Vancomycin Allergy Research Articles

Local delivery of linezolid in the treatment of complex orthopedic bone and joint infections in patients with vancomycin allergy: a case series.

Introduction: Osteomyelitis is a challenging bone infection associated with ischemia, trauma, or various surgical procedures (e.g., joint reconstruction). Treatment involves eradicating infected bone and soft tissue, local antibiotic delivery, and a 6-week course of antibiotics. Methicillin-resistant Staphylococcus aureus (MRSA) infections are common, and vancomycin is the standard treatment, but alternatives like linezolid are needed in vancomycin-resistant and vancomycin-allergic patients. Methods: A retrospective chart review was conducted on patients treated by the senior author between 2013 and 2021. The study included patients who received local delivery of linezolid for bone and/or joint infection with documented evidence of vancomycin allergy. Patient demographics, surgical details, linezolid delivery method, and outcomes were recorded. Clinical outcomes and subsequent procedures leading to infection eradication were documented. Results: A total of 13 patients were treated with linezolid-antibiotic-laden spacers with polymethyl methacrylate (PMMA) carrier. Nine patients were successfully treated using limb-salvage techniques and were still infection-free after a mean follow-up of 55.5 months. Conclusions: Linezolid-loaded bone cement is an option for managing chronic bone and joint infections, particularly MRSA, in patients with vancomycin allergy.

Evaluation of Dalbavancin in Vancomycin Allergic Patients: A Case Series

PurposeThere is a paucity of data regarding dalbavancin use in patients with a vancomycin allergy because of potential cross-reactivity between the 2 glycopeptide antibiotics. MethodsA retrospective medical record review was performed between February 2016 and February 2021 in patients with a listed vancomycin allergy who received dalbavancin as an outpatient infusion and had a listed vancomycin allergy in the electronic health record. FindingsThere were 559 unique patients during the study period who received dalbavancin as an outpatient infusion, 10 of whom had a documented vancomycin allergy in the electronic health record. Four of the 10 patients had a history of a type I IgE-mediated reaction to vancomycin, 1 patient reported delayed rash, 2 patients reported a vancomycin infusion reaction, 2 patients reported acute kidney injury, and 1 patient reported intolerance with general malaise. All 10 patients received at least 1 dose of dalbavancin with no reported adverse events. ImplicationsThis case series displays that all patients who received dalbavancin tolerated the infusion well with no adverse events reported. Dalbavancin may be a viable option for patients with a listed vancomycin allergy.

1056. Safety and Tolerability of Dalbavancin in Vancomycin Allergic Patients – A Case Series

BackgroundVVancomycin and dalbavancin, both in the glycopeptide class of antibiotics, are used in the treatment of Gram-positive infections, including methicillin-resistant Staphylococcus aureus. Antibiotics in this class contain a heptapeptide core that has potential for cross-sensitivity. Due to this risk, dalbavancin carries a warning in the package insert for use in patients with a glycopeptide allergy. Dalbavancin, a semi-synthetic derivative of vancomycin, has lipophilic side chains which reduce the risk of cross-sensitivity to vancomycin. This case series evaluated patients with a listed vancomycin allergy in their electronic health record who received dalbavancin as an outpatient infusion.MethodsThis study was a non-randomized, retrospective chart review of adult patients who had a documented vancomycin allergy and received dalbavancin between February 2016 and February 2021 for any indication in the outpatient setting. The primary objective was to evaluate dalbavancin tolerability in patients allergic to vancomycin. Patient characteristics and the specifics of dalbavancin infusion – dose, volume, infusion rate, intravenous line access, and receipt of premedication before infusion – were collected on each patient.Results559 unique patients received dalbavancin over the time frame. Of these, ten had a documented, subjective vancomycin allergy. Patient-reported allergic reactions were rash (4), hives (3), anaphylaxis (2), red man syndrome (2), renal failure (2), and general malaise (1). Six patients had at least 1 additional subjective drug allergy. The various infections treated included cellulitis/abscess (8), osteomyelitis (1), and bacteremia (2). Most patients received 1500mg (2 received 1125mg) of dalbavancin in 300-500mL of dextrose 5% in water infused at either 600 or 1000mL/hr via a peripheral (6) or central (4) intravenous line. All patients tolerated the infusion with no adverse events reported and no receipt of premedication before administration. ConclusionDalbavancin may be a reasonable treatment option in vancomycin allergic patients, despite possible cross-sensitivity. Further investigation into cross-sensitivity between vancomycin, dalbavancin, and other glycopeptide class agents is warranted.Disclosures Kerry O. Cleveland, M.D., AbbVie (Speaker’s Bureau)Merck (Speaker’s Bureau)Pfizer (Speaker’s Bureau) Bruce M. Jones, PharmD, BCPS, Abbvie (Consultant, Advisor or Review Panel member, Speaker’s Bureau)La Jolla (Speaker’s Bureau)Melinta (Consultant)Merck (Consultant)Paratek (Consultant, Speaker’s Bureau)

