[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Pharmacology](https://durgical.com/en/pharmacology/) › [Glycopeptides](https://durgical.com/en/pharmacology/classes/glycopeptides/) › Vancomycin

[Pharmacology](https://durgical.com/en/pharmacology/) · [Glycopeptides](https://durgical.com/en/pharmacology/classes/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](https://durgical.com/en/pharmacology/classes/glycopeptides/)
- Target: D-Ala–D-Ala terminus of the peptidoglycan precursor
- ATC code: J01XA01
- WHO Model List of Essential Medicines

◆**D-Ala–D-Ala terminus of the peptidoglycan precursor**Vancomycin

ⓘ 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](https://www.rcsb.org/structure/1FVM) · Drag to rotate · pinch to zoom

## 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.

- Binds the D-Ala–D-Ala end of the wall precursor
- Blocks chain building and cross-linking
- The gram-positive wall weakens
- 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

- Serious infections by methicillin-resistant staphylococci (MRSA), or by staphylococci in patients who cannot receive β-lactams. [MRSA and other multidrug-resistant organism infections →](https://durgical.com/en/conditions/mrsa-and-other-multidrug-resistant-organism-infections/)
- Staphylococcal endocarditis; with an aminoglycoside for enterococcal endocarditis in penicillin allergy. [Infective endocarditis →](https://durgical.com/en/conditions/infective-endocarditis/)
- Staphylococcal bacteremia and sepsis. [Sepsis and septic shock →](https://durgical.com/en/conditions/sepsis-and-septic-shock/)
- Bone infections due to staphylococci. [Osteomyelitis →](https://durgical.com/en/conditions/osteomyelitis/)
- Part of the initial empirical treatment of bacterial meningitis where penicillin-resistant pneumococci are common. [Bacterial meningitis →](https://durgical.com/en/conditions/bacterial-meningitis/)
- By mouth, Clostridioides difficile colitis. [Clostridioides difficile infection →](https://durgical.com/en/conditions/clostridioides-difficile-infection/)

## 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

### Serious (rare, important)

- Acute kidney injury, more likely with higher exposure and other nephrotoxic drugs; interstitial nephritis
- Hearing loss, tinnitus or vertigo, transient or permanent
- Reversible neutropenia during long courses
- Severe skin reactions: Stevens–Johnson syndrome, toxic epidermal necrolysis, DRESS, linear IgA bullous dermatosis
- Anaphylaxis (true allergy is less common than the infusion reaction)
- Occlusive retinal vasculitis with vision loss after injection inside the eye (not an approved route)

## 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.

## Memory aid

Vancomycin is a «VAN parked on the D-Ala–D-Ala»: the wall builders cannot pass. Drive it too fast and the face goes red; park it too long in the kidney and creatinine rises.

## 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.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/pharmacology/vancomycin/)

## Related drugs

- [Benzylpenicillin (penicillin G)](https://durgical.com/en/pharmacology/benzylpenicillin/)
- [Gentamicin](https://durgical.com/en/pharmacology/gentamicin/)
- [Linezolid](https://durgical.com/en/pharmacology/linezolid/)
- [Daptomycin](https://durgical.com/en/pharmacology/daptomycin/)

## Related conditions

- [MRSA and other multidrug-resistant organism infections](https://durgical.com/en/conditions/mrsa-and-other-multidrug-resistant-organism-infections/)
- [Infective endocarditis](https://durgical.com/en/conditions/infective-endocarditis/)
- [Sepsis and septic shock](https://durgical.com/en/conditions/sepsis-and-septic-shock/)
- [Osteomyelitis](https://durgical.com/en/conditions/osteomyelitis/)
- [Bacterial meningitis](https://durgical.com/en/conditions/bacterial-meningitis/)
- [Clostridioides difficile infection](https://durgical.com/en/conditions/clostridioides-difficile-infection/)

[← Back to the class: Glycopeptides](https://durgical.com/en/pharmacology/classes/glycopeptides/)

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](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b79d9671-02dd-40e2-97fb-a6c7be85cda1) (DailyMed (U.S. National Library of Medicine), 2026); [Vancomycin Injection: MedlinePlus Drug Information](https://medlineplus.gov/druginfo/meds/a601167.html) (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](https://www.rcsb.org/structure/1FVM) (RCSB Protein Data Bank, 2026).

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Representative model, for educational purposes only.

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