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

Vancomycin-Induced Neutropenia With Subsequent Perioperative Readministration: A Case Report

Vancomycin (VCM), an essential antibiotic for antimicrobial-resistant Gram-positive cocci, can lead to complications such as neutropenia. Here, we present a case of a 25-year-old male with noncommunicating hydrocephalus due to an intraventricular tumor who developed neutropenia during VCM therapy. Despite the suspected VCM-induced neutropenia, short-term readministration was deemed necessary for perioperative infection prophylaxis. This patient was readministered without neutropenia. A review of the literature revealed an earlier onset of VCM-induced neutropenia than that previously reported, emphasizing the importance of vigilant monitoring. Although readministration of VCM in patients with neutropenia is uncommon, it may be feasible with careful risk assessment, particularly in cases of mild neutropenia and short-term therapy. However, the mechanisms underlying VCM-induced neutropenia remain unclear, necessitating further research on the optimal management strategies.

Vancomycin-Induced Leukopenia and Neutropenia: Time Will Tell

Purpose: Neutropenia is an uncommon adverse effect associated with prolonged vancomycin therapy. Methods: This was a case report on a 62-year-old African American male with hypertension, paranoid schizophrenia, and a history of polysubstance abuse developed foot osteomyelitis. The patient was initially maintained on intravenous Vancomycin & Ceftriaxone for ~3 weeks but adjusted to Daptomycin & Ceftriaxone while in hospital due to neutropenia. Patient's neutropenia quickly resolved once discontinuation of Vancomycin occurred. Results: Vancomycin is a potential cause of drug induced leukopenia and neutropenia. Monitoring of leukocytes and neutrophils is warranted in patients receiving long term intravenous Vancomycin therapy. Conclusion: Vancomycin is a bactericidal glycopeptide antibiotic with activity against gram-positive organisms such as Staphylococci. Well-known adverse drug events include nephrotoxicity and ototoxicity. Vancomycin-induced neutropenia on the other hand is less common and reported at lower rates. It is defined as an ANC less than 1000 µL in patients maintained on Vancomycin infusions. According to Black et al, neutropenia is more likely associated with prolonged therapy; generally occurring at least 20 days after initiation.

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.

Neutropenia, Thrombocytopenia, and Eosinophilia: An Unusual Triad in a Patient on Long-Term Vancomycin Therapy

Patient: Female, 46-year-old

Final Diagnosis: Adverse drug reaction • epidural abscess

Symptoms: Eosinophilia • neutropenia • thrombocytopenia

Medication: —

Clinical Procedure: —

Specialty: General and Internal Medicine

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.

Agranulocytosis Induced by Vancomycin. Case Report and Literature Review

Patient: Male, 38

Final Diagnosis: Agranulocytosis induced by Vancomycin

Symptoms: Fever • pain

Medication: Vancomycin

Clinical Procedure: Antibiotic treatment

Specialty: Hematology

Glycopeptide-Induced Neutropenia: Cross-Reactivity Between Vancomycin and Teicoplanin

Objective:

To report teicoplanin-related neutropenia that developed after an episode of neutropenia induced by vancomycin therapy.

Case Summary:

A 57-year-old female suffered from osteomyelitis of the left humerus, with a white blood cell (WBC) count of 2.8 × 103/mm3 and absolute neutrophil count (ANC) of 0.28 × 103/mm3, occurring after 24 days of vancomycin therapy. Vancomycin was changed to teicoplanin and the agranulocytosis resolved 4 days later. However, a new episode of neutropenia, with a WBC count of 2.8 × 103/mm3 and ANC of 0.448 × 103/mm3, occurred 11 days after teicoplanin initiation. Agranulocytosis resolved 4 days following withdrawal of teicoplanin.

Discussion:

Because of the close time relationship between drug administration and the development of symptoms and signs, as well as between drug withdrawal and changes in WBC count and ANC, the episodes of neutropenia were suspected to be drug related. Teicoplanin-induced agranulocytosis that followed vancomycin-induced agranulocytosis suggests a possible cross-reactivity between the 2 drugs. Both reactions were categorized as probable according to the Naranjo probability scale.

