Vancocin, Firvanq
Evidence Grade A — Regulatory approved. 39588 published studies. 599 registered clinical trials.
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Vancomycin is one of medicine's most important antibiotics — the go-to treatment for serious MRSA infections and severe C. difficile gut infections. Available as an intravenous infusion for bloodstream and deep-tissue infections and as an oral formulation for intestinal infections, it has been a cornerstone of hospital medicine since the 1950s and remains on the WHO's List of Essential Medicines.
39,588 published studies: 24515 human, 3109 animal, 5235 in-vitro, 4142 reviews
Vancomycin is marketed as Vancocin and Firvanq (approved 1958, with oral solution Firvanq approved 2018). It is the standard treatment for serious MRSA infections (bloodstream infections, endocarditis, pneumonia, bone infections) and is first-line for severe C. difficile colitis.
Vancomycin requires therapeutic drug monitoring — blood levels must be checked regularly to ensure the dose is effective without causing kidney damage or hearing loss. The rise of vancomycin-resistant enterococci (VRE) and occasional vancomycin-intermediate S. aureus (VISA) strains represent ongoing challenges. Despite being nearly 70 years old, vancomycin remains irreplaceable for many serious infections, though newer alternatives like daptomycin and the lipoglycopeptides offer advantages in specific settings.
Vancomycin works by binding to a specific chemical structure (D-Ala-D-Ala) on the building blocks that bacteria use to construct their cell walls. By physically blocking this target with five precise hydrogen bonds, vancomycin prevents the enzymes that cross-link the cell wall from doing their job. Without a properly constructed cell wall, the bacterium cannot maintain its structural integrity and dies. This mechanism targets a fundamental bacterial process that human cells do not use.
With over 60 years of clinical experience, vancomycin is one of the most thoroughly understood antibiotics. It requires regular blood level monitoring to ensure doses are effective without causing kidney damage or hearing loss. Administration must be slow to avoid "Red Man Syndrome" — a flushing reaction caused by rapid infusion. The rise of vancomycin-resistant bacteria (particularly enterococci) is an ongoing concern, and occasional vancomycin-intermediate S. aureus strains have been identified. Despite being nearly 70 years old and despite the availability of newer alternatives like daptomycin and the lipoglycopeptides, vancomycin remains irreplaceable for many serious gram-positive infections. Research continues into optimal dosing strategies, particularly in obese patients and children.
Expanded Access to Cyclic Irrigation in Patients Undergoing Exchange Arthroplasty
Vancomycin Resistant Enterococci in Patients Awaiting Liver Transplantation at the University of Michigan: Prevalence, Risk Factors, Natural History and Outcome of Colonization
Vancomycin and Fecal Microbiota Transplant in a Single Patient With Autism Spectrum Disorder
Use of Fidaxomicin Compared to Vancomycin for Decolonization of C. Difficile in Patients With Inflammatory Bowel Disease
Local Antibiotic Concentrations With Tissue Expanders in Breast Reconstruction
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Corticotropin is marketed as H.P. Acthar Gel (currently ANI Pharmaceuticals). It carries approximately 19 FDA-labelled indications including infantile spasms (its strongest evidence base), nephrotic syndrome, multiple sclerosis relapses, and rheumatic disorders. Acthar Gel has been at the centre of major pricing and legal controversies. The price rose from approximately $40 per vial in 2001 to over $40,000, driven by successive acquisitions and orphan-like positioning despite broad labelling. The former manufacturer Mallinckrodt agreed to a $260 million settlement over antitrust concerns. Clinically, the strongest evidence supports its use in infantile spasms, where it is considered a first-line treatment. For most other indications, debate continues over whether it offers meaningful advantages over far less expensive oral corticosteroids.
Enfuvirtide is marketed as Fuzeon (approved March 2003). It requires twice-daily subcutaneous injections, and injection-site reactions occur in nearly all patients (98%). In clinical trials (TORO-1 and TORO-2), enfuvirtide combined with an optimised background regimen achieved significantly greater viral suppression than background regimen alone in treatment-experienced patients. Enfuvirtide represented a major advance when HIV drug resistance was a more pressing clinical challenge, but its use has declined substantially with the arrival of more convenient oral antiretrovirals. The twice-daily injection burden, injection-site reactions, high cost, and complex manufacturing (it is one of the largest synthetic peptides manufactured at scale) have limited its role to a last-resort option for patients with highly resistant HIV.
Dalbavancin is marketed as Dalvance (approved May 2014). Originally approved as a two-dose regimen (Day 1 and Day 8), a single-dose regimen was approved in January 2016, and paediatric approval followed in 2021. Indicated for ABSSSI caused by susceptible gram-positive organisms. Dalbavancin's 346-hour half-life is the longest of any approved antibiotic, and there is growing off-label interest in its use for conditions requiring prolonged antibiotic courses, such as osteomyelitis and prosthetic joint infections — conditions where patients would otherwise need weeks of daily intravenous antibiotics. The DOTS trial (2025) showed non-inferiority to standard-of-care antibiotics for bone and joint infections, potentially expanding its clinical role significantly.
