pneumonia?

It is barely absorbed from the gut: it stays in the colon where C. difficile lives, but never reaches the lung.

Which two organs are watched most closely during vancomycin treatment?

The kidney (creatinine, urine output, drug levels) and the ear (tinnitus, hearing loss), especially with aminoglycosides or other nephrotoxic drugs.

Why does vancomycin miss gram-negative bacilli?

It is a large molecule that cannot cross their outer membrane to reach the D-Ala–D-Ala target in the wall.

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Educational content on how drugs work; not a prescribing guide and no substitute for a health professional's advice. No doses are given.

Sources: DailyMed - VANCOMYCIN HYDROCHLORIDE injection, powder, lyophilized, for solution (DailyMed (U.S. National Library of Medicine), 2026); Vancomycin Injection: MedlinePlus Drug Information (MedlinePlus (U.S. National Library of Medicine), 2026); Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed., ch. 58 (McGraw Hill, 2023); RCSB PDB - 1FVM: Complex of vancomycin with DI-acetyl-LYS-D-ALA-D-ALA (RCSB Protein Data Bank, 2026).

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Representative model, for educational purposes only.