Vancomycin-induced neutropenia during treatment of osteomyelitis in an outpatient

Vancomycin-Induced Fever and Neutropenia in an Immunocompetent Patient With Complicated Community-Acquired Pneumonia

Drug-induced fever can be caused by many medications through several mechanisms. One of the most common mechanisms is an immunologic reaction mediated by drug-induced antibodies.

Herein, we report the case of a rare adverse reaction with vancomycin. A six-year-old girl being treated for necrotizing pneumonia with vancomycin developed mild neutropenia, skin rash, and fever two weeks into her therapy. These resolved after stopping vancomycin, with noted reversal of neutropenia and leukopenia. Upon rechallenging the patient with vancomycin, she developed a fever in less than 24 h from the administration. Vancomycin-induced fever was made as a diagnosis of exclusion after all other possible causes were ruled out.

Vancomycin-induced neutropenia: is it dose- or duration-related?

OBJECTIVE

To systematically evaluate the literature to determine whether vancomycin-induced neutropenia is dose- or duration-related and provide clinicians with feasible treatment alternatives.

DATA SOURCES

A literature search of PubMed (1949-November 2010), MEDLINE (1950-November 2010), EMBASE (1980-November 2010), and International Pharmaceutical Abstracts (1970-November 2010) was performed using the terms vancomycin, neutropenia, and leukopenia. Citations from publications were reviewed for additional references.

STUDY SELECTION AND DATA EXTRACTION

Studies and case reports were included if they reported neutropenia with vancomycin administration and excluded if they did not describe vancomycin dosages and/or concentrations, or if neutropenia resolved while the patient was still receiving vancomycin. Cases with significant confounders and those in which authors provided minimal information about patients were also excluded.

DATA SYNTHESIS

Seven retrospective chart reviews (ie, case series) and 33 case reports were identified. Of these, 3 retrospective reviews and 26 case reports met inclusion criteria. To our knowledge, no prospective studies have assessed this clinical complication. Data suggest that vancomycin-induced neutropenia may not be completely related to daily dosages, total cumulative dosage, or supratherapeutic vancomycin concentrations. Furthermore, evidence suggests that neutropenia is more likely associated with therapy longer than 7 days, with the majority of episodes occurring beyond 20 days of therapy. Given these findings, a practical approach is to monitor white blood cell (WBC) count with a differential (including absolute neutrophil count) once a week in patients who are receiving vancomycin for more than 7 days.

CONCLUSIONS

Vancomycin-induced neutropenia is most likely associated with prolonged vancomycin exposure. Patients receiving vancomycin for longer than 7 days should have WBC count, differential, monitored weekly. Vancomycin should be discontinued if there is a high clinical suspicion of it causing neutropenia, and an alternative agent should be initiated. Prospective case-controlled studies are needed to better characterize this adverse event.

Probable Vancomycin-Induced Neutropenia

OBJECTIVE

To report a case of vancomycin-induced neutropenia and provide a review of the literature.

CASE SUMMARY

A 64-year-old white man was treated with intravenous vancomycin 1.5 g/day for finger osteomyelitis. He developed neutropenia after 21 days of vancomycin therapy. The absolute neutrophil count reached a nadir of 418 cells/mm3 during vancomycin use and returned to normal 7 days after its discontinuation. The eosinophil count was also elevated during the neutropenic episode and probably related to vancomycin. Based on the Naranjo probability scale, the reaction was probably related to vancomycin use.

DISCUSSION

Articles describing cases of vancomycin-induced neutropenia were identified. All patients developed neutropenia as a result of vancomycin therapy 12 days. Neutrophil counts generally increased following discontinuation of vancomycin. One article reported successful resolution of neutropenia and infection by switching the patient's therapy to the structurally related antibiotic agent teicoplanin. Other patients were continued on vancomycin therapy, and neutropenia was treated with moderate to good success with filgrastim. Rechallenge was not generally attempted. The mechanism of neutropenia caused by vancomycin is unclear, but appears to be immune-mediated.

CONCLUSIONS

Vancomycin therapy should not be prolonged unless absolutely necessary, and therapy should be reserved for patients with clear indications for the drug, such as infections due to gram-positive organisms resistant to other therapies. Patients should have periodic assessment of white blood cell and neutrophil counts with consideration to discontinue vancomycin if neutropenia develops.

