Lipohypertrophy and glomerulonephritis after the use of aprotinin in an insulin-dependent diabetic

Rectifying Controversial Medical Eponyms: Cleansing the Lexicon

Applying modern race and gender concepts to medical literature before the early 20th century distorts cultural and historical norms. Removing eponyms from medical terminology erases history and contributes to selective memory. Eponyms in medicine provide insight into how societal culture has evolved as it progresses toward achieving gender and racial equality.

Vancomycin Flushing Syndrome: A Case Report

Vancomycin is a bactericidal antibiotic used for various infections but can cause hypersensitivity reactions, including vancomycin flushing syndrome (VFS) and anaphylaxis. VFS, previously known as red man syndrome, is a pseudoallergic reaction characterized by flushing, erythema, and pruritus. We present a case of VFS in a female patient with recurrent Methicillin-resistant Staphylococcus aureus (MRSA) infections receiving vancomycin for back abscesses. Following the second dose, she developed a pruritic rash on her face, neck, and torso, which resolved with treatment. The differential diagnosis included hydromorphone allergy, ruled out due to previous tolerance. Anaphylaxis was unlikely due to the absence of respiratory distress, hypotension, or angioedema. Management involved discontinuing vancomycin, administering corticosteroids and antihistamines, and monitoring for anaphylaxis. The patient was transferred for surgical intervention and alternative antibiotic therapy. This case highlights the importance of recognizing and managing VFS, the significance of differential diagnoses, and the need for enhanced documentation and clinical support in managing vancomycin hypersensitivity reactions.

Towards a More Inclusive Environment in the Dermatology Clinic: An Introduction to Using Thoughtful Language in the Practice of Dermatology

Language is used to convey thought, but it also influences thought and perception, in turn affecting health care delivery. In this review, we seek to highlight ways in which dermatologists can incorporate inclusive language into practice. By using patient-centered and patient-affirming language, avoiding labels, and naming medical conditions with terminology rooted in pathophysiology rather than outmoded, racist convention or eponyms, dermatologists can strengthen therapeutic relationships and improve patient care.

Flushing an Offensive Term for Vancomycin Infusion Reaction From the Electronic Medical Record

BACKGROUND

The medical establishment continues to be complicit in the degradation of native peoples of the United States through the use of the racist phrase "red man syndrome" (RMS) to describe the histamine-release syndrome that accompanies vancomycin infusion.

METHODS

Five months after the transition from 1 electronic health record to another at our freestanding children's hospital, our antimicrobial stewardship team reviewed all active allergy records to identify and then replace use of RMS terminology with preferred alternative "vancomycin flushing syndrome." In partnership with institutional stakeholders, we also launched an educational campaign and instituted in the electronic health record an autocorrect functionality to prevent new RMS entries.

RESULTS

We identified allergy records for 21 034 individual patients. Vancomycin was an allergen for 445 (2.1%) patients, and RMS-related terminology appeared in 274 (61.6%) of these records; we replaced all RMS instances with the vancomycin flushing syndrome term. During the 3-month period after the intervention, we identified allergy records for 8648 additional patients, with vancomycin as allergen in 65 (0.7%) and with RMS terminology identified and replaced in 29 (44.6%). In addition to the lower rate of RMS among allergy records after the intervention, we detected 3 instances of alternative terminology use.

CONCLUSIONS

Implementing an institutional-level change in terminology, even for racist language, requires education, reinforcement, and continued surveillance. To effectively replace this term, we need the support of national stakeholders to remove this language from our medical education systems, our textbooks, and our clinical lexicon.

A Comparison of Intraperitoneal and Intravenous/Oral Antibiotics in CAPD Peritonitis

Eighty patients with CAPD peritonitis were randomised to receive either intraperitoneal (IP) vancomycin and tobramycin, or intravenous (IV) van-comycin and tobramycin followed by oral antibiotics, depending on the results of culture and sensitivity. Five patients were withdrawn, and, of the remaining patients, 39 were in the IP group and 36 in the IV group.

