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," characterized by flushing, hypotension, and rash due to histamine release, may receive vancomycin with slower infusion rates and antihistamine premedication rather than complete avoidance.

Key Considerations

• Caution is warranted in patients with renal impairment as vancomycin is primarily eliminated by the kidneys, requiring dose adjustments based on creatinine clearance and therapeutic drug monitoring to prevent toxicity 1.
• Patients with hearing impairment should be monitored closely as vancomycin can cause ototoxicity, especially when combined with other ototoxic medications.
• Pregnant women should use vancomycin only when clearly needed as it crosses the placenta, though it is generally considered pregnancy category B.
• Vancomycin should be administered with caution in patients receiving other nephrotoxic or ototoxic agents such as aminoglycosides, as the risk of adverse effects increases with combination therapy 1.

Administration Guidelines

• Vancomycin dosages should be infused during the course of at least 1 h to reduce the risk of histamine-release “red man” syndrome 1.
• The recommended dosage is 30 mg per kg per 24 h IV in 2 equally divided doses, not to exceed 2 g per 24 h unless concentrations in serum are inappropriately low 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 should be used with caution in patients with a history of hypersensitivity reactions, and alternative antibiotics should be considered when possible 3, 4

Specific Contraindications

• History of vancomycin-induced anaphylaxis or severe hypersensitivity reaction 5, 6
• History of vancomycin-induced DIHS/DRESS or SJS/TEN 2, 3
• Renal impairment or history of vancomycin-induced nephrotoxicity 2
• Pregnancy or breastfeeding, as vancomycin may be excreted in breast milk and has potential effects on the fetus 4

Precautions

• Vancomycin should be administered slowly and with caution to minimize the risk of infusion reaction 4
• Patients should be monitored closely for signs of hypersensitivity reaction or renal impairment during vancomycin therapy 2, 3
• Alternative antibiotics should be considered in patients with a history of vancomycin hypersensitivity or renal impairment 3, 4