- Email: [email protected]
Allergic Reaction or Adverse Drug Effect: Correctly Classifying Vancomycin-Induced Hypersensitivity Reactions
DANGER ZONE
ALLERGIC REACTION OR ADVERSE DRUG EFFECT: CORRECTLY CLASSIFYING VANCOMYCIN-INDUCED HYPERSENSITIVITY REACTIONS Author: Melissa A. McAuley, PharmD, BCPS, Horsham, PA Section Editor: Susan Paparella, MSN, RN
Earn Up to 10 CE Hours. See page 107.
D
uring the past 5 years, numerous reports have been submitted to the Institute for Safe Medication Practices National Medication Error Reporting Program and to Quantros MEDMARX (an adverse drug event data repository) that described errors and adverse reactions related to vancomycin. Often confusion exists about whether these events are allergic reactions or some other type of adverse event. This confusion often is evidenced by the way the adverse event is recorded and through statements by the health care professionals indicating that the response was “not red man syndrome” or that the “patient had a similar reaction previously, but it was not documented as an allergy.” Typical examples of adverse events with intravenous vancomycin doses are described in the next section.
Melissa A. McAuley is currently completing a Safe Medication Management Fellowship at the Institute for Safe Medication Practices (ISMP*). Before joining ISMP, she worked as the Emergency Medicine Clinical Pharmacy Specialist and Manager of Emergency Department Pharmacy Services at St. Mary Medical Center in Langhorne, PA. She also previously worked as the Emergency Department Clinical Pharmacist at Christiana Care Health System in Newark, DE. *ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is an international resource on safe medication practices in health care. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). The Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications. For correspondence, write: Melissa A. McAuley, PharmD, Institute for Safe Medication Practices, 200 Lakeside Dr, Suite 200, Horsham, PA 19044; E-mail: [email protected]. J Emerg Nurs 2012;38:60-2. Available online 19 September 2011. 0099-1767/$36.00 Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2011.09.010
60
JOURNAL OF EMERGENCY NURSING
Example Reports
The following statements are examples of reports of adverse events with intravenous vancomycin1,2:
• “Preoperatively, 1 gram vancomycin in 250 cc D5W
• • •
•
started at 0815 by gravity. Patient was taken to procedure room at 0840 where nurse noted patient ‘red all over’ and patient c/o itching. Vancomycin infusion by that time was completed.” “Vancomycin infused too quickly; pt suffered bradycardia, hypotension and died.” “Patient received 1 dose Vanco during dialysis & developed blotchy rash on abdomen, arms & legs.” “RN was called into room for possible allergic reaction to medication. Upon entering the room the RN noticed that vancomycin was hanging on the pole without being placed into the pump, and the bag was empty. The patient was extremely red and very itchy, with edema around eyes. Patient states that she saw moving lines on the wall and is anxious and disoriented.” “A dose of vancomycin IVPB was infused quickly resulting in red man syndrome. The premix is 200 mL with directions to infuse over 60-90 minutes. The pump was set at 250 mL/hour; infusion finished in less than 1 hour.”
Misclassification of Red Man Syndrome: Allergic Reaction or Adverse Reaction?
