Immune-mediated reactions to vancomycin: A systematic case review and analysis

Drug Reaction With Eosinophilia and Systemic Symptoms With Pustulosis

This cohort study examines patients with drug reaction with eosinophilia and systemic symptoms who also have pustules.

Intestinal dysbiosis as an intraoperative predictor of septic complications: evidence from human surgical cohorts and preclinical models of peritoneal sepsis

Major surgery exposes the intestinal microbiota to inflammatory and antibiotic stressors, which alter the microbiota composition of the intestinal lumen and fecal contents. However, it is not sufficiently understood, if such dysbiosis develops already during surgery and if alterations in microbiota may be the cause of surgical complications. End-of-surgery composition of the microbiota in the rectum was assessed in 41 patients undergoing either rectal or duodenopancreatic resection and was compared to baseline before surgery using 16S-rRNA sequencing. A subset of patients developed severe dysbiosis at the end of surgery, which was characterized by an overgrowth of the Proteobacteria phylum that includes the facultative pathogen E. coli. To test if dysbiosis impacts on surgical outcomes, dysbiosis was modeled in mice by a single oral administration of vancomycin prior to cecal ligation and puncture. Dysbiosis was associated with impaired post-surgical survival, dysregulation of the host's immune response, elevated bacterial virulence and reduced bacterial metabolism of carbon sources. In conclusion, dysbiosis can be detected already at the end of surgery in a fraction of patients undergoing major surgery. Modelling surgery-associated dysbiosis in mice using single-shot administration of vancomycin induced dysbiosis and resulted in elevated mortality.

Ethics of antibiotic allergy

Antibiotic allergies are commonly reported among patients, but most do not experience reactions on rechallenge with the same agents. These reported allergies complicate management of infections in patients labelled as having penicillin allergy, including serious infections where penicillin-based antibiotics are the first-line (most effective and least toxic) treatment option. Allergy labels are rarely questioned in clinical practice, with many clinicians opting for inferior second-line antibiotics to avoid a perceived risk of allergy. Reported allergies thereby can have significant impacts on patients and public health, and present major ethical challenges. Antibiotic allergy testing has been described as a strategy to circumvent this dilemma, but it carries limitations that often make it less feasible in patients with acute infections or in community settings that lack access to allergy testing. This article provides an empirically informed ethical analysis of key considerations in this clinical dilemma, using Staphylococcus aureus bacteraemia in patients with penicillin allergies as a case study. We argue that prescribing first-line penicillin-based antibiotics to patients with reported allergies may often present a more favourable ratio of benefits to risks, and may therefore be more ethically appropriate than using second-line drugs. We recommend changes to policy-making, clinical research and medical education, in order to promote more ethically acceptable responses to antibiotic allergies than the status quo.

Experimental Evaluation of the Hypersensitivity Reactions of a New Glycopeptide Antibiotic Flavancin in Animal Models

Glycopeptide antibiotics are still in demand in clinical practice for treating infections caused by resistant gram-positive pathogens; however, their use is limited due to severe adverse reactions. Their predominant types of side effects are immunoglobulin E-mediated or nonmediated hypersensitivity reactions. Therefore, the development of new glycopeptide antibiotics with improved toxicity profiles remains an important objective in advancing modern antimicrobial agents. We investigated a new eremomycin aminoalkylamide flavancin, its anaphylactogenic properties, influence on histamine levels in blood plasma, pseudoallergic inflammatory reaction on concanavalin A and the change in the amount of flavancin in the blood plasma after administration. It has been shown that flavancin does not demonstrate anaphylactogenic properties. The injection of flavancin resulted in a level of histamine in the blood three times lower than that caused by vancomycin. The therapeutic dose of vancomycin led to a statistically significant increase in the concanavalin A response index compared to flavancin (54% versus 3.7%). Thus, flavancin does not cause a pseudo-allergic reaction. The rapid decrease in flavancin concentration in the blood and the low levels of histamine in the plasma lead us to assume that any pseudoallergic reactions resulting from flavancin application, if they do occur in clinical practice, will be significantly less compared to the use of vancomycin.

Drug-Induced Linear IgA Bullous Dermatosis in an Oncologic Patient

Blister formation in the skin can result from various conditions, such as autoimmune disorders, drug reactions, infections, etc. A comprehensive patient assessment may offer clues for diagnosis. Linear IgA bullous dermatosis (LABD) is a rare subepidermal blistering disorder characterized by the deposition of IgA at the basement membrane zone of the skin and mucous membranes. Here, we describe a case of a patient with a new onset of painless blisters located in the skin and oral mucosa after initiating antibiotic treatment.

Dermatosis Neglecta Based on Exanthematous Drug Eruption Following Head Trauma: A Case Report and Literature Review

Dermatosis neglecta (DN) is a rare psychogenic dermatosis. To our knowledge, this is the first reported case of DN based on exanthematous drug eruption. We report a 68-year-old Chinese male patient who presented with thick, yellowish-brown crusting on his face and scalp and scaly skin for 6 days. Dermoscopy revealed diffusely distributed yellow-green serescrust-like plaques with different sizes and uneven thickness on a red background, and some demonstrated dot or globular hemorrhages. We considered DN and exanthematous drug eruptions based on the combination of the clinical medication and the history before the rash.

