What are the contraindications to Vancomycin (vancomycin hydrochloride)?

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" (a non-IgE-mediated reaction characterized by flushing, pruritus, and hypotension) may receive vancomycin with slower infusion rates and premedication rather than complete avoidance. Some key points to consider when using vancomycin include:

• Caution is warranted in patients with pre-existing hearing loss or renal impairment, as vancomycin can be nephrotoxic and ototoxic, though these are not absolute contraindications but rather situations requiring dose adjustment and careful monitoring 1.
• Pregnant women should use vancomycin only if clearly needed, as it is pregnancy category C.
• While not a contraindication, concomitant use with other nephrotoxic or ototoxic medications (like aminoglycosides) requires careful monitoring 1. The reason for these precautions is that vancomycin can cause direct cellular toxicity to the kidneys and inner ear, particularly at high serum concentrations, and allergic reactions can range from mild to severe, including anaphylaxis in sensitized individuals. Vancomycin dosages should be infused during the course of at least 1 h to reduce the risk of histamine-release “red man” syndrome 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 cases of DIHS/DRESS compared to non-vancomycin-associated cases 2
• Vancomycin infusion reaction, also known as "red man syndrome", is a common reaction caused by infusion rate-dependent direct mast cell degranulation 4
• IgE-mediated hypersensitivity reactions to vancomycin are rare, but can occur 5, 6
• Desensitization protocols are available for vancomycin hypersensitivity, including rapid and slow desensitization protocols 6
• Vancomycin skin testing yields high false positive rates, and direct provocation challenge with slower infusion rate and/or antihistamine pre-treatment is preferred for diagnosis 4

Specific Contraindications

• History of vancomycin-induced anaphylaxis or severe hypersensitivity reaction 3, 5
• History of vancomycin-induced DIHS/DRESS or SJS/TEN 2, 3
• Renal impairment or nephrotoxicity 2
• Pregnancy or breastfeeding, as vancomycin can cause fetal harm or be excreted in breast milk 4

Precautions

• Monitor patients for signs of hypersensitivity reactions, including anaphylaxis, during vancomycin administration 3, 5
• Use vancomycin with caution in patients with renal impairment or nephrotoxicity 2
• Consider desensitization protocols for patients with vancomycin hypersensitivity who require vancomycin therapy 6