How to manage Red Man Syndrome from Vancomycin (vancomycin hydrochloride)?

From the Guidelines

Red-man syndrome from vancomycin can be managed by slowing the infusion rate to at least 1 hour and administering antihistamines before vancomycin doses, as recommended by the most recent guidelines 1. To manage red-man syndrome from vancomycin, the following steps can be taken:

• Slow the infusion rate to at least 1 hour to reduce the risk of histamine-release "red man" syndrome, as suggested by the 2018 Infectious Diseases Society of America clinical practice guideline for the management of outpatient parenteral antimicrobial therapy 1.
• Administer antihistamines before vancomycin doses, such as diphenhydramine 25-50 mg orally or intravenously 30-60 minutes before each vancomycin dose.
• If symptoms occur during infusion, stop the infusion immediately, administer diphenhydramine, and once symptoms resolve, restart at a slower rate.
• For subsequent doses, extend the infusion time to 2-4 hours, depending on the dose, as recommended by the guidelines 1.
• In severe cases, consider switching to an alternative antibiotic if clinically appropriate. Red-man syndrome is a histamine-mediated reaction caused by rapid vancomycin infusion triggering mast cell degranulation, not a true allergy. It typically presents as flushing, rash, and pruritus on the face, neck, and upper body, sometimes with hypotension and angioedema. Most patients can safely continue vancomycin with appropriate precautions, but monitoring is essential, especially during the first few doses. For patients requiring long-term vancomycin, symptoms often diminish over time as tolerance develops. Some key points to consider when managing red-man syndrome include:
• The importance of slowing the infusion rate to reduce the risk of histamine-release "red man" syndrome 1.
• The use of antihistamines, such as diphenhydramine, to prevent and treat symptoms of red-man syndrome.
• The need for close monitoring of patients during the first few doses of vancomycin, especially if they have experienced red-man syndrome in the past.
• The potential for symptoms to diminish over time as tolerance develops in patients requiring long-term vancomycin therapy.

From the FDA Drug Label

Vancomycin hydrochloride for injection should be administered in a diluted solution over a period of not less than 60 minutes to avoid rapid-infusion-related reactions. Stopping the infusion usually results in prompt cessation of these reactions

The management of Red-Man Syndrome from vancomycin includes:

• Administering vancomycin in a diluted solution over a period of not less than 60 minutes to avoid rapid-infusion-related reactions 2
• Stopping the infusion usually results in prompt cessation of these reactions 2
• Slowing the infusion rate may also help minimize the reaction
• Monitoring the patient for signs and symptoms of the reaction is essential 2

From the Research

Management of Red-Man Syndrome from Vancomycin

To manage red-man syndrome from vancomycin, several strategies can be employed:

• Discontinuation of the vancomycin infusion and administration of diphenhydramine can abort most of the reactions 3
• Slow intravenous administration of vancomycin should minimize the risk of infusion-related adverse effects 3
• Pretreatment with diphenhydramine (50 mg) can prevent red-man syndrome, as shown in a prospective trial where none of the 16 patients pretreated with diphenhydramine had a first-dose reaction 4
• Pretreatment with histamine antagonists, such as hydroxyzine, can also provide significant protection against vancomycin-induced red-man syndrome 5

Prevention of Red-Man Syndrome

Prevention is key to managing red-man syndrome:

• Administering vancomycin slowly can reduce the risk of red-man syndrome 3
• Pretreating patients with antihistamines, such as diphenhydramine or hydroxyzine, can prevent the occurrence of red-man syndrome 4, 5
• Monitoring patients closely during the infusion of vancomycin can help identify early signs of red-man syndrome, allowing for prompt intervention 3

Other Considerations

Other factors to consider when managing red-man syndrome:

• Red-man syndrome can be associated with elevated plasma histamine levels, especially in severe reactions 4
• Other antibiotics, such as oritavancin, may also be associated with a higher risk of red-man syndrome 6
• The involvement of the MRGPRX2 gene and Carbonic anhydrase II (CA2) in the development of red-man syndrome may provide potential targets for therapeutic agents 6