Current understanding of genetic associations with delayed hypersensitivity reactions induced by antibiotics and anti-osteoporotic drugs

Drug-induced delayed hypersensitivity reactions (DHRs) is still a clinical and healthcare burden in every country. Increasing reports of DHRs have caught our attention to explore the genetic relationship, especially life-threatening severe cutaneous adverse drug reactions (SCARs), including acute generalized exanthematous pustulosis (AGEP), drug reactions with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). In recent years, many studies have investigated the immune mechanism and genetic markers of DHRs. Besides, several studies have stated the associations between antibiotics-as well as anti-osteoporotic drugs (AOD)-induced SCARs and specific human leukocyte antigens (HLA) alleles. Strong associations between drugs and HLA alleles such as co-trimoxazole-induced DRESS and HLA-B*13:01 (Odds ratio (OR) = 45), dapsone-DRESS and HLA-B*13:01 (OR = 122.1), vancomycin-DRESS and HLA-A*32:01 (OR = 403), clindamycin-DHRs and HLA-B*15:27 (OR = 55.6), and strontium ranelate (SR)-SJS/TEN and HLA-A*33:03 (OR = 25.97) are listed. We summarized the immune mechanism of SCARs, update the latest knowledge of pharmacogenomics of antibiotics- and AOD-induced SCARs, and indicate the potential clinical use of these genetic markers for SCARs prevention in this mini review article.

Vancomycin-Induced Leukocytoclastic Vasculitis: A Rare Complication From a Commonly Used Medication

Leukocytoclastic vasculitis (LCV) is a cutaneous small vessel vasculitis that is characterized by the development of a non-blanching palpable purpura. Diagnosis is made by skin biopsy and histopathology which shows subepidermal acantholysis with dense neutrophilic infiltrate leading to fibrinoid necrosis of the dermal blood vessels. Etiology is generally idiopathic in most cases but secondary causes include chronic infections, malignancies, systemic autoimmune conditions, and medication use. Treatment involves supportive measures in the case of idiopathic LCV, and treatment of the offending condition or agent in LCV due to a secondary cause. A 59-year-old male presented with purulent ulcers on the plantar surface of the right foot. Radiograph of the right foot showed soft tissue swelling without evidence of osteomyelitis. Empiric antibiotic treatment with vancomycin was initiated. A wound culture was obtained from the purulent drainage which grew positive for methicillin-resistant Staphylococcus aureus (MRSA). On the fourth day of treatment with vancomycin, multiple symmetric, purpuric lesions arose on the patient's trunk and extremities. Skin biopsy with histopathology showed subepidermal acantholysis with neutrophil-predominant inflammatory infiltrate consistent with leukocytoclastic vasculitis. Vancomycin was discontinued and the patient's exanthem began to regress, with full resolution after 30 days post withdrawal of the antibiotic.

A rare case of infant eosinophilia induced by oral vancomycin: a case report and literature review

Oral vancomycin is mainly used to treat and prevent active Clostridium difficile infection. Because it is widely believed that there is a very low absorption rate via the gastrointestinal tract, reports of adverse reactions following oral vancomycin administration are rare. This case report describes for the first time a case of antibiotic-associated diarrhoea in a 2-month-old infant treated with oral vancomycin. After oral vancomycin treatment, the number of eosinophils increased significantly and the levels gradually recovered after drug withdrawal. A review and analysis of the previously reported adverse reactions caused by oral vancomycin and eosinophilia caused by vancomycin confirm the need for physicians to pay close attention to vancomycin-related adverse reactions, to monitor the required concentration and to measure eosinophil counts in patients with rash-related adverse reactions. Patients with concomitant diseases and children should be monitored for adverse events as it is possible that they have increased gastrointestinal absorption of vancomycin following oral administration. When vancomycin causes eosinophilia, fever and rash, physicians should be alert to the possibility of organ damage.

Outcome of preoperative cefazolin use for infection prophylaxis in patients with self-reported penicillin allergy

BACKGROUND

Cephalosporins are the preferred antibiotics for prophylaxis against surgical site infections. Most studies give a rate of combined IgE and non-IgE penicillin allergy yet it is recommended that cephalosporins be avoided in patients having the former but can be used in those with the latter. Some studies use penicillin allergy while others penicillin family allergy rates. The primary goal of this study was to determine the rates of IgE and non-IgE allergy as well as cross reactions to both penicillin and the penicillin family. Secondary goals were to determine the surgical services giving preoperative cefazolin and the types of self reported reactions that patients' had to penicillin prompting their allergy status.

METHODS

All patients undergoing elective and emergency surgery at a University Health Sciences Centre were retrospectively studied. The hospital electronic medical record was used for data collection.

RESULTS

8.9% of our patients reported non-IgE reactions to penicillin with a cross reactivity rate of 0.9% with cefazolin. 4.0% of our patients reported IgE reactions to penicillin with a cross reactivity rate of 4.0% with cefazolin. 10.5% of our patients reported non-IgE reactions to the penicillin family with a cross reactivity rate of 0.8% with cefazolin. 4.3% of our patients reported IgE reactions to the penicillin family with a cross reactivity rate of 4.0% with cefazolin.

