Desensitization vancomycin

In a patient with a positive penicillin skin test or a history of immediate hypersensitivity to penicillin, vancomycin is the agent of choice. Vancomycin, however, kills S. aureus slowly and is generally regarded as inferior to penicillinase-resistant penicillins for MSSA. Penicillin-allergic patients who fail on vancomycin therapy should be considered for penicillin desensitization. 

Vancomycin anaphylaxis is a major management problem in patients with methicillin-resistant S. aureus sepsis. However, desensitization in patients with previous anaphylaxis is possible (87). 

The authors of the second report could not exclude that the previous anaphylactoid reaction had not been due to gentamicin, as no specific testing was done. Although successful vancomycin desensitization has been described, this would be the first time in a patient with a history of anaphylactoid reaction. 

In some patients the clinical presentation of red man syndrome is identical to that of acute IgE-mediated anaphylaxis. Vancomycin desensitization should therefore be considered for severe red man syndrome reactions that do not respond to premedication and a slower rate of infusion, and in anaphylactic reactions to vancomycin when substitution of another antibiotic is not feasible. Rapid desensitization is preferred, as it is effective in the majority of patients and enables administration of vancomycin within 24 hours. In patients who fail rapid desensitization, a slow desensitization protocol may be tried (90). 

Chopra N, Oppenheimer J, Derimanov GS, Fine PL. Vancomycin anaphylaxis and snccessfnl desensitization in a patient with end stage renal disease on hemodialysis by maintaining steady antibiotic levels. Ann Allergy Asthma Immunol 2000 84(6) 633-5. 

Sorensen SJ, Wise SL, al-Tawfiq JA, Robb JL, Cushing HE. Successful vancomycin desensitization in a patient with end-stage renal disease and anaphylactic shock to vancomycin. Ann Pharmacother 1998 32(10) 1020-3. 

Wazny LD, Daghigh B. Desensitization protocols for vancomycin hypersensitivity. Ann Pharmacother 2001 35(ll) 1458-64. 

Skin testing with vancomycin and teicoplanin has not been well studied and the procedure remains to be validated with both positive and negative predictive values unknown. Skin test results, and particularly details of drug concentrations used and methodologies employed, are hard to find in the vancomycin-teicoplanin literature on adverse reactions. In a case study of vancomycin anaphylaxis followed by successful desensitization, intradermal skin tests with the drug were positive at a concentration of 0.1 pg/ml. Control subjects showed positive responses at concentrations of 10 pg/ml or greater. A loss of skin test reactivity to vancomycin has been demonstrated in one case study after successful desensitization to the drug. 

There are occasions with a drug like vancomycin when desensitization is appropriate or even required. Circumstances where desensitization would be considered include anaphylaxis to vancomycin and the difficult situation where a case of red man syndrome cannot be overcome by slowing the infusion rate of vancomycin, where premedication with histamine antagonists proves... 

Both rapid (carried out over several horns) and slow (over a period of days) desensitization protocols for vancomycin sensitivity have proved effective. 

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