Vancomycin, which primarily is administered intravenously, is used to treat many life-threatening infections, including methicillin-resistant Staphylococcus aureus (MRSA)-induced sepsis, endocarditis, pneumonia, and soft tissue infections. Although vancomycin is one of the most effective antibiotics against MRSA, numerous adverse reactions are associated with its use, including ototoxicity, neutropenia, fever, anaphylaxis, thrombocytopenia, and phlebitis.3 One of the most common adverse reactions is an infusion-related reaction frequently referred to as the “red-man syndrome” (RMS) or “red-neck syndrome.”4 The aforementioned
VOLUME 38 • ISSUE 1
January 2012
McAuley/DANGER ZONE
reports are actually all descriptions of the RMS reaction, and the probable cause of these reactions is related to the rate of infusion. In patients being treated for infections, the occurence of RMS varies between 3.7% and 47%.4 Data from studies with healthy volunteers receiving 1 g of vancomycin over 60 minutes indicate that the incidence of RMS is about 80% to 95%. However, data indicate an incidence of 30% in patients given the same dose over 2 hours.5 One possible reason for these results is that infection induces a certain amount of histamine as part of the natural immune response, and having an increased histamine level is thought to downregulate the effect of vancomycin on mast cells and basophils. Studies indicate that the most severe reactions occur in patients younger than 40 years, specifically in children.4 RMS is actually an adverse reaction that is not proven to be immune mediated, but it resembles an allergic reaction and often is mistaken as such. Misclassifying RMS as an allergic reaction instead of an adverse drug reaction (ADR) and documenting this reaction incorrectly in the patient’s medication record may subsequently lead prescribers to choose alternative antibiotic treatments that may be less effective, of a broader spectrum than necessary, or more expensive.6 Adverse Drug Reactions Versus Allergic Drug Reactions
The World Health Organization defines an ADR as “a noxious and unintended response to a drug that occurs at a dose normally used in man.”7 Included in the many types of ADRs are hypersensitivity drug reactions. Hypersensitivity reactions are divided into 2 categories: (1) allergic drug reactions that result from an over-response of the immune system and (2) adverse drug effects that resemble allergic reactions in their clinical presentation but are not proven to be immune mediated.6 Examples of immune-mediated allergic reactions include anaphylaxis from penicillins, Stevens-Johnson syndrome from sulfonamides, allopurinol hypersensitivity syndrome, and serum sickness from phenytoin. Examples of nonimmune hypersensitivity reactions include shock after radiocontrast media, aspirin-induced asthma, opiate-related urticaria, and vancomycin-induced RMS.8 Hypersensitivity reactions represent about one third of all ADRs. Between 10% to 20% of hospitalized patients are affected by ADRs.6 Clinical Presentation, Etiology, and Treatment of Red Man Syndrome
The two types of hypersensitivity reactions caused by vancomycin include RMS and anaphylaxis. RMS is the most common hypersensitivity reaction. Anaphylaxis is rare, but does occur. The incidence of anaphylaxis is unknown. RMS is
January 2012
VOLUME 38 • ISSUE 1
related to the rate of infusion of vancomycin, which often results in pruritus, diffuse burning, generalized discomfort, and erythematous flushing, particularly of the face and neck (hence the name “red man syndrome”). Tachycardia, hypotension, and angioedema may be seen occasionally. Other clinical symptoms may include wheezing, dizziness, agitation, headaches, fever, paresthesia around the mouth, pain, and muscle spasms of the chest and back. Although some patients report chest pain and dyspnea in severe cases, cardiac arrest or seizures are rare. Generally, the syndrome is a mild, transient pruritus at the end of the infusion that is not reported by many patients.3,4 The release of histamine as a result of the degranulation of mast cells and basophils causes RMS. The level of histamine release is related partly to the amount and rate of the vancomycin infusion, which appears to be the cause of these allergic-like symptoms, including hypotension.9 The time to the onset of this reaction varies; signs and symptoms may appear 4 to 10 minutes after the start of an infusion or may not occur until after the infusion is completed. Symptoms usually resolve spontaneously over 1 hour to several hours after discontinuing the infusion. Symptoms often are associated with doses infused over less than 1 hour. The reaction severity may increase after subsequent doses; however, it may occur for the first time after several doses or when the drug is infused over a period of 1 hour or longer. In fact, delayed reactions have been reported at or near the end of 90- or 120-minute infusions in patients who had been undergoing vancomycin therapy for more than 7 days without a previous reaction. Case reports of RMS with intraperitoneal and oral administration of vancomycin have been published as well.4 It may be surprising to learn that other medications can cause RMS, including antibiotics such as ciprofloxacin, amphotericin B, rifampin, and teicoplanin. Combination of these antibiotics with or without vancomycin can amplify the RMS reaction. Additionally, opioids, muscle relaxants, or contrast dye with vancomycin can exacerbate RMS because these drugs also can cause the release of histamine.4 If RMS appears, the following treatment and documentation steps should be initiated: 1. Discontinue the infusion immediately and notify the prescriber. If a clinical pharmacist is available, consult him or her regarding the best treatment options. 2. Depending on the severity of the reaction, the prescriber may order diphenhydramine (Benadryl), 25 to 50 mg intravenously or orally. 3. Once the rash and itching dissipate, the prescriber may choose to restart the infusion at a slower rate and/or at a lower dosage.