CONCLUSIONS

Our rate of combined IgE and non-IgE reactions for both penicillin and penicillin family allergy was within the range reported in the literature. Our rate of cross reactivity between cefazolin and combined IgE and non-IgE allergy both to penicillin and the penicillin family were lower than reported in the old literature but within the range of the newer literature. We found a lower rate of allergic reaction to a cephalosporin than reported in the literature. We documented a wide range of IgE and non-IgE reactions. We also demonstrated that cefazolin is frequently the preferred antibiotics for prophylaxis against surgical site infections by many surgical services and that de-labelling patients with penicillin allergy is unnecessary.

Risk Factors for Vancomycin Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome

This case-control study uses single-institution data to explore risk factors associated with vancomycin drug reaction with eosinophilia and systemic systems (DRESS) syndrome.

Stevens-Johnson Syndrome Following Vancomycin and Linezolid: A Real-World Analysis of Post-Marketing Surveillance Data

Background: Stevens-Johnson syndrome (SJS) has been reported as a serious adverse effect in patients treated with vancomycin or linezolid, and there is currently a lack of real-world studies comparing specific differences in adverse effects of SJS.

Methods: According to the FDA’s Adverse Event Reporting System (FAERS), from January 2004 to July 2021, the data of suspected SJS after the use of vancomycin and linezolid were analyzed by imbalance and Bayesian analysis. The onset time, fatality rate and hospitalization rate of vancomycin-associated SJS and linezolid-associated SJS were also investigated.

Results: 276 cases of vancomycin-related SJS reports and 63 cases of linezolid-related SJS reports were identified. These two drugs are more common in middle-aged patients (45–64 years) than other age groups, and less common in underage children (<18). Among them, linezolid-related SJS is more common in middle-aged and elderly patients (45–74 years old) than other groups. Except for unspecified data, in vancomycin-associated SJS cases, there are more men than women (49.28% vs 43.84%), while in linezolid-associated SJS cases, the proportion of men and women is almost equal (44.44%). From the point of view of the areas where adverse reactions were reported, about 1/2 of the reports on Vancomycin-related SJS came from North America, and 1/3 of the reports came from Europe. The median onset time of Linezolid-related SJS was 5 days (interquartile range [IQR] 2–7.75), which was significantly earlier than that of Vancomycin-related SJS (12 days, IQR 4–20) (Mann-Whitney test, p < 0.0001). There were no significant differences in mortality and hospitalization rates after vancomycin and linezolid caused SJS.

Conclusion: The analysis of faers data provides a comprehensive overview of the adverse reactions of SJS caused by the use of vancomycin and linezolid, and can warn clinical workers to timely intervene and continuously monitor the patients at risk of SJS when using such drugs.

Broad-Spectrum Antibiotics for Breast Expander/Implant Infection: Treatment-Related Adverse Events and Outcomes

BACKGROUND

Despite best practices, infection remains the most common complication after breast reconstruction with expanders and implants, ranging from 2% to 29%. Empiric broad-spectrum antibiotics are frequently used in nonsurgical treatment of implant-associated infections in an effort to salvage the reconstruction. Pitfalls of antibiotherapy include adverse events, vascular access site complications, and drug resistance. Our goals were to describe management of implant infections with broad-spectrum antibiotics, review treatment related adverse events, and report on outcomes of therapy.

PATIENTS AND METHODS

A retrospective review was carried out to identify patients who were treated with intravenous (IV) antibiotics for periprosthetic infection. Patient characteristics, surgical details, and antibiotic therapy-related adverse events were collected. Eventual outcome related to expander/implant salvage was noted.

RESULTS

A total of 101 patients (111 treatment episodes) were identified. Mean duration of antibiotic treatment was 18 days (range, 1-40 days). The most commonly used parenteral treatment was a combination of daptomycin with piperacillin-tazobactam (65%) or an alternative agent (16%). Fifty-nine percent of treatment episodes resulted in salvage of the expander or implant. Thirty-five percent treatment episodes were associated with 1 or more adverse events: diarrhea (12.6%), rash (10%), vaginal candidiasis (3.6%), agranulocytosis/neutropenic fever (3.6%), nausea (3.6%), urinary complaint (0.9%), myositis (0.9%), headache (0.9%), vascular line occlusion (1.8%), deep vein thrombosis (1.8%), and finger numbness (0.9%). No patients developed Clostridium difficile colitis. Five episodes (4%) needed discontinuation of antibiotics because of severe adverse events. The prosthesis was explanted in 3 of the cases of discontinued treatment.

CONCLUSIONS

Our findings show favorable outcomes and well-tolerated adverse effects with broad-spectrum parenteral antibiotherapy for periprosthetic infection. However, every effort should be made to deescalate therapy by narrowing the spectrum or limiting the duration, to minimize adverse events and development of bacterial resistance. Treating surgeons need to carefully weigh benefits of therapy and be aware of potential complications that might necessitate discontinuation of treatment.

