What are the contraindications for using vancomycin, especially in patients with a history of hypersensitivity reactions, impaired renal function, or suspected/confirmed Enterococcus (E.) faecium infections?

Vancomycin Contraindications

The only absolute contraindication to vancomycin is known hypersensitivity to the drug itself. 1

Absolute Contraindication

• Known hypersensitivity to vancomycin is the sole FDA-labeled contraindication 1
• This includes patients with documented IgE-mediated anaphylaxis to vancomycin 2, 3

Critical Clinical Situations Requiring Alternative Therapy

While not absolute contraindications, the following scenarios mandate avoiding vancomycin or switching to alternative agents:

Hypersensitivity Reactions

• Patients with prior severe dermatologic reactions (toxic epidermal necrolysis, Stevens-Johnson syndrome, DRESS syndrome, acute generalized exanthematous pustulosis, or linear IgA bullous dermatosis) should not receive vancomycin 1
• Vancomycin causes diverse hypersensitivity reactions with a 16% mortality rate in reported cases, with linear IgA bullous dermatosis being most common (median onset 7 days) 2
• DRESS syndrome from vancomycin presents uniquely with 75% renal involvement and median onset of 21 days 4
• Re-challenge with vancomycin after hypersensitivity reactions is not recommended, as it may cause recurrence with potential permanent renal failure 5

Confirmed Vancomycin-Resistant or Tolerant Organisms

• Vancomycin should not be used when MIC ≥2 μg/mL (vancomycin-intermediate or vancomycin-resistant organisms), as target AUC/MIC ratios are not achievable with conventional dosing 6
• Switch to alternative agents (daptomycin, linezolid, or ceftaroline) for MRSA with vancomycin MIC ≥2 μg/mL 7
• E. faecium infections are nearly always vancomycin-resistant and should be treated with alternative agents 8
• Vancomycin-tolerant strains (normal MIC but elevated MBC >64 μg/mL) may fail therapy despite in vitro susceptibility; high-dose daptomycin (12 mg/kg IV q24h) is effective 8

Specific Infection Contexts Where Vancomycin Should Be Avoided

• Vancomycin is not recommended as standard empirical therapy for febrile neutropenia unless specific indications exist (suspected catheter-related infection, skin/soft-tissue infection, pneumonia, or hemodynamic instability) 9
• For patients with immediate-type penicillin hypersensitivity (hives, bronchospasm), use ciprofloxacin plus clindamycin or aztreonam plus vancomycin as alternatives to β-lactams 9

Important Warnings Requiring Extreme Caution (Not Absolute Contraindications)

Renal Impairment

• Vancomycin must be dose-adjusted in renal dysfunction, but renal impairment is not a contraindication 1
• The risk of nephrotoxicity increases substantially with trough levels >20 μg/mL, especially with concurrent nephrotoxic agents 7, 1
• Monitor serum creatinine closely; nephrotoxicity is defined as ≥0.5 mg/dL increase or 150% increase from baseline 7

Ototoxicity Risk

• Use with extreme caution in patients with underlying hearing loss or those receiving concurrent ototoxic agents (aminoglycosides) 1
• Ototoxicity may be transient or permanent and occurs mostly with excessive doses or prolonged high blood concentrations 1

Administration Precautions

• Never administer as rapid bolus; infuse over ≥60 minutes to avoid infusion-related reactions (hypotension, shock, cardiac arrest) 1
• Rapid infusion may cause "red man syndrome" (histamine-release reaction) 6

Common Pitfalls to Avoid

• Do not confuse vancomycin tolerance with vancomycin resistance—tolerant strains have normal MIC but elevated MBC and may fail standard therapy 8
• Do not use vancomycin for empirical coverage of VRE—E. faecium is nearly always vancomycin-resistant 9
• Do not continue vancomycin if severe cutaneous reactions develop—discontinue at first sign of TEN, SJS, DRESS, AGEP, or LABD 1
• Do not assume all enterococcal infections respond to vancomycin—vancomycin-gentamicin combinations are less active than penicillin/ampicillin-gentamicin combinations 9