When all episodes of bacterial peritonitis are considered, the treatment failure rate was higher in the IV group (34.1%), than in the IP group (10.3%) (p < 0.02). This was also the case when gram-positive organisms resistant to tobramycin were considered separately (p < 0.05), but not for vancoinycin-resistant organisms. We conclude that vancomycin should be administered by the intraperitoneal route: the case for intraperitoneal tobramycin is “not proven”.

Red man syndrome caused by vancomycin powder

Red man syndrome (RMS) is a well-known hypersensitivity reaction caused by intravenous administration of vancomycin, with symptoms ranging from flushing, erythematous rash, pruritus, mild to profound hypotension, and even cardiac arrest. RMS has not previously been described from local application of vancomycin powder in a surgical wound, a technique increasingly utilized for infection prophylaxis in many surgical disciplines including neurosurgery. We describe the first reported case of RMS as a result of local intra-wound application of vancomycin powder for infection prophylaxis. A 73-year-old male with a history of Parkinson's disease underwent 2-stage deep brain stimulation implantation surgeries. Vancomycin powder was applied locally in the surgical wounds for infection prophylaxis during both of the surgeries. The patient developed a well-demarcated, geometric erythematous pruritic rash following the second surgery that was clinically diagnosed as RMS and resolved without sequelae.

Characterization of Vancomycin Reactions and Linezolid Utilization in the Pediatric Population

BACKGROUND

Red man syndrome (RMS) occurs because of non-IgE-mediated histamine release. Unlike vancomycin allergy, which necessitates the use of an alternative drug (often linezolid), RMS does not typically preclude further vancomycin use. Care should be taken to differentiate these reaction types from one another to prevent unnecessary vancomycin avoidance.

OBJECTIVE

To characterize vancomycin reaction types in our population, and to determine whether having a reaction consistent with RMS is associated with otherwise unexplained vancomycin avoidance and linezolid use.

METHODS

We retrospectively reviewed charts for children with documented vancomycin reactions. We classified the in-hospital reactions via an objective analysis and estimated the prevalence of different reaction types. We then identified children who received linezolid over 3 years, and investigated reasons for linezolid use instead of vancomycin.

RESULTS

Of the 78 in-hospital reactions we characterized, 72 (92%) were objectively consistent with RMS, 5 we could not objectively classify (2 most likely RMS, 3 more suspicious for possible IgE-mediated allergy), and 1 was a non-RMS/non-IgE reaction. Of 60 children who received linezolid, 19 had previous reactions consistent with RMS, which should not preclude further vancomycin. Nevertheless, only 7 of 19 (37%) had a clear explanation for receiving linezolid instead of vancomycin compared with 32 of 39 (82%) children without previous vancomycin reactions (P < .001).

CONCLUSIONS

The vast majority of patients had vancomycin reactions consistent with RMS. These patients are at risk for unnecessary vancomycin avoidance and linezolid utilization. We propose that this may be related to how reactions appear in the electronic medical record.

Infectious Diseases: Tolerance of Vancomycin for Surgical Prophylaxis in Patients Undergoing Cardiac Surgery and Incidence of Vancomycin-Resistant Enterococcus Colonization

Background:

In 2001, vancomycin replaced cefuroxime for antibiotic prophylaxis in patients undergoing cardiac surgery at our institution due to high rates of surgical site infections caused by methicillin-resistant Staphylococcus spp. However, few data supported the use of vancomycin for surgical prophylaxis.

Objective:

To determine the tolerance of vancomycin for antibiotic prophylaxis and incidence of vancomycin-resistant Enterococcus (VRE) in cardiac surgery patients.