Deciphering adverse drug reactions: in vitro priming and characterization of vancomycin-specific T-cells from healthy donors expressing HLA-A*32:01

Drug rash with eosinophilia with systemic symptoms (DRESS) is a serious adverse event associated with use of the glycopeptide antibiotic vancomycin. Vancomycin-induced drug rash with eosinophilia with systemic symptoms is associated with the expression of human leukocyte antigen (HLA)-A*32:01, suggesting that the drug interacts with this HLA to activate CD8+ T cells. The purpose of this study was to utilize peripheral blood mononuclear cell from healthy donors to: (1) investigate whether expression of HLA-A*32:01 is critical for the priming naïve of T cells with vancomycin and (2) generate T-cell clones (TCC) to determine whether vancomycin exclusively activates CD8+ T cells and to define cellular phenotype, pathways of drug presentation and cross-reactivity. Dendritic cells were cultured with naïve T cells and vancomycin for 2 weeks. On day 14, cells were restimulated with vancomycin and T-cell proliferation was assessed by [³H]-thymidine incorporation. Vancomycin-specific TCC were generated by serial dilution and repetitive mitogen stimulation. Naïve T cells from HLA-A*02:01 positive and negative donors were activated with vancomycin; however the strength of the induced response was significantly stronger in donors expressing HLA-A*32:01. Vancomycin-responsive CD4+ and CD8+ TCC from HLA-A*32:01+ donors expressed high levels of CXCR3 and CCR4, and secreted IFN‐γ, IL-13, and cytolytic molecules. Activation of CD8+ TCC was HLA class I-restricted and dependent on a direct vancomycin HLA binding interaction with no requirement for processing. Several TCC displayed cross-reactivity with teicoplanin and daptomycin. To conclude, this study provides evidence that vancomycin primes naïve T cells from healthy donors expressing HLA-A*32:01 through a direct pharmacological binding interaction. Cross-reactivity of CD8+ TCC with teicoplanin provides an explanation for the teicoplanin reactions observed in vancomycin hypersensitive patients.

When fever is more than infection: two cases of vancomycin-induced drug reaction with eosinophilia and systemic symptoms (DRESS)

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, but serious systemic hypersensitivity reaction associated with a range of medications. We present two cases of vancomycin-induced DRESS, which occurred simultaneously in the orthopaedic ward in an outer metropolitan hospital. These cases demonstrate the complexity in the diagnosis and management of this inflammatory syndrome on the background of known infection as well as evidence for linezolid as an alternative to vancomycin. The first case was managed conservatively, but developed progressive renal and liver injury along with demonstrated cytomegalovirus reactivation and recurrent colitis, and was eventually palliated. The second was commenced on intravenous glucocorticoids and achieved remission, although had ongoing renal dysfunction at the time of discharge from outpatient follow-up.

Graded Dalbavancin Challenge in a Patient With Severe Vancomycin Hypersensitivity Reaction

Cross-reactivity should be considered when treating patients with a previous hypersensitivity reaction within the same class of antibiotics that share similar chemical structures. This case report describes a patient with severe hypersensitivity reaction to vancomycin who successfully tolerated a dalbavancin graded challenge.

Vancomycin Hypersensitivity Reactions Documented in Electronic Health Records

BACKGROUND

Vancomycin, the most common antimicrobial used in US hospitals, can cause diverse adverse reactions, including hypersensitivity reactions (HSRs). Yet, little is known about vancomycin reactions documented in electronic health records.

OBJECTIVE

To describe vancomycin HSR epidemiology from electronic health record allergy data.

METHODS

This was a cross-sectional study of patients with 1 or more encounter from 2017 to 2019 and an electronic health record vancomycin drug allergy label (DAL) in 2 US health care systems. We determined prevalence and trends of vancomycin DALs and assessed active DALs by HSR phenotype determined from structured (coded) and unstructured (free-text) data using natural language processing. We investigated demographic associations with documentation of vancomycin red man syndrome (RMS).

RESULTS

Among 4,490,618 patients, 14,426 (0.3%) had a vancomycin DAL with 18,761 documented reactions (2,248 [12.0%] free-text). Quarterly mean vancomycin DALs added were 253 ± 12 and deleted were 12 ± 2. Of 18,761 vancomycin HSRs, 7,903 (42.1%) were immediate phenotypes and 3,881 (20.7%) were delayed phenotypes. Common HSRs were rash (32% of HSRs) and RMS (16% of HSRs). Anaphylaxis was coded in 6% cases of HSRs. Drug reaction eosinophilia and systemic symptoms syndrome was the most common coded vancomycin severe cutaneous adverse reaction. RMS documentation was more likely for males (odds ratio, 1.30; 95% CI, 1.17-1.44) and less likely for blacks (odds ratio, 0.59; 95% CI, 0.47-0.75).

CONCLUSIONS

Vancomycin causes diverse adverse reactions, including common (eg, RMS) and severe (eg, drug reaction eosinophilia and systemic symptoms syndrome) reactions entered as DAL free-text. Anaphylaxis comprised 6% of documented vancomycin HSRs, although true vancomycin IgE-mediated reactions are exceedingly rare. Improving vancomycin DAL documentation requires more coded entry options, including a coded entry for RMS.

