Can vancomycin cause Stevens-Johnson syndrome?

From the Guidelines

Vancomycin is not commonly associated with Stevens-Johnson syndrome (SJS), and the provided evidence does not list SJS as a potential adverse drug reaction for vancomycin. According to the 2019 clinical practice guideline for the management of outpatient parenteral antimicrobial therapy 1, vancomycin's most common potentially serious adverse drug reactions include nephrotoxicity and infusion-related reactions, with no mention of SJS. In contrast, trimethoprim/sulfamethoxazole is listed as a medication that can cause Stevens-Johnson syndrome.

Key Points to Consider

• Vancomycin's adverse drug reaction profile, as outlined in the guideline, does not include SJS 1.
• The guideline emphasizes the importance of monitoring for nephrotoxicity and infusion-related reactions in patients receiving vancomycin 1.
• Stevens-Johnson syndrome is a severe skin reaction that requires immediate medical attention, but it is not typically associated with vancomycin therapy based on the provided evidence.
• If a patient on vancomycin develops a severe skin reaction, it is crucial to seek medical attention promptly, but the evidence suggests that vancomycin is not a common cause of SJS 1.

Clinical Implications

• Clinicians should be aware of the potential adverse drug reactions associated with vancomycin, including nephrotoxicity and infusion-related reactions, and monitor patients accordingly 1.
• The lack of association between vancomycin and SJS in the provided evidence suggests that alternative explanations for severe skin reactions should be considered in patients receiving vancomycin therapy.

From the FDA Drug Label

Severe dermatologic reactions such as toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS), drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), and linear IgA bullous dermatosis (LABD) have been reported in association with the use of vancomycin Patients have been reported to have had anaphylaxis, drug fever, nausea, chills, eosinophilia, rashes including exfoliative dermatitis, Stevens-Johnson syndrome (see WARNINGS, Severe Dermatologic Reactions), and vasculitis in association with the administration of vancomycin.

Vancomycin and Stevens-Johnson Syndrome:

• Vancomycin can cause Stevens-Johnson syndrome (SJS), a severe dermatologic reaction.
• The drug label warns of the risk of SJS and other severe dermatologic reactions, including toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), and linear IgA bullous dermatosis (LABD) 2, 3.
• If signs and symptoms of SJS or other severe dermatologic reactions occur, vancomycin should be discontinued.

From the Research

Vancomycin and Stevens-Johnson Syndrome

• Vancomycin has been reported to cause Stevens-Johnson syndrome, a rare but severe immunologic reaction that can involve skin and mucosal surfaces 4, 5, 6, 7, 8.
• The symptoms of vancomycin-induced Stevens-Johnson syndrome can include a pruritic, raised maculopapular eruption, fever, neutropenia, eosinophilia, lymphadenopathy, hepatitis, and multiple serologic abnormalities 4.
• Cessation of vancomycin treatment can lead to resolution of symptoms, and corticosteroid therapy may be instituted to improve symptoms 4, 5.
• Vancomycin-induced Stevens-Johnson syndrome can occur in patients with or without a history of allergies or previous reactions to the drug 4, 5, 6, 7, 8.
• The onset time of vancomycin-induced Stevens-Johnson syndrome can vary, with a median onset time of 12 days reported in one study 7.

Risk Factors and Demographics

• Vancomycin-induced Stevens-Johnson syndrome can occur in patients of any age, including children under 2 years old 8.
• Middle-aged patients (45-64 years) may be more commonly affected by vancomycin-induced Stevens-Johnson syndrome than other age groups 7.
• The proportion of men and women affected by vancomycin-induced Stevens-Johnson syndrome may vary, with one study reporting a higher proportion of men than women 7.

Diagnosis and Treatment

• Skin biopsy remains the gold standard for diagnosing Stevens-Johnson syndrome, but non-invasive options such as the granulysin rapid test may be used, especially in children 8.
• Cessation of vancomycin treatment and institution of corticosteroid therapy may be necessary to improve symptoms and prevent further complications 4, 5.