What is the relationship between Vancomycin (Vancomycin) and neutropenia (a condition characterized by a low neutrophil count)?

From the Guidelines

Vancomycin can cause neutropenia as a rare but serious adverse effect, typically occurring after 1-3 weeks of therapy. The relationship between vancomycin and neutropenia is a significant concern in clinical practice, particularly in patients with cancer or those undergoing prolonged antibiotic therapy 1. According to the 2010 update by the Infectious Diseases Society of America, the duration of antibiotic therapy in patients with neutropenia should be dictated by the particular organism and site of infection, and therapy should continue until the neutrophil count recovers 1.

Key Considerations

• Neutrophil counts usually recover within 3-7 days after stopping vancomycin 1
• The mechanism of vancomycin-induced neutropenia is thought to be immune-mediated bone marrow suppression rather than direct toxicity 1
• Risk factors for vancomycin-induced neutropenia include prolonged therapy, high trough levels (>20 mg/L), renal impairment, and concurrent use of other myelosuppressive medications 1

Clinical Recommendations

• Patients receiving prolonged vancomycin therapy (>7 days) should have complete blood counts monitored weekly to detect neutropenia early 1
• If vancomycin is absolutely necessary despite previous neutropenia, consultation with infectious disease and hematology specialists is recommended, as desensitization protocols or granulocyte colony-stimulating factor (G-CSF) may be considered in select cases 1
• Alternative glycopeptides like telavancin or lipoglycopeptides such as dalbavancin may be options for patients with a history of vancomycin-induced neutropenia, though cross-reactivity remains possible 1

Evidence-Based Practice

The 2011 clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer recommends continuing antibiotic therapy until the neutrophil count recovers or longer if clinically necessary 1. This guideline emphasizes the importance of individualizing treatment based on the patient's specific condition and the suspected or documented infection. By prioritizing the most recent and highest-quality evidence, clinicians can make informed decisions about vancomycin use and minimize the risk of neutropenia and other adverse effects.

From the FDA Drug Label

Reversible neutropenia has been reported in patients receiving vancomycin hydrochloride for injection (see ADVERSE REACTIONS). Patients who will undergo prolonged therapy with vancomycin hydrochloride for injection or those who are receiving concomitant drugs which may cause neutropenia should have periodic monitoring of the leukocyte count Hematopoietic Reversible neutropenia, usually starting 1 week or more after onset of therapy with vancomycin or after a total dosage of more than 25 g, has been reported for several dozen patients Neutropenia appears to be promptly reversible when vancomycin is discontinued.

Vancomycin and neutropenia are related in that reversible neutropenia has been reported in patients receiving vancomycin. Key points to note include:

• Reversible neutropenia usually starts 1 week or more after onset of vancomycin therapy or after a total dosage of more than 25 g.
• Neutropenia appears to be promptly reversible when vancomycin is discontinued.
• Patients undergoing prolonged vancomycin therapy or receiving concomitant drugs that may cause neutropenia should have periodic monitoring of the leukocyte count 2, 2.

From the Research

Relationship Between Vancomycin and Neutropenia

• Vancomycin-induced neutropenia is a potentially serious adverse event associated with the use of vancomycin, with an incidence of 12% in patients receiving home intravenous vancomycin therapy 3.
• The development of neutropenia is not associated with total vancomycin doses used or serum concentrations, but rather with the duration of vancomycin therapy, with most episodes occurring beyond 20 days of therapy 3, 4.
• Neutropenia typically resolves promptly after discontinuation of vancomycin, with laboratory monitoring performed on a weekly basis 3, 5, 6.
• The mechanism of neutropenia caused by vancomycin is unclear, but appears to be immune-mediated 5.
• Clinicians should monitor hematologic parameters at least weekly in patients receiving home intravenous vancomycin therapy, and consider discontinuing vancomycin if neutropenia develops 3, 4.

Risk Factors and Treatment

• Prolonged vancomycin exposure is a significant risk factor for the development of neutropenia, with most episodes occurring after 7 days of therapy 4.
• Treatment options for vancomycin-induced neutropenia include discontinuation of vancomycin and substitution with an alternative antibiotic, such as teicoplanin 7.
• Filgrastim may also be used to treat vancomycin-induced neutropenia, with moderate to good success 5.

Monitoring and Prevention

• Regular monitoring of white blood cell and neutrophil counts is essential in patients receiving vancomycin therapy, particularly in those receiving treatment for more than 7 days 4.
• Clinicians should be aware of the potential for vancomycin-induced neutropenia and take steps to prevent and manage this adverse event, including discontinuing vancomycin if necessary and initiating alternative therapy 3, 4.