Adverse reactions to vancomycin and cross-reactivity with other antibiotics

PURPOSE OF REVIEW

Glycopeptide antibiotics such as vancomycin are frequently utilized to treat resistant Gram-positive infections such as methicillin-resistant Staphylococcus aureus. The current literature on glycopeptide and lipoglycopeptide structure, hypersensitivity and potential cross-reactivity was reviewed, highlighting implications for safe prescribing.

RECENT FINDINGS

Structurally similar, glycopeptides could theoretically cross-react. Immediate reactions to vancomycin include non-IgE-mediated reactions (e.g. red man syndrome) and IgE-mediated hypersensitivity (e.g. anaphylaxis), sharing clinical features. Vancomycin can activate mast cells via MAS-related G-protein-coupled receptor X2, an IgE-independent receptor implicated in non-IgE reactions. In-vivo and in-vitro testing for suspected IgE-mediated reactions to glycopeptides remain ill-defined. Vancomycin is increasingly recognized to cause severe cutaneous adverse reactions (SCAR), with drug reaction with eosinophilia and systemic symptoms (DRESS) predominantly reported. Vancomycin DRESS has been associated with HLA-A32:-01, with a number needed to prevent of 1 in 74. Data demonstrating cross-reactivity amongst glycopeptides and lipoglycopeptides is limited to case reports/series.

SUMMARY

Further studies and in-vivo/in-vitro diagnostics are required for better differentiation between IgE and non-IgE glycopeptide reactions. Despite its association with vanomycin DRESS, utility of pharmacogenomic screening for HLA-A32: 01 is ill-defined. Although HLA-A32:01 has been associated with vancomycin DRESS, its utility for pharmacogenomic screening is ill defined. Further clinical and immunological cross-reactivity data for glycopeptide/lipoglycopeptide antibiotics is required.

Incidence of teicoplanin adverse drug reactions among patients with vancomycin-associated adverse drug reactions and its risk factors

BACKGROUND/AIMS

Teicoplanin can be used as an alternative to vancomycin when treating beta-lactam-resistant gram-positive bacterial infections. Both vancomycin and teicoplanin are associated with relatively high rates of adverse drug reactions (ADRs), including hypersensitivity reactions. There is limited data on teicoplanin-vancomycin cross-reactivity. This study examined the incidence of teicoplanin ADRs and risk factors for cross-reactivity between vancomycin and teicoplanin.

METHODS

We analyzed the incidence of teicoplanin ADRs in a retrospective study of 304 newly teicoplanin-exposed, immunocompetent, hospitalized patients at a single Korean Medical Center between January 1, 2006 and December 31, 2015.

RESULTS

Among 304 patients, 238 (78.3%) experienced vancomycin-associated ADRs prior to their teicoplanin exposure and 58 (19.1%) experienced teicoplanin- associated ADRs, which were mostly hypersensitivity reactions without acute kidney injury. The incidence of teicoplanin ADRs was higher in patients who previously experienced vancomycin-related ADRs (23.1% vs. 5.3%, p < 0.001). History of drug allergy was a statistically significant risk factor of teicoplanin ADRs. The incidence of teicoplanin ADRs significantly increased in patients with multiple organ involvement in vancomycin hypersensitivity reactions.

CONCLUSION

Teicoplanin should be administered with caution and clinicians must consider the risk factors of cross-reaction when prescribing teicoplanin to individuals with a history of vancomycin hypersensitivity.

Glycopeptide Hypersensitivity and Adverse Reactions

Glycopeptides, such as vancomycin and teicoplanin, are primarily used in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections, such as cellulitis, endocarditis, meningitis, pneumonia, and septicemia, and are some of the most commonly prescribed parenteral antimicrobials. Parenteral glycopeptides are first-line therapy for severe MRSA infections; however, oral vancomycin is used as a first-line treatment of Clostridioides difficile infections. Also, we currently have the longer-acting lipoglycopeptides, such as dalbavancin, oritavancin, and telavancin to our armamentarium for the treatment of MRSA infections. Lastly, vancomycin is often used as an alternative treatment for patients with β-lactam hypersensitivity. Common adverse effects associated with glycopeptide use include nephrotoxicity, ototoxicity, and Redman Syndrome (RMS). The RMS is often mistaken for a true allergy; however, it is a histamine-related infusion reaction rather than a true immunoglobulin E (IgE)-mediated allergic reaction. Although hypersensitivity to glycopeptides is rare, both immune-mediated and delayed reactions have been reported in the literature. We describe the various types of glycopeptide hypersensitivity reactions associated with glycopeptides and lipoglycopeptides, including IgE-mediated reactions, RMS, and linear immunoglobulin A bullous dermatosis, as well as describe cross-reactivity with other glycopeptides.