Methods:

In 2 separate studies, we assessed the adverse effects in patients given perioperative vancomycin (study 1) and the incidence of VRE in patients given perioperative vancomycin (study 2). Study 1 was a prospective cohort study of patients undergoing coronary artery bypass graft (CABG) or valve replacement surgery given vancomycin (1 dose preoperatively/2 doses postoperatively) for antibiotic prophylaxis between October 2003 and December 2004. Patients were assessed for tolerance to the antibiotic regimen. In study 2, cardiac surgery patients receiving perioperative vancomycin were screened for VRE before therapy and at day 7 of hospitalization. VRE was detected using standard microbiologic procedures.

Results:

In study 1, 1161 patients (CABG = 75%; valve = 19%; both = 6%) were evaluated. All patients but one (99.9%) were prescribed preoperative vancomycin. Therapy was changed for 34 (2.9%) patients, of which 20 changes were due to physician preference for another antibiotic. The only toxicity that required a change in the vancomycin regimen was red man's syndrome, which was experienced by 9 (0.8%) patients. Four patients did not receive a second postoperative dose due to prior renal insufficiency. Patients were most commonly switched to cefuroxime (n = 26), linezolid (n = 2), cefepime (n = 2), gatifloxacin, cefazolin, levofloxacin, or ceftriaxone (n = 1, each). In study 2, 100 patients were screened for the emergence of VRE colonization. No patient was VRE positive at baseline and 4 (4%) were positive at day 7.

Conclusions:

Surgical antibiotic prophylaxis with vancomycin was reasonably well tolerated in CABG and valve replacement surgery, with a 4% incidence of VRE colonization.

Vancomycin reaction during spinal anaesthesia

A 77-year-old female received uneventful spinal anaesthesia for a total knee replacement. Upon the advice of the microbiologists and at the request of the orthopaedic surgeon, a vancomycin infusion was commenced prior to the application of the leg tourniquet. Five minutes later, having received only 40 mg of the antibiotic dose, she became unconscious and suffered severe cardiovascular collapse, from which she was resuscitated with intravenous ephedrine and adrenaline.

Antibiotic side effects

Antibiotic side effects are approached best from an individual agent perspective rather than from a class-related standpoint. As this article indicates, with the exception of drug fevers and drug rashes, most antibiotic side effects are related to individual agents and not class side effects. Clinicians should view antimicrobial side effects as related to each organ system and be aware that more often a nonmicrobial medication is the explanation for the drug side effect rather than the antimicrobial. Nonantimicrobial medications are the most common cause of drug fever; among antimicrobials, beta-lactams and sulfonamides are the most common causes of drug-induced fevers. Antimicrobial side effects have important implications for the patient, legal and economic implications for the hospital, and medicolegal implications for the physician. Antibiotic side effects that prolong hospitalization in today's managed care environment have important economic implications. Clinicians should be familiar with the most common side effects of the most frequently used antimicrobials, to minimize the potential of having adverse reactions occur in patients. Most adverse events related to antimicrobials are reversible rapidly on cessation of the medication. Irreversible toxicities include aminoglycoside-induced ototoxicity, Stevens-Johnson syndrome, and toxicity secondary to nitrofurantoin. The most common acute fatal drug reactions include hypersensitivity reactions resulting in anaphylaxis or the Stevens-Johnson syndrome and fatal hepatic necrosis secondary to trovafloxacin. Clinicians should eliminate the use of drugs associated with chronic or fatal toxicities because multiple therapeutic alternatives exist for virtually every potential infection.

Potentiation of vancomycin-induced histamine release by muscle relaxants and morphine in rats