Conclusions:

For all patients with vancomycin-induced neutropenia, possible cross-reactivity of teicoplanin should be monitored.

Epidemiology of Vancomycin-Induced Neutropenia In Patients Receiving Home Intravenous Infusion Therapy

Background:

Vancomycin is frequently used to manage serious resistant gram-positive Infections. Neutropenia, whose epidemiology has not been well characterized, is a potentially serious adverse event associated with the use of vancomycin.

Objective:

To characterize the incidence and risk factors for development of vancomycin-induced neutropenia in patients treated with home intravenous vancomycin therapy.

Methods:

A retrospective chart review was conducted of adult patients receiving vancomycin therapy through the University of New Mexico Home Intravenous Infusion Clinic between January 1998 and December 2004. Data collection included demographics, comorbid conditions, dose and duration of vancomycin therapy, indications for vancomycin use, vancomycin concentrations, all concurrent medications, laboratory data, culture and susceptibility data, reasons for antibiotic alteration or discontinuations, all other recorded adverse events, management of adverse events, and outcomes of adverse events.

Results:

A total of 372 charts of patients managed through the clinic were reviewed and 114 patients treated with vancomycin were identified. Fourteen (12%) cases of vancomycin-induced neutropenia were identified; 4 (3.5%) cases included a reduction in absolute neutrophil count to 500 cells/mm3 or less. The mean ± SD duration of vancomycin therapy and time to neutropenia were 32 ± 29 and 26 ± 15 days, respectively. Laboratory monitoring was performed on a weekly basis and resolution of vancomycin-induced neutropenia occurred promptly after discontinuation. Total vancomycin doses used and serum concentrations were not associated with the development of neutropenia.

Conclusions:

Vancomycin-induced neutropenia may occur at a higher frequency than previously reported. Clinicians should monitor hematologic parameters at least weekly in patients receiving home intravenous vancomycin therapy.

A Case of Teicoplanin-Induced Pancytopenia Caused by Excessive Dosing

Teicoplanin is reported to be as effective as vancomycin but with minimal side effects. We report a case of teicoplanin-induced pancytopenia, which has not been demonstrated previously. A 44-year-old man with tetraplegia was treated with a diagnosis of urinary tract infection and pneumonia, and a high-dose of teicoplanin (400 mg every 12 hours) was administered for 4 days inadvertently. Although the infection rapidly improved, the patient developed pancytopenia by the fourth day of teicoplanin therapy, which was improved after reducing the dose of teicoplanin (200 mg/d). Our patient represents a probable case of teicoplanin-induced pancytopenia with adverse drug reaction probability score of 6.

Pure White Cell Aplasia and Necrotizing Myositis

Pure white cell aplasia (PWCA) is a rare hematologic disorder characterized by the absence of neutrophil lineages in the bone marrow with intact megakaryopoiesis and erythropoiesis. PWCA has been associated with autoimmune, drug-induced, and viral exposures. Here, we report a case of a 74-year-old female who presented with severe proximal weakness without pain and was found to have PWCA with nonspecific inflammatory necrotizing myositis and acute liver injury on biopsies. These findings were associated with a recent course of azithromycin and her daily use of a statin. Myositis improved on prednisone but PWCA persisted. With intravenous immunoglobulin and granulocyte-colony stimulating factor therapies, her symptoms and neutrophil counts improved and were sustained for months.

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.

Tolerability of teicoplanin in 117 hospitalized adults with previous vancomycin-induced fever, rash, or neutropenia: a retrospective chart review

BACKGROUND

Vancomycin has reliable antibacterial activity against many gram-positive pathogens but is associated with many adverse events. Teicoplanin, another glycopeptide, is associated with fewer adverse events, but its use in patients with previous vancomycin-induced adverse reactions remains controversial.