Drug-induced tubulointerstitial nephritis: hypersensitivity and necroinflammatory pathways

More than 250 drugs carry a small but important dose-independent risk of initiating a delayed-type hypersensitivity reaction that leads to acute tubulointerstitial nephritis (TIN). Clinical manifestations are often non-specific, making epidemiological studies challenging. In severe cases, if cessation of the offending drug is not followed by a prompt improvement in renal function, corticosteroid therapy appears to enhance renal recovery rates. Other drugs, classified as potential nephrotoxins, may induce dose-dependent acute tubular necrosis. Studies over the past decade have identified a unique form of tubular cell death called "necroptosis" that is accompanied by a specific and significant interstitial inflammatory response to certain insults, including some nephrotoxins. Insights into the molecular basis of this necroinflammatory pathway have emerged. There is still a paucity of pediatric data on these two distinct types of drug-induced TIN. Early recognition is essential to minimize the risk of chronic kidney damage.

More Frequent Premature Antibiotic Discontinuations and Acute Kidney Injury in the Outpatient Setting With Vancomycin Compared to Daptomycin

Vancomycin and daptomycin are often used in outpatient parenteral antimicrobial therapy for gram-positive coverage. Vancomycin's narrow therapeutic window poses challenges. We retrospectively assessed acute kidney injury (AKI) and other adverse drug events in outpatient parenteral antimicrobial therapy patients receiving vancomycin or daptomycin at home after hospital discharge. Among 191 patients included, AKI was the most common adverse drug event. Early antibiotic discontinuation and AKI were more frequent in the vancomycin group. Vancomycin use (odds ratio [OR], 4.57; 95% confidence interval [CI], 1.02-20.51); p = 0.04], female sex (OR, 3.28; 95%CI, 1.41-7.67; P < .01), and longer hospitalization (OR, 1.06; 95%CI, 1.01-1.11; P = .02] independently predicted moderate-to-severe AKI. In the vancomycin group, trough concentrations increased after discharge, and were higher in female compared to male patients, and in those who developed moderate-to-severe AKI compared to those who did not. Female sex (OR, 8.37; 95%CI, 2.35-29.82; P < .01) and higher concentrations (OR, 1.12; 95%CI, 1.05-1.19; P < .01) predicted moderate-to-severe AKI in patients receiving vancomycin. In conclusion, premature antibiotic discontinuations and nephrotoxicity are more frequent in patients treated at home with vancomycin compared to daptomycin. Among patients receiving vancomycin, plasma concentrations increased after hospital discharge and predicted moderate-to-severe AKI. Women had higher vancomycin concentrations and higher risk for AKI.

Eosinophilic Pneumonia Putatively Induced by Vancomycin: A Case Report

Patient: Male, 65

Final Diagnosis: Eosinophilic Pneumonia putatively induced by vancomycin

Symptoms: Dyspnea • fatigue • fever • hypoxia

Medication: Vancomycin

Clinical Procedure: Discontinuation of vancomycin and administration of prednisolone

Specialty: General and Internal Medicine

Antimicrobial Desensitization: A Review of Published Protocols

Antimicrobial desensitization represents a last-line option for patients with no alternative therapies, where the benefits of this intensive process must outweigh the potential harm from drug exposure. The goal of antimicrobial desensitization procedures is to establish a temporary state of tolerance to drugs that may otherwise cause hypersensitivity reactions. While no universal antimicrobial desensitization protocols exist, this review critically analyzes previously published desensitization protocols. The purpose of this review is to provide a greater insight for clinicians and institutions to ensure desensitization procedures are efficacious while minimizing potential for patient harm. With an increasing rate of antimicrobial resistance and the critical need to preserve antimicrobial agents, desensitization may represent another option in our antimicrobial stewardship toolkit.

HLA-A*32:01 is strongly associated with vancomycin-induced drug reaction with eosinophilia and systemic symptoms

BACKGROUND

Vancomycin is a prevalent cause of the severe hypersensitivity syndrome drug reaction with eosinophilia and systemic symptoms (DRESS), which leads to significant morbidity and mortality and commonly occurs in the setting of combination antibiotic therapy, affecting future treatment choices. Variations in HLA class I in particular have been associated with serious T cell-mediated adverse drug reactions, which has led to preventive screening strategies for some drugs.

OBJECTIVE

We sought to determine whether variation in the HLA region is associated with vancomycin-induced DRESS.

METHODS

Probable vancomycin-induced DRESS cases were matched 1:2 with tolerant control subjects based on sex, race, and age by using BioVU, Vanderbilt's deidentified electronic health record database. Associations between DRESS and carriage of HLA class I and II alleles were assessed by means of conditional logistic regression. An extended sample set from BioVU was used to conduct a time-to-event analysis of those exposed to vancomycin with and without the identified HLA risk allele.

RESULTS

Twenty-three subjects met the inclusion criteria for vancomycin-associated DRESS. Nineteen (82.6%) of 23 cases carried HLA-A*32:01 compared with 0 (0%) of 46 of the matched vancomycin-tolerant control subjects (P = 1 × 10-8) and 6.3% of the BioVU population (n = 54,249, P = 2 × 10-16). Time-to-event analysis of DRESS development during vancomycin treatment among the HLA-A*32:01-positive group indicated that 19.2% had DRESS and did so within 4 weeks.

CONCLUSIONS

HLA-A*32:01 is strongly associated with vancomycin-induced DRESS in a population of predominantly European ancestry. HLA-A*32:01 testing could improve antibiotic safety, help implicate vancomycin as the causal drug, and preserve future treatment options with coadministered antibiotics.