The intravenous injection of vancomycin sometimes causes anaphylactoid reactions, in which histamine release may play a major role. These reactions are more frequently manifested when vancomycin is injected into anesthetized patients. We examined the vancomycin-induced histamine release and the interaction of vancomycin with muscle relaxants or opioid in rats. In an in vitro study with rat peritoneal mast cells, treatment with vancomycin at concentrations of greater than 1.25 mM produced significant histamine release. Tubocurarine, vecuronium, pancuronium, succinylcholine, and morphine up to concentrations of 0.25, 1, 5, 30, and 5 mM, respectively, produced no significant histamine release. However, the nonsignificant histamine release induced by 0.5 mM vancomycin was clearly enhanced by combining vancomycin with any of these agents. In the in vivo study, the intravenous injection of vancomycin significantly increased the plasma histamine levels in rats when vancomycin was injected at 200 mg/kg of body weight (63.2 +/- 34.0 ng/ml [mean +/- standard deviation]) but not when it was injected at 100 mg/kg (30.8 +/- 20.2 ng/ml) compared with that in the saline-treated rats (22.5 +/- 11.4 ng/ml). Although the subcutaneous administration of morphine (10 mg/kg) never increased the plasma histamine levels, the intravenous injection of vancomycin (100 mg/kg) 30 min after this morphine treatment markedly increased the plasma histamine levels (56.0 +/- 26.9 ng/ml). These findings provide experimental evidence that the combination of muscle relaxants or an opioid with vancomycin may increase the risk of anaphylactoid reactions by enhancing the release of histamine.

Life-threatening reaction to vancomycin given for noninfectious fever

OBJECTIVE

To report a case of vancomycin-induced anaphylaxis (or anaphylactoid reaction) in a patient with a fever of unrecognized noninfectious origin.

CASE SUMMARY

An 83-year-old white man, who was a patient of the Veterans Affairs Medical Center, developed a serious anaphylactic (or anaphylactoid) reaction while receiving intravenous vancomycin as empiric therapy for a nosocomial fever of unknown origin. The fever was subsequently proved to have been due to acute polyarticular gout rather than an infection.

DISCUSSION

This patient developed respiratory distress and an increased serum troponin concentration, suggestive of a myocardial enzymatic leak as a result of vancomycin therapy. Vancomycin was given before the noninfectious cause of his fever was recognized.

CONCLUSIONS

Even with cautious slow infusion, intravenous vancomycin can precipitate life-threatening infusion-related reactions in some patients. Because of this, and to reduce selective pressure for vancomycin resistance, sources of fever that do not require treatment with vancomycin should be diligently investigated prior to the institution of empiric vancomycin therapy in febrile patients, particularly when the past medical history is suggestive of an alternative diagnosis.

Adverse reactions to vancomycin prophylaxis in cardiac surgery

Several adverse effects of vancomycin have been reported. The aim of this study was to assess the incidence of adverse responses to antibiotic prophylaxis with vancomycin in cardiac surgical patients. Prospectively, 116 consecutive patients (106 adults and 10 children) undergoing cardiac surgical procedures in this institution from January to June 1990 were studied. After the anesthetic induction, vancomycin, 1 g in adults and 10 mg/kg in children, was intravenously administered over 30 minutes. The infusion rate was slowed if any adverse effect was observed. As a control group, 10 similar patients were evaluated during the same period of 30 minutes after anesthetic induction but prior to vancomycin administration and surgical stimulation. Thirty-one patients (26.72%) developed an adverse effect, mainly hypotension (29 patients, 25%), which was considered severe in 15 patients (12.93%). Seven patients (6.03%) developed a maculopapular erythema that was associated with hypotension (Red-Man's syndrome) in 5 patients and with bronchospasm in 1 patient. The incidence of adverse reactions in children (20%) was similar to the overall incidence. Only 1 patient in the control group (10%) developed hypotension during the period studied. The incidence of adverse reactions was not related to age, body weight, vancomycin dose administered per kilogram body weight, type of surgical procedure, or associated disease. Mean duration of the infusion was similar in patients with and without adverse responses (34.60 +/- 12.41 minutes and 37.38 +/- 14.55 minutes, respectively). It is concluded that perioperative prophylaxis with vancomycin in cardiac surgery produces a high and unpredictable risk of significant hypotension.

"Red man syndrome" with vancomycin: report of case

Vancomycin is a recommended alternative prophylactic antibiotic for penicillin-allergic patients with prosthetic mitral valves. During the course of recommended treatment, a drug reaction known as "red man syndrome" was encountered. Because vancomycin is appropriate for some dental situations, the general practitioner should be acquainted with its use and possible side effects.

