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Side effects of vancomycin

Question
Dear expert team,
at my last visit at the CF-center, MRSA has unfortunately been detected in my sputum. We decided to start an eradication trial with linezolid orally and in parallel vancomycin i.v.
At the first dosage of vancomycin (Perfusor syringe pump was running with 50ml/h) the skin of my head started to itch about 20 minutes after starting, to get red and to burn, which spreaded in the end to the back and neck. My doctor stopped the infusion and gave me cortisone and clemastin i.v., whereon the symptoms subsided after a few minutes. According to my doctor, I have an allergy against vancomycin, so that the treatment with it was discontinued completely and instead tobramycin was given.
I have occupied myself a bit with the side effects of vancomycin and have come across the Red-man-syndrome, which symptoms would fit here, too. It is said to be independent of anaphylaxia and should subside on its own with a reduced infusion speed resp. after several courses and after termination of the infusion.

As the choice of antibiotics is anyway very limited because of the MRSA, I find it difficult to abandone for all times another drug because of a bit itching of the skin of the head which probably would disappear of its own.

I am aware of course, that you can not estimate from the distance if it would make sense in spite of the known risk to give the drug another time and that the decision has fianlly to be made by my treating physician.
Nevertheless, I would be interested in furhter medical opinions about the symptoms that occured to me and in informations about the Red-man-syndrome in contrast to an allergic reaction. Furthermore, if and in how far a termination of the therapy in case of such reactions represent indeed the suitable and only measure or if in general not also for example a reduced speed of the infusion for testing purposes would make sense.
Many thanks for your help in advance.
Yours sincerely,
Answer
Dear questioner,
You want to know if the reactions that occured to you at the first dosage of vancomycin-infusion (itching, burning, redness of the skin of the head, neck and back) could be an expression of the so-called Red-man-syndrome. According to your description, a Red-man-syndrome can not be excluded, but as an anaphylaxia to vancomycin is also possible, the decision of your treating physician was correct also in our opinion to stop the infusion and to give cortisone and clemastin i.v.
In the Red-man-syndrome, there is in most patients admittedly only a slight, transient itching at the end of the infusion, however also severe cases with pain in the chest and breathing trouble are described. The differentiation between an anaphylactic reaction and the Red-man-syndrome is not easy and can in the end only be made by an allergy-testing.
First of all, a skin test (pricktest) would be done, which can be done with the concrete drug preparation you reacted to in order to reveal a potential allergy against the substance vancomycin itself or other additives in the drug preparation. If this test shows a positive, immediate reaction, the allergy is proven and no further tests are needed and the respective drugs are not allowed to be given anymore. In case it is negative, another skin test, called intracutaneous test, which brings the substance even deeper into the skin than the pricktest does, is done. In case this test is still negative, an oral or i.v. exposition of the patient with the drug under suspicion is done. The testing has to be in hospital under clinical control, as immediate allergic reactions (which occur in the first 20 minutes after exposure) bear the risk of worsening into an allergic shock. Therefore, if any of the skin test showed a positive immediate reaction, an exposition testing is obsolete.
This flowchart of an allergic diagnostics comprises very tricky investigations, which have to be under standardized conditions in order to make a reliable prediction about an allergy or not. E.g. the skin test and exposition test have not just to be done with the substance itself, but with a row of standardized dilutions. This can only be guaranteed if this tests are performed in an allergy center, in Germany we would strongly recommend to do this diagnostics at a center which belongs to the IVDK (Informationsverbund Dermatologischer Kliniken = informational network of dermatologic hospitals), those centers are for example found in the dermatologic divisions of university hospitals. If you search the web for IVDK, you find a list of participating hospitals.
With this diagnostic setting, one can find out if it is really necessary to avoid vancomycin or not and to abandone an important therapeutic drug such as vancomycin in the treatment of MRSA.
A termination of the therapy in case of reactions, like those that are described by you is indeed the measure of choice as long as an allergy is not excluded porperly. A reduction of the speed of the infusion for testing purposes could make sense, has however to be decided depending on the single case.
Yours sincerely,
Yours Dr. Christina Smaczny


29.11.2010