Outcomes of Infectious Endophthalmitis in Patients with Systemic Antibiotic Allergies to Penicillins, Cephalosporins, or Vancomycin

The mainstay empiric treatments of bacterial endophthalmitis are intravitreal vancomycin and ceftazidime. In the United States, up to 10% of the general population has a reported penicillin (PCN) allergy. Despite low cross-reactivity between PCN and later-generation cephalosporins, some providers alter the intravitreal antibiotic choice for endophthalmitis because of concern for allergic reactions. We evaluated the management strategies of infectious endophthalmitis in the setting of self-reported systemic antibiotic allergies and the association with adverse reactions after standard intravitreal antibiotic administration. Single-center, retrospective cohort study. All patients with endophthalmitis between 2005 and 2019 and documented PCN, PCN-analog, cephalosporin, or vancomycin allergy who received intravitreal antibiotics on the basis of International Classification of Diseases 9th and 10th Revisions, and Current Procedural Terminology codes. Retrospective chart review. Any allergic reaction after intravitreal injection, additional surgical interventions required for treatment, and visual function at last recorded visit. Of the 65 patients included in this cohort, the most common causes of endophthalmitis were postcataract extraction surgery (n = 23, 35.4%) and postintravitreal injection (n = 11, 16.9%). All patients (65/65) received intravitreal vancomycin, and 81.5% (53/65) received intravitreal ceftazidime. Of the 53 patients who received intravitreal ceftazidime, 46 (86.8%) had allergies to PCNs alone, 5 (9.4%) had a cephalosporin allergy alone, and 2 (3.8%) had reported allergies to both PCN and cephalosporin antibiotics. Two patients (3.1%) with a documented vancomycin allergy received intravitreal vancomycin without complication. No patients exhibited any systemic or local allergic reactions or complications after intravitreal injection. There were no documented allergic reactions in this cohort of patients with systemic antibiotic allergies who were treated for infectious endophthalmitis. Our findings are consistent with previous reports of a low allergic cross-reactivity between PCN and later-generation cephalosporins. Ophthalmologists should use evidence-based practices and a careful informed consent process when choosing intravitreal antibiotics for patients with specific antibiotic allergies. In the routine patient with suspected bacterial endophthalmitis, PCN allergy may not be an absolute contraindication to intravitreal cephalosporin use.

Topical vancomycin to reduce surgical-site infections in neurosurgery: Study protocol for a multi-center, randomized controlled trial

Surgical-site infections (SSIs) account for 20% of all healthcare-associated infections, are the most common nosocomial infection among surgical patients, and are a focus of quality improvement initiatives. Despite implementation of many quality care measures (e.g. prophylactic antibiotics), SSIs remain a significant cause of morbidity, mortality, and economic burden, particularly in the field of neurosurgery. Topical vancomycin is increasingly utilized in instrumented spinal and cardiothoracic procedures, where it has been shown to reduce the risk of SSIs. However, a randomized controlled trial assessing its efficacy in the general neurosurgical population has yet to be done.The principle aim of “Topical Vancomycin for Neurosurgery Wound Prophylaxis” (NCT02284126) is to determine whether prophylactic, topical vancomycin reduces the risk of SSIs in the adult neurosurgical population. This prospective, multicenter, patient-blinded, randomized controlled trial will enroll patients to receive the standard of care plus topical vancomycin, or the standard of care alone. The primary endpoint of this study is a SSI by postoperative day (POD) 30. Patients must be over 18years of age. Patients are excluded for renal insufficiency, vancomycin allergy, and some ineligible procedures. Univariate analysis and logistic regression will determine the effect of topical vancomycin on SSIs at 30days.A randomized controlled trial is needed to determine the efficacy of this treatment. Results of this trial are expected to directly influence the standard of care and prevention of SSIs in neurosurgical patients.