WWW.JENONLINE.ORG
61
DANGER ZONE/McAuley
4. For severely hypotensive patients, antihistamines, corticosteroids, intravenous fluids, or vasopressors may be necessary. 5. Report this occurrence as an ADR or, if you are unsure how to report it, contact your clinical pharmacist and/or the pharmacy department. 6. If the electronic medical record does not include a field for an “adverse drug reaction” entry and only has an “allergy” field, confer with a pharmacist to identify the best place to document this reaction correctly as an “adverse drug reaction.” This step will help ensure that the patient receives appropriate treatment in the future when presenting for care. Preventing Red Man Syndrome
Emergency department nurses can take steps to prevent the frequency of RMS by infusing vancomycin over a period of at least 1 hour and monitoring the patient’s blood pressure during the infusion. Some hospitals have approved guidelines through their Pharmacy and Therapeutics Committees for intravenous vancomycin to be infused at a maximum rate of 1 g over 90 minutes and have added this drug to their smart pump infusion library to safeguard against incorrect rates of infusion. For patients receiving larger doses, longer infusion times should be used. The Food and Drug Administration– approved label for vancomycin states: “In studies of normal volunteers, infusion-related events did not occur when vancomycin was administered at a rate of 10 mg/min or less.”10 Patients’ increased tolerance to smaller and more frequent doses of vancomycin has been described in studies. Patients with previous reactions usually are able to receive subsequent doses without adverse effects as long as the vancomycin dose is administered at a slow rate over several hours. For these patients and patients for whom longer infusion times are not feasible in certain clinical situations, such as trauma patients who require emergency surgery, pretreatment with antihistamines (H1 and possibly H2 receptor blockers) may be beneficial.4 Some studies suggest combining an H1 receptor blocker (diphenhydramine or hydroxyzine) and an H2 receptor blocker (cimetidine) as prophylaxis against RMS.11 Correctly Classifying the Reaction
Presentation of RMS may resemble an allergic drug reaction, when in fact it is considered to be a nonimmune-
62
JOURNAL OF EMERGENCY NURSING
mediated hypersensitivity drug reaction. It is important to recognize all possible clinical symptoms of RMS and to understand how to treat and document this type of reaction.12 With the continued rise of resistant bacteria and limited antibiotic choices, it is important that patients’ adverse reactions to antibiotics not be misclassified as allergic reactions so that prescribers have the opportunity to prescribe the most narrow spectrum, safest, and most cost-effective antibiotic. REFERENCES 1. 2. 3.
Quantros. MEDMARX Data Report 2006–2011. Milpitas, CA: Quantros; 2011. Institute for Safe Medication Practices. National Medication Error Reporting Program. Horsham, PA: Institute for Safe Medication Practices; 2011. American Society of Health-System Pharmacists. Vancomycin. In: American Hospital Formulary Service Drug Information 2010. Bethesda, MD: American Society of Health-System Pharmacists; 2010:479-87.
4.
Sivagnanam S, Dirk D. Red man syndrome. Crit Care. 2003;7:119-20.
5.
Healy D, Sahai J, Fuller S, Polk R. Vancomycin-induced histamine release and “red man syndrome”: comparison of 1- and 2-hour infusions. Antimicrob Agents Chemother. 1990;34(4):550-4.
6.
Gomes E, Demoly P. Epidemiology of hypersensitivity drug reactions. Curr Opin Allergy Clin Immunol. 2005;5:309-16.
7.
World Health Organization. International drug monitoring: the role of national centres. World Health Organ Tech Rep Ser. 1972;498:1-25.
8.
Sylvia LM, DiPiro JT. Allergic and pseudoallergic drug reactions. In: Dipiro JT, Talbert RL, Yee GC, et-al, editors. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York, NY: McGraw-Hill Medical; 2011.
9.
MacDougall C, Chambers HF. Protein synthesis inhibitors and miscellaneous antibacterial agents. In: Burton LL, Chabner BA, Knollmann BC, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 12th ed. New York, NY: McGraw-Hill Professional; 2010.
10. Vancomycin [package insert]. Lake Forest, IL: Akorn-Strides; 2009. 11. Renz C, Thurn J, Finn HA, Lynch JP, Moss J. Antihistamine prophylaxis permits rapid vancomycin infusion. Crit Care Med. 1999;27: 1732-7. 12. Lee C, Zembower T, Fotis M, et al. The incidence of antimicrobial allergies in hospitalized patients. Arch Intern Med. 2000;160: 2819-22.