Vancomycin-Induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome Masquerading as Elusive Sepsis

We present a unique case of vancomycin-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome masquerading as elusive endocarditis. A 37-year-old female actively using intravenous drugs presented with worsening right upper extremity pain, fever, and chills. Workup revealed methicillin-resistant staphylococcus aureus (MRSA) bacteremia and multiple right-sided septic pulmonary emboli. Echocardiogram was negative for vegetation. Vancomycin was initiated for bacteremia management suspected secondary to right upper extremity abscesses. However, despite resolution of abscesses, fevers persisted, raising suspicion for endocarditis not detected by echocardiogram. On hospital day 25, the patient began showing signs of DRESS syndrome, ultimately manifesting as transaminitis, eosinophilia, and a diffuse, maculopapular rash. Vancomycin was switched to Linezolid and she improved on high dose steroids. The persistent fevers throughout this hospital course were thought to be an elusive endocarditis before DRESS syndrome fully manifested. Although Vancomycin-induced DRESS is uncommon, this case highlights the importance of identifying early signs of significant adverse effects.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome Identified in the Electronic Health Record Allergy Module

BACKGROUND

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare but severe hypersensitivity reaction that remains poorly characterized in the United States.

OBJECTIVE

To identify and describe DRESS syndrome cases in an integrated health care system using electronic health record (EHR) allergy module free-text searches.

METHODS

We identified DRESS syndrome cases with rash, absolute eosinophil count of 500/L or more, organ involvement, and a European Registry of Severe Cutaneous Adverse Reactions to Drugs and Collection of Biological Samples score of 2 or more by reviewing those patients from 1980 to 2016 whose EHR allergic reaction matched DRESS-related key words. Liver injury required alanine aminotransferase level of 100 U/L or more, and renal injury required creatinine increase by 0.5 mg/dL (or 50%) or more. Patient and DRESS characteristics were described, resource use was determined, and cost was estimated.

RESULTS

Among 3,162,562 patients with 3,319,387 million allergy entries, 538 reactions matched key words, and 69 were DRESS syndrome cases (prevalence 2.18 per 100,000). Patients with DRESS had liver (42%) or renal (42%) injury; 11 (16%) had both liver and renal injury. Primary drug culprits were antibiotics (74%) (vancomycin [39%], β-lactams [23%], fluoroquinolones [4%], tetracyclines [4%], and sulfonamides [3%]) and anticonvulsants (20%). Of 65 (94%) hospitalized patients with DRESS, 43 (66%) were hospitalized for DRESS syndrome management with median length of stay of 9 days (interquartile range, 6-17 days) and cost approximately $17,101 per patient.

CONCLUSIONS

Using free-text search of the EHR allergy module identified a large US DRESS syndrome cohort. DRESS prevalence was 2.18 per 100,000 patients. Both liver and kidney injury were frequent, and vancomycin was the most common drug culprit. DRESS cases were morbid and resource-intensive.

A practical management of children with antibiotic allergy

About 10% of the parents reported that their children are allergic to one drug and the betalactam antibiotics are the most frequently suspected. Even if most of the adverse events following antibiotic prescriptions to children are considered allergic, after a full allergy work-up only a few of the suspected reactions are confirmed. For this reason, many children are incorrectly labelled as "allergic" and this represents an important challenge for the choice of the antibiotic therapy in these "labelled" children, who are frequently improperly deprived of narrow-spectrum antibiotics because considered as allergic. When an allergic reaction is suspected a precise diagnosis and a choice of a safe and effective alternative is essential for the future antibiotic option. In the light of this, the main aim of this paper is to try to provide a practical approach to managing the individuals who have reported adverse reactions to antibiotics.

Evaluation and Management of Penicillin Allergy: A Review

IMPORTANCE

β-Lactam antibiotics are among the safest and most effective antibiotics. Many patients report allergies to these drugs that limit their use, resulting in the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance and adverse events.

OBSERVATIONS

Approximately 10% of the US population has reported allergies to the β-lactam agent penicillin, with higher rates reported by older and hospitalized patients. Although many patients report that they are allergic to penicillin, clinically significant IgE-mediated or T lymphocyte-mediated penicillin hypersensitivity is uncommon (<5%). Currently, the rate of IgE-mediated penicillin allergies is decreasing, potentially due to a decreased use of parenteral penicillins, and because severe anaphylactic reactions to oral amoxicillin are rare. IgE-mediated penicillin allergy wanes over time, with 80% of patients becoming tolerant after a decade. Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2% of cases, less than the 8% reported previously. Some patients have a medical history that suggests they are at a low risk for developing an allergic reaction to penicillin. Low-risk histories include patients having isolated nonallergic symptoms, such as gastrointestinal symptoms, or patients solely with a family history of a penicillin allergy, symptoms of pruritus without rash, or remote (>10 years) unknown reactions without features suggestive of an IgE-mediated reaction. A moderate-risk history includes urticaria or other pruritic rashes and reactions with features of IgE-mediated reactions. A high-risk history includes patients who have had anaphylaxis, positive penicillin skin testing, recurrent penicillin reactions, or hypersensitivities to multiple β-lactam antibiotics. The goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Broad-spectrum antimicrobial agents also increase the risk of developing Clostridium difficile (also known as Clostridioides difficile) infection. Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories. Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95% and approaches 100% when combined with amoxicillin challenge. Clinicians performing penicillin allergy evaluation need to identify what methods are supported by their available resources.

