Vancomycin Injection for Oral Use Given Intramuscularly

The Institute for Safe Medication Practices received a report from a long-term care (LTC) pharmacy that discovered administration errors at 2 of the LTC facilities it serviced. The pharmacy had received orders for vancomycin 125 mg orally every 6 hours to treat Clostridium difficile—associated diarrhea for residents at these facilities. Vancomycin is available in capsule form for oral use. However, the powder in vials of vancomycin injection can also be reconstituted with sterile water to make an oral solution.

Due to the high cost of VANCOCIN brand capsules and occasional problems obtaining specific vancomycin products, the pharmacy elected to send the LTC facilities a supply of vials of the injectable form of vancomycin powder, along with diluent, for the nurses to reconstitute the powder to make an oral solution. The vials and diluent were provided in 2 separate bags, along with directions for mixing and storing the oral solution, and the volume of solution to administer for each 125-mg dose. But soon after, a series of medication errors occurred.

The nurses at both facilities were unfamiliar with the practice of using injectable vancomycin for oral administration. Although nurses reconstituted the powdered drug correctly, they administered each dose intramuscularly (IM). The error was discovered when the director of nursing at one LTC facility mentioned to a consultant pharmacist that she was concerned the medication had not been provided in capsule form and needed to be reconstituted by nurses at the facility. One patient received 5 doses of the drug IM before the error was detected. This resident not only experienced pain at the administration sites when the drug was injected (IM administration of the drug is not advised), but also a delay in proper treatment of the C difficile infection.

Unfortunately, parenteral vancomycin (IM or intravenous [IV]) does not treat a C difficile infection in the bowel. This put the residents at risk for worsening infection, and the duration of oral therapy had to be extended to cover the missed treatment. It is also worth noting that parenteral vancomycin has been inappropriately prescribed for this purpose, and oral vancomycin has been prescribed, or otherwise used erroneously, to treat a systemic infection in other patients.

For the treatment of C difficile diarrhea, oral metroNIDAZOLE may be a viable alternative if the patient is experiencing his or her first episode and it is not a resistant case.^1,2 However, if oral vancomycin is needed, and vancomycin injection will be reconstituted for oral use, pharmacists should prepare the solution in the pharmacy and provide each individual resident dose in an oral syringe marked “FOR ORAL USE ONLY.” Oral syringes are designed to prevent connection to an IV port or attachment of a needle. Dispensing medications in the most ready-to-administer form should be the prevailing practice for all pharmacies that provide medications to LTC facilities.

Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.

References

• Pepin J. Vancomycin for the treatment of Clostridium difficile infection: for whom is this expensive bullet really magic? Clin Infect Dis. 2008;46(10):1493-1498.
• Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(4):431-455.