OBJECTIVES

The aims of this work were to evaluate the clinical characteristics of hospitalized patients with vancomycin-induced fever (ie, drug fever), rash, or neutropenia and to examine the tolerability of teicoplanin in these patients.

METHODS

This was a retrospective review of the medical charts of patients aged >or=18 years who were hospitalized between January 2002 and October 2007 at National Cheng Kung University Hospital in Tainan, Taiwan. Patients were included if they experienced drug-induced fever (ie, "drug fever"), rash, or neutropenia during vancomycin treatment. Their antimicrobial therapy was subsequently switched to teicoplanin. Clinical information and the development of drug fever, rash, or neutropenia with teicoplanin were determined from the charts.

RESULTS

Antibiotic therapy was switched to teicoplanin in 117 patients with vancomycin-induced fever alone (n = 24), rash alone (n = 77), both drug fever and rash (n = 8), or neutropenia (n = 8). The mean (SD) age of these patients was 53.1 (22.8) years, and 65 (56%) were male. The major clinical indications for vancomycin therapy among these patients were wound infections (21%), respiratory tract infections (14%), and bacteremia (13%). The dosages for vancomycin ranged from 1 g every 5 days to 1 g BID, and for teicoplanin ranged from 400 mg daily to 400 mg q72h, adjusted by the degree of renal dysfunction. Overall, 12 patients with vancomycin-induced fever (n = 2), rash (n = 6), or neutropenia (n = 4) subsequently developed teicoplanin-induced fever (n = 3), rash (n = 3), or neutropenia (n = 6). Specifically, of 8 patients with vancomycin-induced neutropenia, 4 (50%) subsequently developed neutropenia after switching to teicoplanin. Vancomycin- and teicoplanin-induced neutropenia was often noted after 1 week of treatment. Among patients with vancomycin-induced fever, rash, or neutropenia, there were no differences between patients with or without teicoplanin-induced fever, rash, or neutropenia in terms of age, sex, weight, dosage or duration of vancomycin therapy, dosage of teicoplanin, or underlying disease. There was no difference in mortality rates between patients with or without teicoplanin-induced fever, rash, or neutropenia. The cause of all deaths was progression of infectious or underlying disease, unrelated to vancomycin or teicoplanin use.

CONCLUSIONS

Based on this retrospective chart review of hospitalized patients with vancomycin-induced fever, rash, or neutropenia, only 10% experienced subsequent teicoplanin-induced fever, rash, or neutropenia. However, it should be noted that half of the patients with vancomycin-induced neutropenia developed teicoplanin-induced neutropenia.

Thiopental-Induced Neutropenia in Two Patients with Severe Head Trauma

Thiopental has been used for decades in the treatment of refractory intracranial hypertension in patients with traumatic and nontraumatic head injuries. Commonly reported adverse effects include hypotension, hypokalemia, respiratory complications, and hepatic dysfunction. Neutropenia has rarely been reported as an adverse effect of thiopental. We witnessed probable thiopental-induced neutropenia in two patients with traumatic brain injuries who developed increased intracranial hypertension that was refractory to standard therapy. Based on a MEDLINE search of published case reports and literature, we propose two mechanisms by which thiopental-related neutropenia might be explained. The first is inhibition of inflammatory mediator nuclear factor-kappa B (NF-kappa B), leading to granulocyte apoptosis. The second mechanism involves inhibition of calcineurin. Although the precise link between these two mechanisms has not been elucidated, calcineurin is known to regulate NF-kappa B activity. Development of neutropenia does not appear to be correlated with time but may correlate with plasma concentrations of thiopental. The optimum management of drug-induced neutropenia is unclear. The decision to discontinue thiopental in patients who develop neutropenia should be made by weighing the risks versus benefits. Broad-spectrum antibiotics may be required in the presence of fever. The role of hematopoietic growth factors such as granulocyte colony-stimulating factor is not yet defined. Given the adverse infectious consequences of neutropenia, it is essential to closely monitor neutrophil counts in patients receiving thiopental.