Piperacillin-induced Thrombocytopenia in a Dual Heart and Kidney Transplant Patient: A Case Report

BackgroundThe present study reports a case of piperacillin-induced thrombocytopenia in a dual heart and kidney transplant patient on January 28, 2016 (taking mycophenolate mofetil and tacrolimus). Before the transplant, the patient was treated with Zosyn twice, with no reports of thrombocytopenia or allergy. However, he was diagnosed with heparin-induced thrombocytopenia and vancomycin allergy during each of those hospitalizations, respectively. Eight months after the transplant, the patient presented with infectious symptoms and was started on Zosyn. ResultsOne day after starting Zosyn, the patient experienced a drop in platelet count from 6,000/μL from 216,000/μL. Platelets decreased as low as 1 on day 3 of hospitalization. Administration of mycophenolate mofetil, tacrolimus, Bactrim, vancomycin, Zosyn, ranitidine, and Rivaroxaban were discontinued. Platelet counts stabilized the day after Zosyn was discontinued and slowly increased after the patient was treated with 2 doses of intravenous immunoglobulin, 4 units of platelets, and a tapered dose of prednisone. ConclusionsThe patient was initially diagnosed with vancomycin-induced thrombocytopenia but then tested positive for antibodies to piperacillin and negative for antibodies to vancomycin and tazobactam. The patient was discharged with a diagnosis of piperacillin-induced thrombocytopenia. This case report presents a case of piperacillin-induced thrombocytopenia, previously misdiagnosed as vancomycin-induced thrombocytopenia and heparin-induced thrombocytopenia.

Characterization of Vancomycin Reactions and Linezolid Utilization in the Pediatric Population

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

Daptomycin in treatment of Methicillin-resistant Staphylococcus aureus diskitis

Sir, Daptomycin is a new lipopeptide antibiotic with potent activity against Methicillin-resistant Staphylococcus aureus. It is a bactericidal agent that has the potential to treat infections caused by multi-drug-resistant gram-positive organisms. Although the mainstay of treatment is based on glycopeptides, treatment with vancomycin is frequently reported as often unsuccessful [1–3]. We describe a case of Methicillin-resistant Staphylococcus aureus (MRSA) diskitis successfully treated with intravenous daptomycin. A 38-year-old man was admitted to our department for lumbar pain and fever. Other surgeons have submitted the patient to surgery for L5-S1 discectomy and they discharged him with empirical treatment of ceftriaxone (2 g/day). At admission to our department, he had no notable examination findings, except for fever of 39.2°C. CT revealed typical findings of diskitis (Fig. 1a) and MRSA was isolated from blood cultures. We did not perform surgical operation and preferred conservative treatment. Because of the patient’s history of vancomycin allergy, daptomycin treatment was initiated (6 mg/kg every 24 h i.v.) and treatment with other antibiotics was discontinued. Erythrocyte sedimentation rates and serum C-reactive protein levels returned to the preoperative levels, within 15 days after the initiation of the treatment. Additional blood cultures showed no growth after antibiotic therapy was initiated, and daptomycin was tolerated by patient without treatment-related adverse events. Results of follow-up cultures showed bacterial eradication, nevertheless, we decided to stop the therapy, when MR and scintigraphy with labeled leucocytes were normal to avoid the return of the infection and we needed to continue the daptomycin therapy for 92 days; he returned to his work, without any residual neurologic deficits (Fig. 1b, c). The usual therapeutic choice in cases of MRSA infections is a glycopeptide with or without rifampin, but increasing evidence indicates decreasing effectiveness of vancomycin for Staphylococcus aureus infection. [1–3]. For patients who develop a reaction to vancomycin, treatment of MRSA infections remains clinically challenging. Daptomycin has potent bactericidal activity against gram-positive bacteria, i.e., concentration-dependent. Unlike agents that are active against the cell wall, daptomycin causes rapid bactericidal activity without cell lysis, which could reduce the release of bacterial molecules and lessen the inflammatory response [1–3]. The US Food and Drug Administration has approved daptomycin for the treatment of complicated skin and skin structure infections caused by susceptible pathogens as well as for bacteremia, including right-sided endocarditis, caused by MRSA [1–4]. Other authors have reported cases of severe myopathy and acute renal failure related to daptomycin [4, 5]. Our case suggests that daptomycin is a safe and effective option for the treatment of MRSA diskitis, without treatment-related adverse events. Fig. 1 a CT showing typical findings of discitis after left interlaminar approach for L5-S1 discectomy. b MR showing no inflammatory findings, after daptomycin therapy. c Scintigraphy with labeled leucocytes showing normal findings, on this data we decided to ...

