Clinical use

Oral vancomycin is used to treat Clostridioides difficile (C. difficile) infection. See the NICE guideline on antimicrobial prescribing in Clostridioides difficile infection and local guidance for specific recommendations on its place in treatment.

Avoiding delayed or omitted doses

Local guidance on how to order, prepare and administer each chosen formulary option, including when pharmacy services are unavailable, will help reduce the risk of delayed or omitted doses.

Choosing suitable formulary options

This article aims to support local decision-making when choosing which oral vancomycin formulations to include on a formulary. It highlights key considerations and suggests risk mitigations to support formulary decisions. It is not intended to guide clinical decisions regarding the most appropriate formulation for individuals.

The options discussed are not presented in order of preference and may not be exhaustive.

Local formulary choices may depend on:

• national and local guidance
• licensing status of each formulation
• local access to each formulation
• the patient population and the care setting.

Formulary options for swallowing difficulties

Formularies should include oral options for people who cannot safely swallow capsules. This reduces risk of aspiration or choking and doses being delayed or omitted due to prescribing of inappropriate formulations.

Oral liquid formulations may be suitable formulary options for people who are not able to safely swallow capsules, but only if they are able to safely swallow thin liquids.

Specific advice on the most appropriate formulation for an individual depends on the food and fluid they can safely swallow. A swallow assessment report from a speech and language therapist is needed for individuals who cannot safely swallow food and fluid.

The SPS guidance on swallowing difficulties gives advice on using medicines safely and effectively in people with swallowing difficulties. This advice may be helpful for developing local guidance to support safe use of chosen formulary options.

Licensed capsules

Vancomycin capsules are only suitable for people who can safely swallow them. Additional formulary options are needed for people who cannot safely swallow capsules. These are described below.

Licensed injectable solution for oral use

Vancomycin injectable solution can be prepared for oral administration. Some products are licensed for oral administration, and some are not.

Formulary teams should consider

• if this option is suitable for their patient population and care setting
• how it will be supplied and prepared
• the oral devices needed to prepare the solution
• the SPS advice on assessing injectables for enteral administration.

Medicines intended for oral administration should not be prepared using intravenous needles and syringes because of the risk of the medicine being given intravenously in error. Enteral devices should be used.

Using enteral ENFit devices

An ENFit needle attached to an enteral ENFit syringe can be used to pierce the vancomycin vial bung to reconstitute and withdraw the solution for oral administration.

Several ENFit devices are available through the NHS supply chain (NHSSC). The ENFit website has more information and includes the NHSSC codes.

ENFit devices may not be routinely stocked by some clinical areas and clinical staff may be unfamiliar with using them, leading to a risk of delayed or omitted doses.

Reviewing stock processes and ensuring staff are familiar with the devices will help ensure that ENFit devices are available and used without delay when needed. This may involve:

• working with procurement and dispensary teams to ensure ENFit devices are kept in stock and supplied when vials are dispensed for oral use
• reviewing stock holding of ENFit devices in clinical areas and out-of-hours cupboards
• using electronic functionality in prescribing and dispensing systems to highlight the need for ENFit devices when vials are supplied for oral use
• adding prompts in electronic out-of-hours cupboards and ward stock cupboards to highlight the need for ENFit devices when vials are selected for oral use
• attaching a label or leaflet to vial stock held in pharmacy, wards and out-of-hours cupboards, to highlight the need for ENFit devices when selected for oral use
• providing staff education and written guidance on how to use ENFit devices.

Extemporaneously prepared oral liquid

Extemporaneously prepared oral liquid vancomycin is an ‘off-label’ use of a licensed product.

When this method of preparation is not planned for, the formulation may not be immediately available, leading to a risk of delayed or omitted doses.

Local or regional manufacturing facilities may prepare a liquid formulation using the injectable solution. To reduce the risk of delay, local arrangements should be agreed in advance and guidance made available on how to obtain supply.

Imported oral liquid

A suitable quality imported oral liquid vancomycin may be available as an unlicensed ‘special’. The SPS article series on understanding unlicensed medicines has information on using, purchasing, evaluating and making unlicensed specials.

Delays in obtaining and quality assuring the imported ‘special’ can lead to delayed or omitted doses.

A number of importers stock oral vancomycin liquid. Local guidance on how to order the imported oral liquid will help reduce the risk of delays.

Other treatment options for Clostridioides difficile

The SPS article on choosing between fidaxomicin options has advice to help local formulary and commissioning teams choose between fidaxomicin options.

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