What is Red Man Syndrome, also known as Vancomycin (Vancomycin)-induced Red Man Syndrome?

From the Guidelines

Red Man Syndrome, also known as Vancomycin-induced Red Man Syndrome, is a hypersensitivity reaction that occurs during rapid intravenous administration of vancomycin, presenting as flushing, redness, and sometimes an itchy rash on the face, neck, upper chest, and arms, often accompanied by hypotension and, rarely, cardiac arrest. This reaction is not a true allergy but results from vancomycin-induced histamine release from mast cells and basophils, which causes vasodilation 1. To prevent this reaction, vancomycin should be administered slowly, over at least 60 minutes (or even 90-120 minutes for higher doses), at a concentration not exceeding 5 mg/mL.

Key Considerations

• The reaction is rate-dependent rather than dose-dependent, so patients with a history of Red Man Syndrome can usually continue vancomycin therapy with appropriate precautions.
• If Red Man Syndrome occurs, immediately stop the vancomycin infusion and administer diphenhydramine 25-50 mg intravenously.
• After symptoms resolve, vancomycin can be restarted at a slower infusion rate.
• For subsequent doses, premedication with diphenhydramine 30-60 minutes before vancomycin administration can help prevent recurrence.

Management and Prevention

• The management of Red Man Syndrome focuses on preventing the reaction by slow administration of vancomycin and treating the symptoms if they occur.
• There is no direct mention of Red Man Syndrome in the provided evidence, but the general principles of vancomycin administration and management of hypersensitivity reactions can be applied 1.
• It is essential to note that the provided evidence discusses the management of persistent MRSA bacteremia and vancomycin treatment failures, which is a different context than Red Man Syndrome. However, the principles of vancomycin administration and management of adverse reactions can be applied in both situations.

From the Research

Definition and Characteristics of Red Man Syndrome

• Red Man Syndrome, also known as Vancomycin-induced Red Man Syndrome, is a pseudoallergic reaction characterized by flushing, erythema, and pruritus 2, 3, 4, 5, 6.
• It is a common toxicity of vancomycin therapy, often associated with rapid infusion of the first dose of the drug 3, 5.
• The syndrome can also be caused by other antibiotics, such as ciprofloxacin, amphotericin B, rifampicin, and teicoplanin, which stimulate histamine release 3.

Incidence and Etiology

• The incidence of Red Man Syndrome can be as high as 47% in patients receiving vancomycin without pretreatment 4.
• The etiology of the syndrome is attributed to the release of histamine, which can be infusion rate-dependent 5.
• Elevated plasma histamine levels are associated with the severity of the reaction 4, 5.

Management and Prevention

• Discontinuation of vancomycin infusion and administration of diphenhydramine can abort most reactions 3, 4.
• Slow intravenous administration of vancomycin can minimize the risk of infusion-related adverse effects 3.
• Pretreatment with diphenhydramine can prevent Red Man Syndrome in some patients 4.

Unconventional Causes

• Red Man Syndrome can also be caused by local application of vancomycin powder in surgical wounds, as reported in a case study 6.