Two-stage Treatment Protocol for Isolated Septic Acetabular Cup Loosening

The aim of this study was to evaluate the treatment of isolated septic acetabular cup loosening without involvement of the prosthesis stem by insertion of an antibiotic-loaded spacer head and stem retention. Between 1999 and 2008, 13 patients (5 men, 8 women, mean age 69 years) were treated according to this regimen. S. epidermidis and S. aureus were the two most commonly identified pathogens. In 12 cases the polymethylmethacrylate spacers were impregnated with 0.5 g gentamicin + 2 g vancomycin per 40 g bone cement, except in one patient with vancomycin allergy, in whom 0.5 g gentamicin + 0.4 g teicoplanin were used. The spacers acted as hemiarthroplasties. The mean spacer head implantation time was 88 (35-270) days. At a mean follow-up of 55 (12-83) months, infection eradication was achieved in 11 out of 12 cases (91.6%). Complications included a draining sinus, and one spacer and one definitive prosthesis dislocation. One patient died after reimplantation due to cardiopulmonary decompensation.

Vancomycin-Related Eosinophilic Peritonitis

Eosinophilic peritonitis (EP) is a well-described complication of peritoneal dialysis and is often associated with either a reaction to a constituent of the dialysis system (tubing, sterilant, or solution) or an underlying bacterial or fungal reaction. EP has also been described in the setting of icodextrin use. We report a case of EP associated with intraperitoneal vancomycin used in the treatment of peritonitis secondary to methicillin-resistant Staphylococcus epidermidis. Causation was based upon temporal association, negative cultures, concomitant peripheral eosinophilia, and resolution with cessation of vancomycin. Vancomycin allergy should be considered in the differential diagnosis of EP in the right clinical context. Negative bacterial and fungal cultures are essential to exclude other etiologies.

Vancomycin Allergy Presenting as Fever of Unknown Origin

A 37-year-old woman receiving long-term hemodialysis was admitted to the hospital with a fever of unknown origin (6 weeks of unexplained, persistent, low-grade fever). Although she had received vancomycin hydrochloride 5 days before the onset of fever, the drug was not suspected as the cause because of the duration of fever, the administration of vancomycin on prior occasions without incident, and the lack of allergic stigmata. After hospitalization, vancomycin and gentamicin sulfate were administered empirically. Immediately thereafter, her temperature rose to 40 degrees C, and over the ensuing 24 hours, eosinophilia and a maculopapular rash developed that resolved entirely when antibiotic therapy was stopped and low-dose steroid therapy was instituted. The prolonged hypersensitivity reaction after a single dose of vancomycin is consistent with the greatly extended half-life of this drug in the population with end-stage renal disease and should alert physicians to the possibility of such persistent idiosyncratic reactions in this group.

Vancomycin allergy presenting as fever of unknown origin

Vancomycin allergy presenting as fever of unknown origin