CONCLUSIONS AND RELEVANCE

Many patients report they are allergic to penicillin but few have clinically significant reactions. Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship.

Antibiotic allergy

Antibiotics are the commonest cause of life-threatening immune-mediated drug reactions that are considered off-target, including anaphylaxis, and organ-specific and severe cutaneous adverse reactions. However, many antibiotic reactions documented as allergies were unknown or not remembered by the patient, cutaneous reactions unrelated to drug hypersensitivity, drug-infection interactions, or drug intolerances. Although such reactions pose negligible risk to patients, they currently represent a global threat to public health. Antibiotic allergy labels result in displacement of first-line therapies for antibiotic prophylaxis and treatment. A penicillin allergy label, in particular, is associated with increased use of broad-spectrum and non-β-lactam antibiotics, which results in increased adverse events and antibiotic resistance. Most patients labelled as allergic to penicillins are not allergic when appropriately stratified for risk, tested, and re-challenged. Given the public health importance of penicillin allergy, this Review provides a global update on antibiotic allergy epidemiology, classification, mechanisms, and management.

Vancomycin-Induced Leukocytoclastic Vasculitis: A Rare Case Report

Vancomycin causes different types of hypersensitivity reactions, ranging from localized skin reactions to generalized cardiovascular collapse. However, cases of vancomycin-induced leukocytoclastic vasculitis are rare. In this article, we present a case where the patient developed palpable purpura on his bilateral lower limbs following treatment with vancomycin. He was diagnosed with vancomycin-induced leukocytoclastic vasculitis that resolved without sequelae after withdrawal of vancomycin.

Two Consecutive Preoperative Cardiac Arrests Involving Vancomycin in a Patient Presenting for Hip Disarticulation: A Case Report

While an abundance of literature exists describing adverse reactions to vancomycin (eg, nausea, vomiting, red man syndrome, acute kidney injury), there is scarce evidence demonstrating vancomycin anaphylactic reactions requiring cardiopulmonary resuscitation. We report a case of a patient who had 2 separate preoperative episodes of cardiac arrest following vancomycin that occurred 4 weeks apart. Both episodes of anaphylaxis required cardiopulmonary resuscitation, which led to a successful patient outcome. We discuss identification and treatment of vancomycin-induced anaphylaxis.

Rash induced by enteral vancomycin therapy in an older patient in a long-term care ventilator unit: case report and review of the literature

BACKGROUND

Oral vancomycin is a first-line treatment for severe Clostridium difficile colitis. Oral vancomycin is perceived to lack systemic absorption or systemic adverse effects; however, a few cases of hypersensitivity to oral vancomycin have been reported, all in hospitalized patients.

CASE PRESENTATION

In the present case, a 66-year-old woman with end-stage neurodegenerative disease residing in a long-term care facility developed a maculopapular rash following treatment with enteral vancomycin for recurrent C. difficile colitis. The rash resolved after withdrawal of the drug.

CONCLUSION

Rashes associated with oral vancomycin treatment include maculopapular rash, urticaria, red man syndrome, and linear IgA bullous dermatitis. Risk factors for systemic vancomycin absorption include renal insufficiency, severe intestinal inflammation, and high vancomycin dose and duration. Routine serum testing of vancomycin levels, even in these high risk cases, is not recommended. Clinicians should be aware that enteral vancomycin can cause hypersensitivity reactions which may be serious.

Case report: atypical presentation of vancomycin induced DRESS syndrome: a case report and review of the literature

Background

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe hypersensitivity drug reaction involving the skin and multiple internal organ systems. The symptoms typically present with fever and skin rash, and rapidly progress to multiple organ failures. Vancomycin is a rare drug to cause DRESS syndrome with 23 cases reported to date.

Case presentation

We described a case of a 39 year-old man who was treated with vancomycin for osteomyelitis of the foot. The patient subsequently developed acute respiratory distress syndrome (ARDS) followed by rash and acute interstitial nephritis. These symptoms were improved by withdrawal of vancomycin and a pulsed corticosteroid regimen. According to the European Registry of Severe Cutaneous Adverse Reaction Criteria (RegiSCAR) (Kardaun et al, British Journal of Dermatology, 169:1071-1080, 2013), the probability of vancomycin induced DRESS syndrome was scored as “Definite”. A literature search of vancomycin induced DRESS syndrome was also performed and the overall pulmonary involvement was estimated as 5%. To our knowledge, this was the first case reported with pulmonary involvement as the initial symptom.

Conclusion

This is the first case to report pulmonary manifestation as the initial symptom in vancomycin induced DRESS syndrome. Prompt recognition of this entity can expedite proper treatment and hasten recovery.

Electronic supplementary material

The online version of this article (10.1186/s12890-017-0564-6) contains supplementary material, which is available to authorized users.