Vancomycin-induced neutropenia in a patient positive for an antineutrophil antibody

A 48-year-old man, hospitalized after experiencing subarachnoid hemorrhage secondary to a basilar aneurysm, received vancomycin for methicillin-resistant Staphylococcus aureus sepsis. He developed neutropenia 16 days after the start of vancomycin therapy, and his white blood cell count decreased to a nadir of 1200 cells/mm3. Vancomycin was discontinued, and granulocyte-colony stimulating factor (G-CSF) therapy was begun. The patient was rechallenged with a single dose of vancomycin 1 g in preparation for intraarterial aneurysm coiling. His white blood cell count dropped to 600 cells/mm3 but returned to normal with continued G-CSF therapy. A diagnosis of vancomycin-induced neutropenia was considered. Subsequent testing by granulocyte agglutination and granulocyte immunofluorescence assays revealed that his serum was positive for an antigranulocyte antibody. A test for HLA antibody reactivity was negative. Monoclonal antibody immobilization of granulocyte antigens assay failed to determine the antigen specificity of his granulocyte antibody.

Vancomycin-induced neutropenia resolves after substitution with teicoplanin

Neutropenia is an uncommon adverse effect associated with prolonged vancomycin therapy. Neutrophil counts normally recover after discontinuation of vancomycin in this situation, but treatment options are needed for those patients who require ongoing antibiotic therapy. We describe a case of vancomycin-induced neutropenia in which the neutropenia resolved after vancomycin was replaced by the structurally related compound teicoplanin.

[Glycopeptides]

OBJECTIVES

To review pharmacology, pharmacokinetic and therapeutic use of glycopeptides in intensive care units.

DATA SOURCES

Extraction from Medline database of French and English articles on glycopeptides and search along with major review articles.

DATA SELECTION

The collected articles were reviewed and selected according to their quality and originality. The more recent data were selected.

DATA SYNTHESIS

Glycopeptides are bactericidal antibiotics which are only active against Gram positive species acting by inhibiting peptidoglycan synthesis. They had been in clinical use for almost 30 years without high-level resistance underlining. For ten years, there have been disturbing reports of first, resistance to vancomycin in enterococcal species and more recently in strains of Staphylococcus aureus by complex and large mechanisms of action. This new resistances may lead to a therapeutic impasse and a fatal issue for infected patients. The only response to this situation is the respect of prescription rules and the careful use of antibiotics.

CONCLUSION

Considering their spectrum, glycopeptides are an antibiotic family which importance is fundamental to treat infected patients of intensive care units. Staff members of intensive care units are responsible for their good use.

Vancomycin-induced neutropenia associated with fever: similarities between two immune-mediated drug reactions

A 39-year-old woman being treated for osteomyelitis with vancomycin developed severe neutropenia and drug fever. After she discontinued therapy, both disorders quickly resolved. These adverse reactions have rarely been reported with vancomycin, and share many similarities with regard to clinical features and postulated mechanisms of induction. To our knowledge this is the first case documenting drug fever as a principal component of vancomycin-induced neutropenia, and provides further evidence in support of an immune-mediated mechanism.

Agranulocytosis induced by vancomycin or ticarcillin/clavulanate

OBJECTIVE

To reacquaint clinicians with a reportedly rare adverse event of agranulocytosis occurring after long-term administration of vancomycin and ticarcillin/clavulanate, with a subsequent review of other reported cases in the literature.

CASE SUMMARY

A 45-year-old white woman with spina bifida developed agranulocytosis (2.7 x 10(3)/mm3 white blood cells with only 3% polymorphonuclear leukocytes and no reported eosinophils or basophils) after long-term administration of vancomycin and ticarcillin/clavulanate for decubitus ulcers and chronic osteomyelitis. Consequently, the cell counts rebounded rapidly on discontinuation of both medications and returned to normal within 1 week.

DISCUSSION

The incidence of vancomycin-associated neutropenia is presumably rare, but the increased use of vancomycin may disclose a more frequent occurrence. It is suggested that the mechanism for the reaction is immunologically mediated, yet this remains unclear. Although it is difficult to determine the causative agent in this case, vancomycin was most suspect clinically. Ticarcillin/clavulanate is less likely because our patient has since been readmitted and treated with oxacillin, imipenem/cilastatin, and amoxicillin/clavulanate without affecting the white blood cell count. In that regard, it could be reasoned that an immunologic reaction to ticarcillin would have resulted in a similar outcome with other penicillins.

CONCLUSIONS

This case serves as a reminder to clinicians that patients receiving long-term treatment with vancomycin should have their white blood cell count monitored at least weekly.

Vancomycin-induced thrombocytopenia: a challenge and rechallenge

OBJECTIVE

To report a case of thrombocytopenia apparently associated with vancomycin use.