Submissions to this column are encouraged and may be sent to Susan Paparella, MSN, RN [email protected]
VOLUME 38 • ISSUE 1
January 2012
ALLERGIC REACTION OR ADVERSE DRUG EFFECT: CORRECTLY CLASSIFYING VANCOMYCIN-INDUCED HYPERSENSITIVITY REACTIONS Author: Melissa A. McAuley, PharmD, BCPS, Horsham, PA Section Editor: Susan Paparella, MSN, RN
Earn Up to 10 CE Hours. See page 107.
D
uring the past 5 years, numerous reports have been submitted to the Institute for Safe Medication Practices National Medication Error Reporting Program and to Quantros MEDMARX (an adverse drug event data repository) that described errors and adverse reactions related to vancomycin. Often confusion exists about whether these events are allergic reactions or some other type of adverse event. This confusion often is evidenced by the way the adverse event is recorded and through statements by the health care professionals indicating that the response was “not red man syndrome” or that the “patient had a similar reaction previously, but it was not documented as an allergy.” Typical examples of adverse events with intravenous vancomycin doses are described in the next section.
Melissa A. McAuley is currently completing a Safe Medication Management Fellowship at the Institute for Safe Medication Practices (ISMP*). Before joining ISMP, she worked as the Emergency Medicine Clinical Pharmacy Specialist and Manager of Emergency Department Pharmacy Services at St. Mary Medical Center in Langhorne, PA. She also previously worked as the Emergency Department Clinical Pharmacist at Christiana Care Health System in Newark, DE. *ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is an international resource on safe medication practices in health care. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). The Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications. For correspondence, write: Melissa A. McAuley, PharmD, Institute for Safe Medication Practices, 200 Lakeside Dr, Suite 200, Horsham, PA 19044; E-mail: [email protected]. J Emerg Nurs 2012;38:60-2. Available online 19 September 2011. 0099-1767/$36.00 Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2011.09.010
60
JOURNAL OF EMERGENCY NURSING
Example Reports
The following statements are examples of reports of adverse events with intravenous vancomycin1,2:
• “Preoperatively, 1 gram vancomycin in 250 cc D5W
• • •
•
started at 0815 by gravity. Patient was taken to procedure room at 0840 where nurse noted patient ‘red all over’ and patient c/o itching. Vancomycin infusion by that time was completed.” “Vancomycin infused too quickly; pt suffered bradycardia, hypotension and died.” “Patient received 1 dose Vanco during dialysis & developed blotchy rash on abdomen, arms & legs.” “RN was called into room for possible allergic reaction to medication. Upon entering the room the RN noticed that vancomycin was hanging on the pole without being placed into the pump, and the bag was empty. The patient was extremely red and very itchy, with edema around eyes. Patient states that she saw moving lines on the wall and is anxious and disoriented.” “A dose of vancomycin IVPB was infused quickly resulting in red man syndrome. The premix is 200 mL with directions to infuse over 60-90 minutes. The pump was set at 250 mL/hour; infusion finished in less than 1 hour.”
Misclassification of Red Man Syndrome: Allergic Reaction or Adverse Reaction?
Vancomycin, which primarily is administered intravenously, is used to treat many life-threatening infections, including methicillin-resistant Staphylococcus aureus (MRSA)-induced sepsis, endocarditis, pneumonia, and soft tissue infections. Although vancomycin is one of the most effective antibiotics against MRSA, numerous adverse reactions are associated with its use, including ototoxicity, neutropenia, fever, anaphylaxis, thrombocytopenia, and phlebitis.3 One of the most common adverse reactions is an infusion-related reaction frequently referred to as the “red-man syndrome” (RMS) or “red-neck syndrome.”4 The aforementioned
VOLUME 38 • ISSUE 1
January 2012
McAuley/DANGER ZONE
