Alternative Routes of Administration Guidance

Vancomycin 500 mg vial for ORAL administration:

• To be used if capsules not available or for patients with swallowing difficulties.
• Only applicable to the following brands of Vancomycin 500mg vials – Bowmed Ibisqus, SGS Pharma, Hameln, Flynn pharma, and Kent pharma.
• Please consult with pharmacy if the brand is not listed above as some brands may not be licensed for oral administration.

How to prepare and administer:

1. Reconstitute a vancomycin 500 mg vial with 10 mL of water for injection to give a concentration of 50 mg/mL.
2. Withdraw the required volume – for 125 mg dose withdraw 2.5 mL, for 250 mg dose withdraw 5 mL, and for 500 mg dose withdraw 10 mL of solution.
3. Dilute each dose further to 30 mL with water for injection for the patient to drink.

Vancomycin 500 mg vial for ENTERAL TUBE administration:

• This is an unlicensed route of administration - please use oral route where possible and consult pharmacy for advice.

How to prepare and administer:

1. Reconstitute a vancomycin 500 mg vial with 10 mL of water for injection to give a concentration of 50 mg/mL.
2. Withdraw the required volume – for 125 mg dose withdraw 2.5 mL, for 250 mg dose withdraw 5 mL, and for 500 mg dose withdraw 10 mL of solution.
3. Dilute each dose further to 30 mL with water for injection and flush it down the enteral tube.
4. Flush the tube post dose with 10 mL of water for injection.

PLEASE NOTE:

• Some Vancomycin vials may state for “for single use only” but this is only applicable for intravenous administrations.
• The reconstituted vials for ORAL/ENTERAL route may be stored at 2-8^oc for up to 24 hours. The same vial can be used to administer further doses within this period.

• This is an unlicensed route of administration and is only recommended under the advice of microbiology/Infectious Diseases (ID).
• Review intra-colonic route daily and change to oral/enteral route as soon as appropriate.
• Usual dose for vancomycin enema – 500 mg every 6 hours.

How to prepare and administer:

1. Reconstitute a vancomycin 500 mg vial with 10 mL of water for injection to give a concentration of 50 mg/mL.
2. Withdraw the total volume (10 mL for 500mg dose) and add to a 100 mL bag of sodium chloride 0.9% to give a concentration of 5 mg/mL.
3. Distribute the 100 mL of vancomycin 5 mg/mL evenly in two 50 mL syringes.
4. Lay the patient on their side and insert a lubricated, 18 gauge Foley catheter with a 30mL balloon into the rectum with care.
5. Inflate the balloon with sterile water (supplied with catheter).
6. Administer the vancomycin solution into the catheter and securely plug the Foley catheter with a green catheter plug (spigot for catheters).
7. After 60 minutes, deflate the catheter balloon and remove the Foley catheter.
8. Repeat every 6 hours.

Note: Systemic absorption is rare but there have been case reports in patients with renal impairment. Serum vancomycin levels may be taken if concerns of systemic absorption.

Administration of fidaxomicin via NG tubing

• There is now available fidaxomicin 40mg/ml granules for oral suspension, brand name Dificlir®, manufacturer Tillotts Pharma UK limited.
• The granules for oral suspension should be reconstituted prior to giving to the patient. It can be given via an enteral feeding tube using an appropriate syringe.
• The full instructions for reconstitution of fidaxomicin granules can be found in the product information here

Remember: the bottle should be stored in the fridge after reconstitution and after each use. It should be taken out of the fridge 15 minutes prior to administration, and gently shaken 10 times.