What is the treatment for Vancomycin (Vancomycin)-induced Red Man Syndrome?

From the Guidelines

Red Man Syndrome should be treated by immediately stopping vancomycin infusion and administering antihistamines, such as diphenhydramine (25-50 mg IV or oral), to relieve symptoms, as recommended by the most recent guidelines 1.

Treatment Approach

The treatment approach for Red Man Syndrome involves several key steps:

• Immediately stopping the vancomycin infusion to prevent further histamine release
• Administering antihistamines, such as diphenhydramine, to relieve symptoms
• Considering premedication with diphenhydramine 30-60 minutes before vancomycin administration to prevent recurrence
• Slowing the infusion rate of vancomycin to over 2 hours or longer if it is still clinically necessary

Prevention and Management

To prevent and manage Red Man Syndrome, the following measures can be taken:

• Infusing vancomycin over at least 1 hour to reduce the risk of histamine-release "red man" syndrome, as recommended by the American Heart Association 1
• Monitoring patients closely for signs of Red Man Syndrome, such as flushing, rash, and pruritus
• Having supportive care, including IV fluids, oxygen, and rarely epinephrine, available in case of severe reactions

Pathophysiology

Red Man Syndrome is a pseudoallergic reaction caused by vancomycin-induced histamine release from mast cells, not a true allergy. It typically presents as flushing, rash, and pruritus on the face, neck, and upper body, often accompanied by hypotension. The reaction is usually related to rapid infusion rates rather than drug sensitivity, which is why slowing the infusion often allows continued use of this important antibiotic.

From the Research

Treatment of Red Man Syndrome

• Discontinuation of the vancomycin infusion and administration of diphenhydramine can abort most of the reactions 2
• Slow intravenous administration of vancomycin should minimize the risk of infusion-related adverse effects 2
• 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 3
• Pretreatment with hydroxyzine (50 mg) can also provide significant protection against vancomycin-induced red-man syndrome 4

Prevention of Red Man Syndrome

• Administering vancomycin slowly can help prevent the syndrome 2
• Pretreatment with antihistamines such as diphenhydramine or hydroxyzine can help prevent red man syndrome 3, 4

Notes on Red Man Syndrome

• The term "Red Man Syndrome" is considered imprecise and can lead to suboptimal classification and management, with recent calls advocating for the discontinuation of its use 5
• Red man syndrome is associated with elevated plasma histamine levels, especially in severe reactions 3