reports are actually all descriptions of the RMS reaction, and the probable cause of these reactions is related to the rate of infusion. In patients being treated for infections, the occurence of RMS varies between 3.7% and 47%.4 Data from studies with healthy volunteers receiving 1 g of vancomycin over 60 minutes indicate that the incidence of RMS is about 80% to 95%. However, data indicate an incidence of 30% in patients given the same dose over 2 hours.5 One possible reason for these results is that infection induces a certain amount of histamine as part of the natural immune response, and having an increased histamine level is thought to downregulate the effect of vancomycin on mast cells and basophils. Studies indicate that the most severe reactions occur in patients younger than 40 years, specifically in children.4 RMS is actually an adverse reaction that is not proven to be immune mediated, but it resembles an allergic reaction and often is mistaken as such. Misclassifying RMS as an allergic reaction instead of an adverse drug reaction (ADR) and documenting this reaction incorrectly in the patient’s medication record may subsequently lead prescribers to choose alternative antibiotic treatments that may be less effective, of a broader spectrum than necessary, or more expensive.6 Adverse Drug Reactions Versus Allergic Drug Reactions
The World Health Organization defines an ADR as “a noxious and unintended response to a drug that occurs at a dose normally used in man.”7 Included in the many types of ADRs are hypersensitivity drug reactions. Hypersensitivity reactions are divided into 2 categories: (1) allergic drug reactions that result from an over-response of the immune system and (2) adverse drug effects that resemble allergic reactions in their clinical presentation but are not proven to be immune mediated.6 Examples of immune-mediated allergic reactions include anaphylaxis from penicillins, Stevens-Johnson syndrome from sulfonamides, allopurinol hypersensitivity syndrome, and serum sickness from phenytoin. Examples of nonimmune hypersensitivity reactions include shock after radiocontrast media, aspirin-induced asthma, opiate-related urticaria, and vancomycin-induced RMS.8 Hypersensitivity reactions represent about one third of all ADRs. Between 10% to 20% of hospitalized patients are affected by ADRs.6 Clinical Presentation, Etiology, and Treatment of Red Man Syndrome
The two types of hypersensitivity reactions caused by vancomycin include RMS and anaphylaxis. RMS is the most common hypersensitivity reaction. Anaphylaxis is rare, but does occur. The incidence of anaphylaxis is unknown. RMS is
January 2012
VOLUME 38 • ISSUE 1
related to the rate of infusion of vancomycin, which often results in pruritus, diffuse burning, generalized discomfort, and erythematous flushing, particularly of the face and neck (hence the name “red man syndrome”). Tachycardia, hypotension, and angioedema may be seen occasionally. Other clinical symptoms may include wheezing, dizziness, agitation, headaches, fever, paresthesia around the mouth, pain, and muscle spasms of the chest and back. Although some patients report chest pain and dyspnea in severe cases, cardiac arrest or seizures are rare. Generally, the syndrome is a mild, transient pruritus at the end of the infusion that is not reported by many patients.3,4 The release of histamine as a result of the degranulation of mast cells and basophils causes RMS. The level of histamine release is related partly to the amount and rate of the vancomycin infusion, which appears to be the cause of these allergic-like symptoms, including hypotension.9 The time to the onset of this reaction varies; signs and symptoms may appear 4 to 10 minutes after the start of an infusion or may not occur until after the infusion is completed. Symptoms usually resolve spontaneously over 1 hour to several hours after discontinuing the infusion. Symptoms often are associated with doses infused over less than 1 hour. The reaction severity may increase after subsequent doses; however, it may occur for the first time after several doses or when the drug is infused over a period of 1 hour or longer. In fact, delayed reactions have been reported at or near the end of 90- or 120-minute infusions in patients who had been undergoing vancomycin therapy for more than 7 days without a previous reaction. Case reports of RMS with intraperitoneal and oral administration of vancomycin have been published as well.4 It may be surprising to learn that other medications can cause RMS, including antibiotics such as ciprofloxacin, amphotericin B, rifampin, and teicoplanin. Combination of these antibiotics with or without vancomycin can amplify the RMS reaction. Additionally, opioids, muscle relaxants, or contrast dye with vancomycin can exacerbate RMS because these drugs also can cause the release of histamine.4 If RMS appears, the following treatment and documentation steps should be initiated: 1. Discontinue the infusion immediately and notify the prescriber. If a clinical pharmacist is available, consult him or her regarding the best treatment options. 2. Depending on the severity of the reaction, the prescriber may order diphenhydramine (Benadryl), 25 to 50 mg intravenously or orally. 3. Once the rash and itching dissipate, the prescriber may choose to restart the infusion at a slower rate and/or at a lower dosage.
