Limited Coverage Drugs - Vancomycin

Generic Name

vancomycin

Strength

125 mg, 250 mg
Form capsule

Special Authority Criteria

Approval Period

For the treatment of patients diagnosed with symptomatic Clostridium Difficile Infection (CDI) that:

  1. Are allergic, resistant or intolerant to metronidazole

OR

  1. Have failed to respond to 4-6 days of oral metronidazole at doses of 500 mg three times a day

OR

  1. Have severe diseasei and initial doses are prescribed by an infectious disease or gastro-intestinal specialist

OR

  1. Are experiencing a second recurrenceii and are recommended vancomycin on consultation from an infectious disease or gastro-intestinal specialist.

Notes:

  1. Severe is defined as having any of the following symptoms:
    • white blood cell count > 15,000 mm3 and fever
    • acute kidney injury with rising serum creatinine ≥ 1.5 times premorbid level or ≥ 175 micromole/litre
    • Pseudomembranous colitis, hypotension, shock, or megacolon.
  2. Recurrence is defined as a subsequent CDI episode occurring within 2-8 weeks of a previous episode from the date of diagnosis.

Initial: Up to 14 days

Second or Further Recurrence: 14 days
 

Practitioner Exemptions

  • None

Special Notes

  • Important: As this medication may be required urgently, pharmacists can contact the PharmaNet HelpDesk to request that a Special Authority for vancomycin be entered for a patient if the patient has confirmed that they have a diagnosis of CDI and that at least one of the four criteria above applies. The HelpDesk is available 24 hours a day, seven days a week.

Special Authority Request Form(s)