From the Guidelines
Vancomycin is contraindicated in patients with a known hypersensitivity or allergic reaction to vancomycin or any component of its formulation. According to the guidelines, vancomycin therapy is recommended only for patients unable to tolerate penicillin or ceftriaxone 1. Patients with a history of "Red Man Syndrome" may receive vancomycin with slower infusion rates and antihistamine premedication rather than complete avoidance. Key considerations for vancomycin use include:
- Pre-existing renal impairment, as vancomycin is primarily eliminated by the kidneys and can cause nephrotoxicity, requiring dose adjustments rather than absolute contraindication 1
- Hearing impairment, as vancomycin can cause ototoxicity, necessitating careful monitoring
- Pregnancy, as vancomycin is classified as FDA pregnancy category C, and should be used only if clearly needed
- Concomitant use of other nephrotoxic or ototoxic medications, which warrants cautious use of vancomycin Therapeutic drug monitoring is essential to maintain effective concentrations while minimizing toxicity, with trough levels typically targeted between 10-20 mg/L depending on the infection being treated 1.
From the Research
Contraindications to Vancomycin
- Vancomycin is associated with several hypersensitivity reactions, including anaphylaxis, linear IgA bullous dermatosis, drug rash eosinophilia and systemic symptoms (DRESS) syndrome, acute interstitial nephritis, and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) 2, 3
- The incidence of renal dysfunction is higher in vancomycin-induced DIHS cases compared to non-vancomycin-associated cases 2
- Vancomycin can cause severe anaphylactic reactions, as reported in a case study of a 23-year-old man 4
- Desensitization protocols are available for vancomycin hypersensitivity, including rapid and slow desensitization protocols 5
- Common hypersensitivity reactions to vancomycin include rash, red man syndrome, and anaphylaxis, with drug reaction eosinophilia and systemic symptoms syndrome being a common severe cutaneous adverse reaction 6
Specific Contraindications
- History of vancomycin-induced hypersensitivity reactions, such as anaphylaxis or DRESS syndrome 3, 4
- Renal impairment, as vancomycin can exacerbate renal dysfunction 2
- Caution should be exercised when using vancomycin in patients with a history of vancomycin-induced red man syndrome or other hypersensitivity reactions 5, 6