Vancomycin-associated exfoliative dermatitis during continuous ambulatory peritoneal dialysis

Vancomycin is commonly prescribed to patients undergoing continuous ambulatory peritoneal dialysis (CAPD) for catheter-related infections and acute episodes of peritonitis. Although adverse dermatological reactions have been reported secondary to the rapid intravenous infusion of vancomycin, the intraperitoneal route of administration has been used routinely during CAPD without these effects. This case report describes a CAPD patient with systemic lupus erythematosus who developed erythema multiforme that progressed to exfoliative dermatitis during intermittent intraperitoneal vancomycin therapy for a catheter-related exit-site/tunnel infection.

Vancomycin: a review

This article reviewed the past experience and updated the present data on vancomycin. In recent years, with the release of more purified preparations of vancomycin and new clinical problems facing the clinician (that is, increasing prevalence of serious methicillin-resistant staphylococcal infections; use of hemodialysis and CAPD; widespread use of prosthetic devices; aggressive chemotherapy), the indication for vancomycin use has increased dramatically. More information is needed on the distribution of vancomycin in body tissues and the incidence and mechanisms of toxicity. Close surveillance of in vitro susceptibility patterns will be necessary as widespread use of vancomycin continues to increase.

Once weekly intraperitoneal therapy for gram-positive peritonitis

The pharmacokinetics and clinical outcome following a 30 mg/kg/2 L intraperitoneal (IP) dose of vancomycin, which was administered once a week for 3 weeks, was studied in ten continuous ambulatory peritoneal dialysis patients with peritonitis. Vancomycin was 91% absorbed following the first dose and rapidly achieved therapeutic serum concentrations, 19 +/- 8 mcg/mL at 1 hour and a peak of 37 +/- 8 mcg/mL at 6 hours. Vancomycin was eliminated slowly with a mean total clearance of 7 +/- 3 mL/min/70 kg and a distribution volume of 1.2 +/- 0.3 L/kg. The resultant mean serum t1/2 over the first week was 184 hours and the mean serum concentration at 168 hours was 10 +/- 4 mcg/mL. Based on the positive clinical outcome (100% cure) among patients with uncomplicated gram-positive peritonitis, the potential use of this alternative vancomycin dosing regimen is proposed.

Monitoring vancomycin therapy

Vancomycin is an effective and widely used antistaphylococcal antibiotic. Despite several decades of use, however, our knowledge of the toxicologic and pharmacokinetic properties of vancomycin remains incomplete. This review summarizes current information regarding the adverse reactions and pharmacokinetics of vancomycin. Although there have been reports of side effects with vancomycin, these effects tend to be infrequent, easily managed, and reversible. Several methods for adjustment of vancomycin therapy have been recommended. The relationship between serum concentrations of vancomycin and the occurrence of ototoxicity or nephrotoxicity has not been well established. However, because of large interpatient variations in pharmacokinetic parameters, it seems preferable to individualize vancomycin therapy based on serum concentration data.

Adverse effects of vancomycin administered in the perioperative period

Indications for the administration of vancomycin in the perioperative period have expanded in recent years. Used in this situation, vancomycin has caused adverse reactions, the most serious of which is hypotension. We describe five patients who had adverse reactions to vancomycin perioperatively. Vancomycin-induced hypotension usually results from a negative inotropic and vasodilator effect produced in part by a histamine-release phenomenon, which occurs most commonly with rapid intravenous infusion of the drug. Such a release of histamine may also produce an acute urticarial flushing of the upper torso (the "red neck syndrome") and symptoms of pain and muscle spasm in the chest or paraspinal muscles, which may mimic myocardial infarction. These effects usually abate promptly when the infusion of vancomycin is discontinued, and their resolution may be expedited by administration of an antihistamine.