Vancomycin-associated drug reaction with eosinophilia and systemic symptoms syndrome

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.

Intraosseous Morphine Decreases Postoperative Pain and Pain Medication Use in Total Knee Arthroplasty: A Double-Blind, Randomized Controlled Trial

BACKGROUND

Intraosseous (IO) infusion of medication is a novel technique for total knee arthroplasty (TKA) antibiotic prophylaxis. To decrease postoperative pain in TKA patients, we investigated addition of morphine to a standard IO antibiotic injection.

METHODS

A double-blind, randomized controlled trial was performed on 48 (24 each) consecutive patients undergoing primary TKA. The control group received an IO injection of antibiotics as per the standard protocol. The experimental group received an IO antibiotic injection with 10 mg of morphine. Pain, nausea, and opioid use were assessed up to 14 days postoperatively. Morphine and interleukin-6 serum levels were obtained 10 hours postoperatively in a subgroup of 20 patients.

RESULTS

The experimental group had lower Visual Analog Scale pain score at 1, 2, 3, and 5 hours postoperatively (P = .0032, P = .005, P = .020, P = .010). This trend continued for postoperative day 1, 2, 8, and 9 (40% reduction, P = .001; 49% reduction, P = .036; 38% reduction, P = .025; 33% reduction, P = .041). The experimental group had lower opioid consumption than the control group for the first 48 hours and second week postsurgery (P < .05). Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores for the experimental group showed significant improvement at 2 and 8 weeks postsurgery (P < .05). Serum morphine levels in the experimental group were significantly less than the control group 10 hours after IO injection (P = .049).

CONCLUSION

IO morphine combined with a standard antibiotic solution demonstrates superior postoperative pain relief immediately and up to 2 weeks. IO morphine is a safe and effective method to lessen postoperative pain in TKA patients.

LEVEL OF EVIDENCE

Therapeutic, Level 1.

Antibacterial antibiotic-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: a literature review

Background

Drug reaction with eosinophilia and systemic symptoms syndrome (DRESS) is a delayed infrequent potentially life-threatening idiosyncratic drug reaction. Aromatic anticonvulsants and allopurinol are the most frequent causative agents. However, various reports of antibiotic-induced DRESS are available. In this review, we try to summarize reports of antibacterial antibiotic-induced DRESS focusing on characteristics of DRESS induced by each antibiotic group.

Methods

The data were collected by searching PubMed/MEDLINE and ScienceDirect. The keywords used as search terms were “DRESS syndrome,” “drug-induced hypersensitivity syndrome (DIHS),” “antibiotics,” “antimicrobial,” and names of various antimicrobial groups. Finally, 254 relevant cases with a definite or probable diagnosis of DRESS based on RegiSCAR criteria were found until 30 May 2020 and reviewed.

Results and conclusion

Totally, 254 cases of antibacterial antibiotic-induced DRESS are reported. Most of them are related to antituberculosis drugs, vancomycin, and sulfonamides, respectively. Rash and fever were most frequent clinical findings. Eosinophilia and liver injury were the most reported hematologic and visceral organ involvement, respectively. Most of the patients are managed with systemic corticosteroids. The death occurred in 16 patients which most of them experienced liver or lung involvement. The reactivation of various viruses especially HHV-6 is reported in 33 cases. The mean latency period was 29 days. It is necessary to perform thorough epidemiological, genetic, and immunological studies, also systematic case review and causality assessment, as well as well-designed clinical trials for better management of antibiotic-induced DRESS.

Electronic supplementary material

The online version of this article (10.1007/s00228-020-03005-9) contains supplementary material, which is available to authorized users.

Drug Reaction, Eosinophilia, and Systemic Symptoms (DRESS) Syndrome As a Mimicker of Spinal Infection: Awareness for Spinal Surgeons

Drug reaction, eosinophilia, and systemic symptoms (DRESS) syndrome is a delayed severe drug hypersensitivity (type IVb) syndrome with cutaneous eruption, hematological abnormalities, and multi-organ involvement. The wide spectrum of the disease manifestations, long-term sequelae, and high mortality rates are a clinical concern. Though not commonly reported in spinal surgery patients, the use of long-term antibiotics is a potential causative agent in spinal infections. DRESS syndrome can mimic systemic spinal infections, and clinical diagnosis requires high awareness and extreme vigilance. Prompt recognition and appropriate action can mitigate the potential poor outcomes and improve patient prognosis.

