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Vancomycin and Red Man Syndrome

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red man syndrome

Vancomycin is a very effective antibiotic for fighting infections, but it can cause a reaction known as red man syndrome. Also called vancomycin flushing syndrome (VFS), it occurs when the drug is given too quickly and triggers mast cells to release histamine.

Fortunately, slowing the rate of infusion will prevent or reduce red man syndrome. Studies show that pretreatment with an antihistamine such as hydroxyzine can significantly reduce erythema and pruritus.


Vancomycin is an antibiotic that can be effective at fighting nasty infections, like MRSA and Clostridium difficile. However, it can also trigger a reaction known as red man syndrome that causes itchy, red rashes on the face and neck. While not typically life threatening, the symptoms can be uncomfortable for patients. If you are taking vancomycin and notice a rash, it is important to seek treatment at a local urgent care clinic like FastMed.

The rash of red man syndrome appears about four to ten minutes after the first dose and can vary in severity from one patient to the next. Usually, it is not a sign of a serious problem and will clear up within about 20 minutes. If you are prone to experiencing this side effect, talk to your doctor about taking antihistamines before you take your first dose of the medication.

This side effect is caused by histamine release as a result of the rapid infusion of vancomycin into the bloodstream. Histamine can cause blood vessels to dilate, which leads to the itchiness and redness of the skin.

Some studies suggest that pretreatment with histamine inhibitors prevents this reaction. In a double-blind study, hydroxyzine (50 mg), ranitidine (20 mg) or placebo was given to volunteers two hours before a 1-hour infusion of vancomycin. Pretreatment with hydroxyzine and ranitidine significantly reduced the severity of the reaction. The erythema and pruritus were much less severe than those experienced with the control group, suggesting that histamine inhibitors reduce the occurrence of red man syndrome.

In a smaller, single-blind, controlled study, histamine1 and histamine2 receptor antagonists were found to be effective in reducing the frequency of this reaction. Twelve adult males received a dose of either hydroxyzine or placebo, followed by the infusion of vancomycin for one hour. The pretreatment with hydroxyzine and ranitidine prevented the onset of red man syndrome in all the participants, while the placebo-treated subjects experienced the most significant adverse reactions.

In addition to vancomycin, other antibiotics may induce this reaction. Drugs such as ciprofloxacin, amphotericin B and rifampicin are capable of inducing red man syndrome by stimulating the degranulation of mast cells and the release of histamine.


A patient with red man syndrome might have a rash that covers the face, neck and middle area of the body. The rash may seem flushed and might be itchy. It might also cause weakness, back or chest pain and a swelling under the skin called angioedema. This reaction is a type of hypersensitivity, not an allergic, reaction to the antibiotic vancomycin. Doctors use this drug to treat serious bacterial infections of the bones, lungs, skin and heart. It is also used before surgery to reduce the risk of infections of the lining of the heart.

The first symptoms of this reaction typically appear 4 to 10 minutes after a dose is started and last about seven days after the end of treatment. This reaction is usually associated with the first rapid infusion of vancomycin, but it can occur after several doses given as a slow infusion.

It is thought that the drug stimulates certain immune cells to release histamine, a chemical that causes some of the symptoms. Histamine causes the rash and other symptoms. Often the infusion of vancomycin must be stopped to stop the symptoms and a antihistamine is given.

Red man syndrome is not a dangerous condition, but it can be uncomfortable. Patients with the rash should be evaluated for signs of other problems, including infection of the blood (sepsis) and a complication of the rash called Stevens-Johnson syndrome. It can be difficult to diagnose this rare condition because it mimics many other clinical conditions.

A patient with this reaction should be treated in the hospital. In some cases, the rash can get worse and itchy. It might also sting, blister or turn into a pus-filled lesion. The doctor will check the patient for other conditions and prescribe medications to help prevent complications. The rash may be caused by other drugs, such as a steroid or a chemotherapy agent. If the rash is caused by these other medicines, it will disappear when the medication is discontinued. The rash can also be a sign of another health problem, such as a liver disease.


Vancomycin is a powerful antibiotic that helps doctors fight serious infections in the bones, lungs, skin, and muscles. It is also used to prevent infections of the lining of the heart before surgery. While the drug is very effective at fighting infection, it can also cause an unpleasant reaction known as red man syndrome. Symptoms include a red, itchy rash on the face, neck, and body that causes patients to feel flushed or hot. The symptoms typically begin within 10-30 minutes after intravenous administration of the medication and may be mild or severe.

The drug causes the reaction by triggering mast cells and basophils, which are parts of the immune system. These cells release histamine, which is the substance that causes the rash and other symptoms. This is a type of anaphylactoid reaction, but it differs from anaphylaxis in that it does not involve preformed immunoglobulin E antibodies.

In some cases, a doctor may give the patient a dose of diphenhydramine to prevent or treat red man syndrome. They can also slow down the rate of vancomycin infusion to reduce the likelihood of a reaction. However, some people still experience the reaction, even when the drug is administered slowly. Other antibiotics can also cause the same type of reaction, such as ciprofloxacin, amphotericin B, and rifampicin.

It is not possible to determine what makes a person more likely to develop red man syndrome. However, the condition appears to be based on a person’s individual immune system. People who are prone to allergic reactions in general tend to have more severe reactions. In addition, women are more likely to develop the condition than men.

It is also important to remember that having one or more risk factors does not mean that an individual will develop the condition. The condition is fairly rare and only affects a small percentage of the population. The symptoms are usually mild, but they can become more severe and can be life threatening in extreme cases. If you are prone to developing the condition, it is best to discuss this with your doctor.


The risk of red man syndrome is greatly reduced by giving a person an antihistamine before the Vancomycin infusion. This can be done orally or intravenously (difenhydramine and ranitidine). Symptoms usually appear about four to ten minutes after starting the antibiotic, and they can vary in intensity. The infusion should be stopped if symptoms occur and saline solution given immediately to help clear the skin. If severe symptoms develop, such as difficulty breathing, stridor, or hives, an epinephrine auto-injector should be administered.

Medical research shows that the symptoms of red man syndrome are caused by the overstimulation of certain immune cells in the body, known as mast cells. These cells correspond to allergic reactions and release a compound called histamine that causes the flushing and erythema of the skin. This reaction is amplified if the patient also receives drugs, such as opioid analgesics, muscle relaxants, or contrast dye, that cause mast cell activation and histamine release.

In a study of normal volunteers, pretreatment with hydroxyzine alone provided significant protection against vancomycin-induced erythema and pruritus compared to placebo. However, a combination of hydroxyzine with ranitidine offered no added benefit. PIDS recommends that the name “Red Man Syndrome” be universally removed from clinical practice and replaced with the more accurate term, “vancomycin infusion reaction.” This name is less of a racial slur and may better reflect the gender- and race-specific distribution of this adverse drug reaction.

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