What are the symptoms of elevated vancomycin (Vancomycin) levels?

Symptoms of High Vancomycin Levels

The most common symptoms of elevated vancomycin levels include nephrotoxicity (kidney damage), infusion-related reactions ("red man syndrome"), and ototoxicity (hearing and balance disturbances). 1

Nephrotoxicity

• Acute kidney injury (AKI) is the most common serious adverse effect of high vancomycin levels, characterized by increases in serum creatinine of ≥0.5 mg/dL or 150% increase from baseline 2, 3
• Risk of nephrotoxicity significantly increases with sustained trough concentrations >20 μg/mL 4, 3
• Nephrotoxicity occurs in approximately 10-20% of patients receiving conventional doses and 30-40% of patients receiving high-dose therapy 3
• The mechanism involves increased production of reactive oxygen species and oxidative stress 3

Infusion-Related Reactions

• "Red man syndrome" - flushing of the upper body, particularly the neck and face 1
• Hypotension, which can be severe enough to cause shock in rare cases 1
• Wheezing and dyspnea (difficulty breathing) 1
• Urticaria (hives) and pruritus (itching) 1
• Chest and back pain with muscle spasm 1
• These reactions typically resolve within 20 minutes but may persist for several hours 1
• More common with rapid infusion; less frequent when vancomycin is administered over ≥60 minutes 1

Ototoxicity

• Hearing loss, which may be transient or permanent 1, 5
• Tinnitus (ringing in the ears) 1, 5
• Vertigo and dizziness 1, 6
• Sensation of "fullness" in the ears 4
• "Buzzing" or whistling sounds in the ears 6
• Risk increases with high serum concentrations, especially when combined with other ototoxic medications 1, 5
• Ototoxicity is relatively rare with modern vancomycin formulations, with a prevalence of only 8% in patients receiving long-term therapy 7

Hematologic Effects

• Reversible neutropenia, typically starting 1 week or more after beginning therapy or after a total dose of >25g 1
• Thrombocytopenia (rare) 1
• Reversible agranulocytosis (very rare) 1

Dermatologic Reactions

• Severe dermatologic reactions can occur, including:
  • Toxic epidermal necrolysis (TEN) 1
  • Stevens-Johnson syndrome (SJS) 1
  • Drug reaction with eosinophilia and systemic symptoms (DRESS) 1
  • Acute generalized exanthematous pustulosis (AGEP) 1
  • Linear IgA bullous dermatosis (LABD) 1
• Rashes, including exfoliative dermatitis 1

Gastrointestinal Effects

• Pseudomembranous colitis (Clostridioides difficile-associated diarrhea) 1
• Nausea 1

Risk Factors for Toxicity

• Trough serum concentrations >20 μg/mL 4, 2
• High daily doses (>4 g/day) 3
• Prolonged therapy (>7 days) 3
• Concomitant administration of other nephrotoxic or ototoxic agents 1, 3
• Pre-existing renal impairment 1, 3
• Pre-existing hearing loss 1, 7
• Admission to intensive care unit 3

Monitoring Recommendations

• Regular monitoring of trough serum vancomycin concentrations is essential for patients receiving prolonged courses of therapy 4, 2
• Monitor renal function with serum creatinine measurements 4, 2
• For patients with symptoms of ototoxicity, consider audiometric evaluation 4, 7
• For patients receiving high-dose therapy or with risk factors, more frequent monitoring is warranted 4, 2

Management of Elevated Levels

• Hold the next scheduled dose of vancomycin and recheck the trough level before administering subsequent doses 2
• Once the trough level decreases to the target range (15-20 mg/L for serious infections), resume vancomycin at a reduced dose or with an extended dosing interval 2
• For patients with normal renal function, consider reducing the dose by approximately 15-20% or extending the dosing interval 2
• In cases of severe toxicity, especially with significant renal impairment, consider alternative antibiotics 2, 4