Haplotype analysis in a 16-year-old boy with vancomycin-induced DRESS syndrome

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but life-threatening multisystem adverse reaction to a medication, with vancomycin being one of the most common cause reported. We present the HLA analysis of a pediatric patient who developed DRESS related to vancomycin and compared the results with the available literature. With further data, the use of pretreatment HLA analysis to prevent vancomycin related DRESS may be a valuable option in the near future.

Drug Rash with Eosinophilia and Systemic Symptoms Syndrome Presenting After the Initiation of Staphylococcus hominis Infectious Endocarditis Treatment: A Case Report and Updated Review of Management Considerations

We present the case of a 62-year-old Caucasian man who was being treated for mitral valve endocarditis via a six-week course of vancomycin. On Day 32 of the treatment, he developed an erythematous, pruritic, desquamating, and painful rash covering 80% of the total body surface area and intermittent fevers. Laboratory findings included leukocytosis with peripheral blood eosinophilia and elevated erythrocyte sedimentation rate, C-reactive protein, and serum creatinine. Although the patient only completed five weeks of antibiotics, the decision was made to not complete the six-week antibiotic course due to suspicion of vancomycin-induced drug rash with eosinophilia and systemic symptoms (DRESS). The patient was then given 80 mg of intramuscular triamcinolone (Kenalog) and advised to apply topical 0.1% triamcinolone twice per day. At the three-month follow-up, the rash, leukocytosis, eosinophilia, and renal dysfunction had resolved. Clinicians must maintain a high index of suspicion for vancomycin-induced DRESS in patients with rash and eosinophilia for early recognition and treatment. DRESS syndrome treatment typically involves discontinuing the causative drug and promptly administering steroids. However, there is a therapeutic dilemma in administering steroids during the course of an active infection. Therefore, this article serves two purposes. First, this case report highlights our approach towards managing a patient with DRESS and concurrent infectious endocarditis. Second, we include a review of the management considerations when prescribing pulsed steroids so that clinicians have a single source as a practical guide towards reducing the potentially severe systemic sequelae in DRESS syndrome and its associated treatment.

Vancomycin-Induced DRESS Syndrome: An Important Concern in Orthopedic Surgery

DRESS (drug reaction with eosinophilia and systemic symptoms) is a potentially serious complication when prolonged courses of antibiotics are given to patients, with an average onset of 2–6 weeks after commencement. There is a high mortality rate (1–10%). We report the case of a 62-year-old male who developed DRESS after seven weeks of antibiotic treatment with vancomycin for a deep spinal metalwork infection. We describe the typical rash and biochemical results, including eosinophilia, as well as the systemic signs seen in this case. The criteria for diagnosis of DRESS, including the RegiSCAR scoring system and commonly affected systems (renal, cardiac, and hepatic), are detailed, and we also discuss evidence for steroid treatment and considerations important in the use of this.

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.

Vancomycin-associated drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: masquerading under the guise of sepsis

A patient presented with what appeared to be severe urosepsis. After admission and antibiotic administration, a newly developed rash and subsequent facial swelling appeared to be a reaction to penicillin class antibiotics. However, despite changing class of therapy with continued antimicrobial coverage, end organ damage continued, the rash worsened and facial oedema developed. Drug reaction with eosinophilia and systemic symptoms was ultimately diagnosed and was consistent with clinical and histopathological findings, as well as meeting all criteria for scoring systems. The patient was started on intravenous methylprednisolone 125 mg per 8 hours with rapid improvement of rash, swelling and end organ damage. Initial challenge to decrease dose failed, but the patient was ultimately able to be discharged on an extended taper.

