From the Guidelines
Red Man syndrome associated with vancomycin infusion is primarily managed by slowing the infusion rate and administering antihistamines, as recommended by the most recent guidelines 1. When Red Man syndrome occurs, the first step is to stop the vancomycin infusion immediately.
- Diphenhydramine 25-50 mg IV or hydroxyzine 25 mg orally should be administered to counteract the histamine-mediated reaction.
- After symptoms resolve, vancomycin can be restarted at a slower infusion rate, typically over 2-3 hours rather than the standard 1 hour.
- For future vancomycin doses, premedication with diphenhydramine 30-60 minutes before infusion can prevent recurrence. Severe cases may require additional supportive measures such as IV fluids and, rarely, epinephrine for hypotension. Red Man syndrome occurs due to non-IgE-mediated histamine release from mast cells and basophils triggered by rapid vancomycin administration, causing flushing, pruritus, and erythematous rash primarily on the face, neck, and upper torso. This reaction is dose and rate-dependent rather than a true allergy, which is why slowing the infusion rate is effective in both treatment and prevention, as supported by studies 1. The American Heart Association recommends infusing vancomycin over at least 1 hour to reduce the risk of Red Man syndrome 1. It is essential to note that vancomycin dosages should be adjusted to achieve a trough concentration range of 10–15 μg/mL, and the infusion rate should be slowed to minimize the risk of Red Man syndrome 1.
From the FDA Drug Label
There have been reports that the frequency of infusion-related events (including hypotension, flushing, erythema, urticaria, and pruritus) increases with the concomitant administration of anesthetic agents Infusion-related events may be minimized by the administration of vancomycin as a 60-minute infusion prior to anesthetic induction.
Red Man Syndrome is managed by minimizing infusion-related events, which can be achieved by:
- Administering vancomycin as a 60-minute infusion prior to anesthetic induction 2
- Avoiding concomitant administration of anesthetic agents if possible
- Monitoring patients for signs of infusion-related reactions, such as hypotension, flushing, erythema, urticaria, and pruritus
- Slowing the infusion rate if reactions occur
- Considering alternative therapies if reactions are severe or persistent.
From the Research
Management of Red Man Syndrome
Red Man syndrome is a common toxicity associated with vancomycin infusion, characterized by symptoms such as rash, itching, and hypotension. The management of Red Man syndrome involves several strategies, including:
- Pretreatment with antihistamines to attenuate the symptoms of Red Man syndrome 3, 4, 5
- Slow intravenous administration of vancomycin to minimize the risk of infusion-related adverse effects 6, 7
- Discontinuation of the vancomycin infusion and administration of diphenhydramine to abort the reaction 6
Prevention of Red Man Syndrome
Several studies have investigated the prevention of Red Man syndrome, including:
- The use of oral antihistamines, such as diphenhydramine and cimetidine, to reduce the side effects of rapid vancomycin infusion 5
- The use of intravenous antihistamines, such as diphenhydramine and cimetidine, to prevent Red Man syndrome 3, 4
- The administration of vancomycin over a longer period, such as 1 hour, to reduce the risk of infusion-related adverse effects 7
Treatment of Red Man Syndrome
The treatment of Red Man syndrome involves: