Vancomycin Hydrochloride for Injection — CareFirst (Caremark)

Initial criteria

• Patient must have infection proven or strongly suspected to be caused by susceptible bacteria
• Use only when indicated for listed infections
• For enterococcal endocarditis, must be used in combination with an aminoglycoside
• For early-onset prosthetic valve endocarditis caused by Staphylococcus epidermidis, must be used in combination with rifampin and an aminoglycoside
• For oral use, restricted to treatment of antibiotic-associated pseudomembranous colitis due to C. difficile and staphylococcal enterocolitis
• Bacterial cultures should be obtained prior to and during treatment to identify etiologic organisms and determine susceptibility to vancomycin