Alternative Enteral Route Administration Guidance

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Oral route should be used when possible.  When alternative enteral routes are needed the options are outlined below. Seek clinical pharmacist advice in these situations.

Vancomycin via NG

Administration of vancomycin via NG tubing

  • The Wockhart product is licensed for nasogastric administration. Ensure that this is used.
  • A solution from a reconstituted intravenous vial can be administered via an NG tube. 
  • Vancomycin vials stating "for single use only" cannot be used for oral use following
    reconstitution.

How to reconstitute and administrate

  1. Reconstitute the 500mg vial with 10ml of water for injection to give a concentration of
    50mg per ml.
  2. The required dose - 500mg (10ml) or 250mg (5ml) or 125mg (2.5ml) - should be
    withdrawn and reconstituted to 30ml with water for injection and given to the patient to
    drink or be diluted to be administered by a nasogastric tube.

Please note:
The reconstituted vials for ORAL use may be stored at 2-8oC for up to 24 hours. The same
vial can be used to administer further doses within this time period. The solution of the vial is stable in the fridge for up to 24 hours.

Vancomycin via retention enema

Administration of vancomycin retention enema (off-label use)

  • Insert 18-gauge Foley catheter with a 30ml balloon into the rectum; inflate balloon
  • Instil vancomycin 500mg (intravenous vial) in 100ml normal saline; clamp catheter for 60 min; deflate balloon and remove catheter
  • Repeat every 6 hours
  • 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.

Fidaxomicin via NG

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.