Limited Coverage Drugs - Vancomycin

Generic Name

Strength

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

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

OR

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

OR

4. 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