Vancomycin infusion reaction

Background

• Also known as Vancomycin Flushing Syndrome or Vancomycin Infusion Reaction
• Anaphylactoid reaction after the rapid infusion of Vancomycin
  • Predominantly seen in intravenous infusions, may occur via oral administration in patients with impaired kidney function
  • Vancomycin triggers the direct release of histamine from mast cells and basophils
  • Different from anaphylaxis in that reaction is not IgE-Mediated, does not preclude future administration
• Related to the rate of infusion
  • Should be administered at a rate no faster than 10mg/minute (minimum of 1g over 100 minutes)
  • Increased incidence when co-administering with opioids, radiocontrast dye, and some muscle relaxers

Clinical Features

• Intensely pruritic, erythematous rash
• Predominantly face/neck/upper torso
• Occasional chest pain/dyspnea, back spasms
• Less common tachycardia, fever, angioedema, hypotension

Differential Diagnosis

Erythematous rash

• Positive Nikolsky’s sign
  • Febrile
    • Staphylococcal scalded skin syndrome (children)
    • Toxic epidermal necrolysis/SJS (adults)
  • Afebrile
    • Toxic epidermal necrolysis
• Negative Nikolsky’s sign
  • Febrile
    • Toxic shock syndrome
    • Kawasaki disease
    • Scarlet fever
    • DRESS syndrome
    • Cellulitis
    • Acute generalized exanthematous pustulosis
  • Afebrile
    • Alcohol intoxication
    • Anaphylaxis
    • Cellulitis
    • Dermatitis (eczema)
    • Drug rash
    • Erysipelas
    • Erythema multiforme
    • Exfoliative erythroderma
    • Scombroid
    • Vancomycin infusion reaction

Evaluation

• Clinical
  • Rule out from Anaphylaxis
  • Assess presence/degree of angioedema
• Mild cases include pruritis and erythema
• Moderate to severe cases include hypotension, angioedema, chest pain and dyspnea

Management

• Immediately stop transfusion
• Supportive care
  • IV H1/H2 blockers
  • IVF for transient hypotension, if hypotension prolonged consider anaphylaxis
• In mild cases, infusion may be restarted after symptom resolution (typically ~20 minutes)
• In moderate to severe cases, consider pre-medicating after an hour or switching to an alternative antibiotic
• If patients require rapid infusion of vancomycin, consider pre-medication with diphenhydramine and cimetidine.

Disposition

• No observation period needed after resolution of symptoms
• Important to education patient to avoid future diagnosis of vancomycin allergy

References

• Martel TJ, Jamil RT, King KC. Vancomycin Flushing Syndrome. [Updated 2023 Jan 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482506/
• Sivagnanam S, Deleu D. Red man syndrome. Crit Care. 2003 Apr;7(2):119-20. doi: 10.1186/cc1871. Epub 2002 Dec 23. PMID: 12720556; PMCID: PMC270616.