In this episode, I’ll discuss whether it is ever appropriate for a patient to be on vancomycin by more than one route of administration.
While IV vancomycin is indicated for a variety of infectious diseases, oral vancomycin is primarily used to treat Clostridioides difficile infection (CDI).
Unlike IV metronidazole, which achieves therapeutic levels in the colon when inflammation is present and can be used to treat CDI, vancomycin does not reach the colon when given intravenously. Conversely, oral vancomycin has negligible bioavailability; it is not absorbed into the bloodstream and acts purely locally.
It is for that reason that oral vancomycin is used, especially when treating severe and fulminant CDI.
As CDI is often a complication of antibiotic therapy, it is entirely possible for a patient who develops CDI to be placed on IV vancomycin to treat a previous infection such as endocarditis, cellulitis, or pneumonia.
When a pharmacist receives an order for an oral antibiotic for a patient already receiving an IV antibiotic, in nearly all cases, the intent to discontinue the IV antibiotic is assumed.
However, with vancomycin, the IV and oral forms are always used to treat different infections, and it is not appropriate to discontinue IV vancomycin upon receipt of an oral vancomycin order. Electronic health records might erroneously flag IV and oral vancomycin as duplicate therapy, potentially causing clinicians affected by alert fatigue to discontinue the systemic treatment inadvertently.
This occurrence of vancomycin by multiple routes of administration is less common today with increased use of fidaxomicin, but it is still possible to encounter. New clinicians, especially those new to hospital practice, should receive education on why IV and oral vancomycin may be given together, and pharmacists monitoring such patients should be on the lookout for this scenario to prevent a patient with endocarditis or other severe infection from having their IV vancomycin treatment unintentionally stopped.
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