Enigma: infection or allergy? Vancomycin-induced DRESS syndrome with dialysis-dependent renal failure and cardiac arrest

A man aged 73 years with infective endocarditis presented with septic shock and was started on immediate antimicrobial therapy. His blood culture yielded no organism. Subsequently, he developed a severe allergic reaction to prolonged empirical vancomycin therapy. This manifested as fever, widespread maculopapular rash and severe progressive acute kidney injury ultimately requiring dialysis. In the context of eosinophilia, this was determined to be drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. Deciphering this complication as allergy in the context of severe infection required extreme caution due to the polarity of treatment with immunosuppression. Ultimately, this was used, with improvement of renal function, resolution of symptoms and absence of recurrence of infection. In summary, we present a case of vancomycin-related DRESS syndrome leading to dialysis-which is unique in the literature-complicating the treatment of culture-negative infective endocarditis.

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

BACKGROUND

Vancomycin is a broad-spectrum antibiotic whose use may be limited by adverse drug reactions (ADRs). Although vancomycin toxic effects are known, there are limited data on vancomycin hypersensitivity reactions (HSRs).

OBJECTIVE

To understand the most commonly reported vancomycin HSRs through systematic case review.

METHODS

We performed a literature search for English-language case reports and series from 1982 through 2015 (last search July 31, 2015) on Ovid MEDLINE and PubMed. The search included the subject heading vancomycin with the subheading adverse effects and separate text searches for vancomycin with a list of specified HSRs. References of identified articles were reviewed to find additional articles. Clinical data were collected and summarized.

RESULTS

Of 201 identified articles, 84 were screened and 57 fully assessed; these 57 articles contained 71 vancomycin HSR cases that were included in analysis. Vancomycin HSRs were immediate (anaphylaxis, n = 7) and nonimmediate (n = 64). Nonimmediate HSRs included linear IgA bullous dermatosis (LABD, n = 34), drug rash eosinophilia and systemic symptoms (DRESS) syndrome (n = 16), acute interstitial nephritis (AIN, n = 8), and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN, n = 6). Median times of vancomycin therapy before HSR onset was 7 days (interquartile range [IQR], 4-10 days) for LABD, 9 days (IQR, 9-22 days) for SJS/TEN, 21 days (IQR, 17-28 days) for DRESS syndrome, and 26 days (IQR, 7-29 days) for AIN. Overall, 11 patients (16%) died, and 4 (6%) had deaths attributed to the HSR.

CONCLUSION

Vancomycin causes a variety of HSRs; the most commonly identified were nonimmediate HSRs, with LABD being most frequent. We observed a high frequency of HSR mortality. Further data are needed to understand the frequency and severity of vancomycin HSRs.

Vancomycin revisited - 60 years later

Vancomycin is one of the older antibiotics that has been now in clinical use close to 60 years. Earlier on, vancomycin was associated with many side effects including vestibular and renal, most likely due to impurities contained in early vancomycin lots. Over the years, the impurities have been removed and the compound has now far less vestibular adverse effects, but still possesses renal toxicity if administered at higher doses rendering trough serum levels of >15 mcg/mL or if administered for prolonged periods of time. Vancomycin is effective against most Gram-positive cocci and bacilli with the exception of rare organisms as well as enterococci that became vancomycin resistant, mostly Enterococcus faecium. The major use of vancomycin today is for infections caused by methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE) and amoxicillin-resistant enterococci. In its oral form, vancomycin is used to treat diarrhea caused by Clsotridium difficile. With S. aureus, there are only a handful of vancomycin-resistant strains. Nevertheless, a "vancomycin creep" that is slow upward trending of vancomycin MIC from <1 mcg/mL to higher values has been noted in several parts of the world, but not globally, and strains that have MIC's of 1.5-2 mcg/mL are associated with high therapeutic failure rates. This phenomenon has also been recently recognized in methicillin-susceptible S. aureus (MSSA). While vancomycin is relatively a safe agent adverse events include the "red man" syndrome, allergic reactions, and various bone marrow effects as well as nephrotoxicity. Vancomycin has been a very important tool in our therapeutic armamentarium that remained effective for many years, it is likely remain effective as long as resistance to vancomycin remains controlled.