Red Man Syndrome

• Occurs principally with parenteral administration but also had linked

with oral administration.
• Usually a rate-related infusion reaction.
• Histamine-mediated flushing during or immediately following infusion
of vancomycin. The extent of histamine release is related to the
amount of medication and rate at which vancomycin is infused.
(Martel, Jamil, & King, 2019)
• Signs of red man syndrome
would appear about 4–10
min after an infusion started
or may begin soon after its
completion.
• Delayed reactions = at or
near the end of a 90 or 120
min infusion in patients who
had been on vancomycin
therapy for longer than 7
days without prior incident.
(Sivagnanam & Deleu, 2003)
 To avoid Red Man
Syndrome…
It has been suggested that vancomycin
should be infused at a rate below than 10
mg/minute or for a one gram dose, over
a minimum of 100 minutes (whichever
results in a slower infusion)
(Choi & Weller, 2016)
Pathophysiology
VC is an antibiotic that Mast cells and basophils
interfere with immune are the storage granules
system cells. for Histamine
Another studies suggested that,
histamine metabolism may also be
delayed due to inhibition of
histamine N-methyltransferase
and diamine oxidase enzymes thus
lead to elevated level of
histamine.
(Martel, Jamil, & King, 2019)
Histamine is the signal
molecules of the immune
system and responsible in
the development of
inflammation.
Excessive histamine in the
circulation causes
symptom associated with
Red Man Syndrome.
Pretreatment with antihistamines reduces the incidence and
severity of RMS, although the optimal regimen has not been
determined:
• RMS was completely prevented in a group of patients receiving 1 g of
vancomycin over 1 hour in which the hypersensitivity reaction was
observed in 47% of the placebo group while zero in patients pre-
treated with 50 mg diphenhydramine orally.
• In a randomized trial in 30 presurgical patients administered with very
rapid infusions (1 gram over 10 minutes) as well as premedication
with both H1 and H2 antihistamines, it is reported that the incidence
of RMS were significantly lower than the placebo group. Fifty percent
of the placebo group also developed hypotension which was not
observe in group pre-treated with antihistamine.
(Choi & Weller, 2016)
 SEVERITY OF RMS
Management Mild cases (mild flushing and
mild pruritus)
Moderate to severe cases
(severe rash, hypotension,
tachycardia, chest pain, back
pain, muscle spasms,
weakness, angioedema) should
be managed according to
severity.
MANAGEMENT
• Diphenhydramine 50 mg orally or IV +
IV Ranitidine 50 mg .
Most episodes will resolve within 20
minutes, and the vancomycin may be
restarted at 50% of the original rate.
Future doses should be given at the new,
slower rate, typically over 2 hours
• Evaluate for anaphylaxis or serious
cause for the symptoms,
• If confirmed RMS, start IV
Diphenhydramine 5IV + IV Ranitidine.
• IV Bolus NS to treat hypotension.
• After symptoms resolved, restart IV VC
over 4 hours.
• If alternatives abx for VC available,
used it.
• If vancomycin must be continued,
patients should be premedicated with
the antihistamine 1 hour before each
dose and VC should be administered
over 4 hours under close observation.
(Martel, Jamil, & King, 2019)
References
• Choi, E. I., & Weller, P. . (2016). Vancomycin hypersensitivity.
UpToDate. Retrieved from
http://www.uptodate.com/contents/vancomycin-hypersensitivity
• Martel, T. J., Jamil, R. T., & King, K. C. (2019). Red Man Syndrome.
StatPearls. StatPearls Publishing. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/29494112
• Sivagnanam, S., & Deleu, D. (2003). Red man syndrome. Critical Care
(London, England), 7(2), 119–120. https://doi.org/10.1186/CC1871