From the Guidelines
If a patient on vancomycin exhibits flushing redness of the neck and upper body, the infusion should be stopped immediately and the healthcare provider notified. This reaction is likely "Red Man Syndrome," a histamine-mediated reaction caused by rapid vancomycin infusion. After stopping the infusion, a second-generation antihistamine (H2) such as loratadine 10 mg orally or cetirizine 10 mg IV or oral should be considered to treat symptoms, as first-generation antihistamines like diphenhydramine may exacerbate hypotension and other adverse events 1. Once symptoms resolve, vancomycin can often be restarted at a slower infusion rate (typically over 2 hours or longer), as suggested by guidelines for the treatment of MRSA infections 1. To prevent recurrence, future vancomycin doses should be administered at this slower rate. Proper documentation of this reaction in the patient's medical record is essential to ensure appropriate precautions with future vancomycin administration. Key considerations in managing this reaction include:
- Stopping the infusion immediately
- Notifying the healthcare provider
- Administering a second-generation antihistamine if necessary
- Restarting vancomycin at a slower infusion rate after symptoms resolve
- Documenting the reaction in the patient's medical record.
From the FDA Drug Label
During or soon after rapid infusion of vancomycin hydrochloride for injection, patients may develop anaphylactoid reactions, including ... flushing of the upper body ("red neck") Rapid infusion may also cause flushing of the upper body ("red neck") or pain and muscle spasm of the chest and back These reactions usually resolve within 20 minutes but may persist for several hours. Such events are infrequent if vancomycin hydrochloride for injection is given by a slow infusion over 60 minutes. Infusion-related events may be minimized by the administration of vancomycin as a 60-minute infusion
Vancomycin infusion should be slowed down or stopped if a patient exhibits a flushing redness of the neck and upper body. The infusion can be restarted at a slower rate, such as over 60 minutes, to minimize infusion-related events 2.
From the Research
Vancomycin Flushing Syndrome
- Vancomycin flushing syndrome (VFS), also known as red man syndrome, is an allergic reaction to vancomycin that typically presents as a rash on the face, neck, and upper torso after intravenous administration of vancomycin 3.
- The syndrome can be treated with cetirizine and methylprednisolone sodium succinate, as seen in a case report where a patient developed VFS after slow local absorption of vancomycin in cement beads 3.
Symptoms and Treatment
- Symptoms of VFS include a pruritic, erythematous, macular rash predominantly on the face, neck, chest, and lower extremities 3.
- Treatment with cetirizine (10 mg, oral) and methylprednisolone sodium succinate (125 mg, intravenous) has been shown to be effective in managing VFS 3.
- It is essential to be aware of this complication, especially in orthopaedic surgeons who routinely use vancomycin with polymethyl methacrylate in chronic osteomyelitis and revision arthroplasty 3.
Comparison with Other Antibiotics
- Linezolid has been compared to vancomycin in the treatment of skin and soft tissue infections, with linezolid showing a significantly better clinical and microbiological cure rate in adults 4.
- However, linezolid has also been associated with a higher incidence of thrombocytopenia and nausea compared to vancomycin 4.
- The use of linezolid combination therapy has been explored for the treatment of serious infections, including those caused by MRSA and VRE 5.