A randomized, open-label, multicenter comparative study of the efficacy and safety of piperacillin-tazobactam and cefepime for the empirical treatment of febrile neutropenic episodes in patients with hematologic malignancies

BACKGROUND

The empirical treatment of febrile, neutropenic patients with cancer requires antibacterial regimens active against both gram-positive and gram-negative pathogens. This study was performed to demonstrate the noninferiority of monotherapy with piperacillin-tazobactam, compared with cefepime.

METHODS

We conducted a randomized-controlled, open-label, multicenter clinical trial among high-risk patients from 34 university-affiliated tertiary care medical centers in the United States, Canada, and Australia who were undergoing treatment for leukemia or hematopoietic stem cell transplantation and were hospitalized for empirical treatment of febrile neutropenic episodes. Patients received piperacillin-tazobactam (4.5 g every 6 h) or cefepime (2 g every 8 h) intravenously. The primary outcome was success (defined by defervescence without treatment modification) at 72 h of treatment, end of treatment, and test of cure in the modified intent-to-treat analysis. Secondary outcomes included time to defervescence, microbiological efficacy, the additional use of glycopeptide antibiotics, emergence of resistant bacteria, and safety.

RESULTS

For 528 subjects (265 received piperacillin-tazobactam and 263 received cefepime), success rates were 57.7% and 48.3%, respectively (P = .04) at the 72-h time point, 39.6% and 31.6% (P = .06) at end of treatment, and 26.8% and 20.5% (P = .11) at the test-of-cure visit. The analyses demonstrated noninferiority for piperacillin-tazobactam at all time points (P< or = .0001). Treatment with piperacillin-tazobactam was independently associated with treatment success in multivariate analysis (odds ratio, 1.65; 95% confidence interval, 1.04-2.64; P = .035). Both regimens were well tolerated.

CONCLUSIONS

This study demonstrates the noninferiority and safety of piperacillin-tazobactam monotherapy, compared with cefepime, for the empirical treatment of high-risk febrile neutropenic patients with cancer.

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.

Treatment of meningitis due to methicillin-resistant Staphylococcus epidermidis with linezolid

Methicillin-resistant Staphylococcus epidermidis (MRSE) can cause nosocomial meningitis in the presence of prosthetic devices. Vancomycin is the treatment of choice, but its penetration into the cerebrospinal fluid is poor, especially in cases without severe meningeal inflammation. We successfully used linezolid to treat a case of posttraumatic MRSE meningitis with a low-level inflammatory response. Therapeutic effectiveness was documented microbiologically and by the simultaneous measurement of linezolid levels in serum and cerebrospinal fluid.

Similar hematologic effects of long-term linezolid and vancomycin therapy in a prospective observational study of patients with orthopedic infections

Linezolid is an alternative to vancomycin for the long-term treatment of gram-positive bacterial orthopedic infections because of its antibacterial spectrum and oral bioavailability, but duration-related myelosuppression could offset its advantages. To evaluate the hematologic effects of these agents, we prospectively studied 65 consecutive adults with gram-positive bacterial orthopedic infections requiring > or =2 weeks of vancomycin therapy (n=52) or linezolid therapy (n=20). Trends suggesting higher incidence of hematologic effects among the patients receiving vancomycin were not significant, regardless of whether the end point was lowest cell count during therapy or change from baseline. The only difference was a higher incidence of thrombocytopenia (<150x10(9) platelets/L) in the subset of the linezolid recipients who had received vancomycin within 2 weeks before starting linezolid therapy than in the linezolid recipients who had not received vancomycin (5 [71%] of 7 patients vs. 2 [15%] of 13; P=.02). All hematologic effects were reversible. In conclusion, hematologic effects were detectable through weekly monitoring and were reversible; therefore, concern about myelosuppression need not preclude linezolid use for orthopedic infections requiring long-term therapy.