Can Vancomycin (Vanco) intravenous (IV) administration cause hives the next day?

From the Guidelines

Yes, intravenous (IV) vancomycin administration can cause hives (urticaria) that appear the next day. This delayed hypersensitivity reaction is one of several possible adverse effects associated with vancomycin, as noted in the study published in the Journal of Allergy and Clinical Immunology 1. Patients who develop hives after receiving vancomycin should inform their healthcare provider immediately, as this may indicate an allergic reaction that requires medical attention. The reaction occurs because vancomycin can trigger the release of histamine from mast cells in the body, leading to skin manifestations like hives, itching, and rash.

These delayed reactions differ from the more immediate "Red Man Syndrome," which typically occurs during infusion and involves flushing, rash, and hypotension related to rapid administration, as mentioned in the guidelines for vancomycin administration 1. If a patient experiences hives after vancomycin administration, their provider may need to consider alternative antibiotics, implement premedication protocols with antihistamines before future doses, or in some cases, perform desensitization if vancomycin is absolutely necessary. The timing of the reaction (next-day appearance) is consistent with a true allergic response rather than the direct histamine release associated with infusion-related reactions.

Some key points to consider in managing vancomycin-related hypersensitivity reactions include:

• Monitoring for signs of allergic reactions, including hives, itching, and rash
• Adjusting vancomycin dosing and administration rates to minimize the risk of infusion-related reactions
• Considering alternative antibiotics in patients with known vancomycin allergy or hypersensitivity
• Implementing premedication protocols with antihistamines or other agents to reduce the risk of allergic reactions
• Performing desensitization procedures in patients who require vancomycin therapy despite a history of allergy or hypersensitivity, as discussed in the study on anaphylaxis diagnosis and management 1.

From the FDA Drug Label

Infusion-Related Events During or soon after rapid infusion of vancomycin hydrochloride for injection, patients may develop anaphylactoid reactions, including ... urticaria, or pruritus. Patients have been reported to have had anaphylaxis, drug fever, nausea, chills, eosinophilia, rashes including exfoliative dermatitis, Stevens-Johnson syndrome, and vasculitis in association with the administration of vancomycin. The following adverse reactions have been identified during post-approval use of vancomycin... Skin and Subcutaneous Tissue Disorders Severe dermatologic reactions such as ... and linear IgA bullous dermatosis (LABD)

Vancomycin (Vanco) IV administration can cause hives (urticaria) as part of an anaphylactoid reaction or severe dermatologic reaction.

• These reactions usually occur during or soon after the infusion, but may persist for several hours.
• It is possible for hives to occur the next day, although the exact timing is not specified in the drug label 2.
• The drug label also mentions that infusion-related events can be minimized by administering the drug slowly over 60 minutes 2.

From the Research

Vancomycin IV Administration and Hives

• Vancomycin intravenous (IV) administration can cause hypersensitivity reactions, including hives, in some individuals 3, 4, 5.
• These reactions can occur despite premedication with antihistamines and corticosteroids, and may require desensitization protocols to manage 4, 5.
• The "red-man syndrome" is a well-known hypersensitivity reaction to vancomycin, characterized by drug-induced histamine release, which can cause symptoms such as erythema, pruritus, and hives 5, 6.
• Desensitization protocols, such as rapid or slow infusion methods, can be effective in managing vancomycin hypersensitivity and allowing for the safe administration of the drug 3, 4, 5, 7.
• In some cases, hives and other allergic reactions to vancomycin may not occur immediately, but rather may be delayed, occurring several hours or even the next day after administration 4, 6.

Factors Contributing to Vancomycin Hypersensitivity

• The rate and dose of vancomycin administration can contribute to the development of hypersensitivity reactions, with faster infusion rates and higher doses increasing the risk of reaction 3, 5, 7.
• The use of narcotics concurrently with vancomycin may also exacerbate hypersensitivity reactions, and discontinuing narcotic administration may be necessary to successfully complete vancomycin treatment 7.
• A detailed allergy history is important when deciding if a patient can receive vancomycin, as patients with a history of allergies to other medications may be at increased risk of reaction 6.