CASE SUMMARY

A 58-year-old white man was admitted to the hospital with chronic osteomyelitis of the foot due to methicillin-resistant Staphylococcus aureus that later spread hematogenously to the cervical vertebrae. During the first course of therapy with vancomycin, his platelet count decreased from 397 x 10(3)/mm3 to 22 x 10(3)/mm3. After discontinuation of the drug, it increased to 310 x 10(3)/mm3. During the second course of vancomycin, the platelet count decreased to 77 x 10(3)/mm3, and increased to 404 x 10(3)/mm3 after discontinuation of the drug.

DISCUSSION

Vancomycin has been reported as a rare cause of thrombocytopenia. Thrombocytopenia can occur as an adverse drug reaction by the following three mechanisms: direct toxic effect, drug absorption (hapten) formation, and an "innocent bystander" immune response.

CONCLUSIONS

We suspect that the thrombocytopenia in this patient, which involved an increased number of megakaryocytes in the bone marrow, was due to vancomycin.

Vancomycin-induced neutropenia during treatment of endocarditis in a pediatric patient

OBJECTIVE

To report a case of reversible vancomycin-associated neutropenia occurring during long-term therapy with vancomycin using weight and age-adjusted dosing.

CASE SUMMARY

A 2-year-old boy was started on vancomycin therapy for presumed endocarditis resulting from his ventriculoseptal defect. After 18 days of treatment, neutropenia with an absolute neutrophil count (ANC) of 990 x 10(6) cells/L was noted. The neutropenia progressed over the next 3 days and reached a nadir concentration of 459 x 10(6) cells/L. Vancomycin therapy was discontinued after 17 days (antibiotic day 20). A rise in the ANC occurred within 2 days of discontinuation. An improved ANC of 1672 x 10(6) cells/L occurred within 5 days. Vancomycin serum concentrations remained within an acceptable range: a peak of 30 micrograms/mL and a trough of 9 micrograms/mL.

DISCUSSION

Case reports in the literature of vancomycin-associated neutropenia in adults were briefly reviewed and compared. The onset and resolution and mechanism of vancomycin-induced neutropenia were studied. The potential relationship between vancomycin, weight-, and age-adjusted dosing and the occurrence of neutropenia in our pediatric patient was postulated.

CONCLUSIONS

Vancomycin is identified as a possible cause of drug-induced neutropenia. More data are needed that clearly indicate vancomycin as the offending agent in children. The vancomycin-induced neutropenia is believed to be immunologically based and independent of drug concentrations.

Vancomycin

Vancomycin is a glycopeptide antibiotic that is active against staphylococci, streptococci, and other gram-positive bacteria. It is the drug of choice for the treatment of infections due to methicillin-resistant staphylococci, Corynebacterium jeikeium, and multiply resistant strains of Streptococcus pneumoniae. Vancomycin is an alternative treatment for serious staphylococcal and streptococcal infections, including endocarditis, when allergy precludes the use of penicillins and cephalosporins. Vancomycin is bactericidal against most strains of staphylococci and nonenterococcal streptococci. Although rare strains of staphylococci and enterococci that are resistant to vancomycin have been reported, bacterial resistance has thus far not emerged as a major clinical problem despite widespread use of vancomycin. When therapy is monitored by periodic determinations of serum concentrations of the drug and rapid infusion rates are avoided, vancomycin is rarely associated with serious toxicity.

High incidence of vancomycin-associated leucopenia and neutropenia in a cardiothoracic surgical unit

A retrospective case record review was undertaken to determine the incidence of vancomycin-associated leucopenia in a cardiothoracic surgical unit. Forty-nine patients received 50 courses of vancomycin therapy. Nine patients (18%) developed reversible leucopenia (white cell count less than 4000 x 10(6)/l) or neutropenia (polymorphonuclear leucocyte count less than 1500 x 10(6)/l). Four patients (8%) had severe neutropenia (less than 1000 x 10(6)/l). The median total dosage associated with leucopenia and neutropenia was 30 g, range 22-56 g. The median duration of treatment in leucopenic and neutropenic patients was 22 days, range 6-28 days. The median recovery time to a normal white cell count was 4 days, range 1-11 days. Patients who developed leucopenia on vancomycin therapy did not differ from those who did not with respect to age, total vancomycin dose, length of therapy, underlying illness, incidence of cardiac surgery or use of concomitant medications. Vancomycin-associated leucopenia and neutropenia is common in patients with cardiothoracic infections, many of whom are on several other medications. White cell counts should be estimated regularly in such patients.