WWW.JENONLINE.ORG
61
DANGER ZONE/McAuley
4. For severely hypotensive patients, antihistamines, corticosteroids, intravenous fluids, or vasopressors may be necessary. 5. Report this occurrence as an ADR or, if you are unsure how to report it, contact your clinical pharmacist and/or the pharmacy department. 6. If the electronic medical record does not include a field for an “adverse drug reaction” entry and only has an “allergy” field, confer with a pharmacist to identify the best place to document this reaction correctly as an “adverse drug reaction.” This step will help ensure that the patient receives appropriate treatment in the future when presenting for care. Preventing Red Man Syndrome
Emergency department nurses can take steps to prevent the frequency of RMS by infusing vancomycin over a period of at least 1 hour and monitoring the patient’s blood pressure during the infusion. Some hospitals have approved guidelines through their Pharmacy and Therapeutics Committees for intravenous vancomycin to be infused at a maximum rate of 1 g over 90 minutes and have added this drug to their smart pump infusion library to safeguard against incorrect rates of infusion. For patients receiving larger doses, longer infusion times should be used. The Food and Drug Administration– approved label for vancomycin states: “In studies of normal volunteers, infusion-related events did not occur when vancomycin was administered at a rate of 10 mg/min or less.”10 Patients’ increased tolerance to smaller and more frequent doses of vancomycin has been described in studies. Patients with previous reactions usually are able to receive subsequent doses without adverse effects as long as the vancomycin dose is administered at a slow rate over several hours. For these patients and patients for whom longer infusion times are not feasible in certain clinical situations, such as trauma patients who require emergency surgery, pretreatment with antihistamines (H1 and possibly H2 receptor blockers) may be beneficial.4 Some studies suggest combining an H1 receptor blocker (diphenhydramine or hydroxyzine) and an H2 receptor blocker (cimetidine) as prophylaxis against RMS.11 Correctly Classifying the Reaction
Presentation of RMS may resemble an allergic drug reaction, when in fact it is considered to be a nonimmune-
62
JOURNAL OF EMERGENCY NURSING
mediated hypersensitivity drug reaction. It is important to recognize all possible clinical symptoms of RMS and to understand how to treat and document this type of reaction.12 With the continued rise of resistant bacteria and limited antibiotic choices, it is important that patients’ adverse reactions to antibiotics not be misclassified as allergic reactions so that prescribers have the opportunity to prescribe the most narrow spectrum, safest, and most cost-effective antibiotic. REFERENCES 1. 2. 3.
Quantros. MEDMARX Data Report 2006–2011. Milpitas, CA: Quantros; 2011. Institute for Safe Medication Practices. National Medication Error Reporting Program. Horsham, PA: Institute for Safe Medication Practices; 2011. American Society of Health-System Pharmacists. Vancomycin. In: American Hospital Formulary Service Drug Information 2010. Bethesda, MD: American Society of Health-System Pharmacists; 2010:479-87.
4.
Sivagnanam S, Dirk D. Red man syndrome. Crit Care. 2003;7:119-20.
5.
Healy D, Sahai J, Fuller S, Polk R. Vancomycin-induced histamine release and “red man syndrome”: comparison of 1- and 2-hour infusions. Antimicrob Agents Chemother. 1990;34(4):550-4.
6.
Gomes E, Demoly P. Epidemiology of hypersensitivity drug reactions. Curr Opin Allergy Clin Immunol. 2005;5:309-16.
7.
World Health Organization. International drug monitoring: the role of national centres. World Health Organ Tech Rep Ser. 1972;498:1-25.
8.
Sylvia LM, DiPiro JT. Allergic and pseudoallergic drug reactions. In: Dipiro JT, Talbert RL, Yee GC, et-al, editors. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York, NY: McGraw-Hill Medical; 2011.
9.
MacDougall C, Chambers HF. Protein synthesis inhibitors and miscellaneous antibacterial agents. In: Burton LL, Chabner BA, Knollmann BC, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 12th ed. New York, NY: McGraw-Hill Professional; 2010.
10. Vancomycin [package insert]. Lake Forest, IL: Akorn-Strides; 2009. 11. Renz C, Thurn J, Finn HA, Lynch JP, Moss J. Antihistamine prophylaxis permits rapid vancomycin infusion. Crit Care Med. 1999;27: 1732-7. 12. Lee C, Zembower T, Fotis M, et al. The incidence of antimicrobial allergies in hospitalized patients. Arch Intern Med. 2000;160: 2819-22.
Submissions to this column are encouraged and may be sent to Susan Paparella, MSN, RN [email protected]
VOLUME 38 • ISSUE 1
January 2012