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Snapshot
  • A 45-year-old man presents to the emergency room for right lower extremity cellulitis. He reports feeling feverish and malaise for the past 2 days and noticed redness and swelling along his right leg. He reports having tripped a few days ago, sustaining a cut on his foot. He denies any recent surgeries or long trips. He has a history of methicillin-resistant Staphylococcus infections. A Doppler is negative for blood clot. On physical exam, he is febrile. He is started on broad-spectrum antibiotics. He requests an anti-histamine prior to infusions, as he has previously had a flushing reaction to this particular antibiotic in the past.  (Cellulitis)
Introduction
  • Drugs
    • vancomycin
  • Mechanism of action
    • binds to D-Ala-D-Ala, a cell wall precursor, and prevents peptidoglycan formation
    • mainly bactericidal but bacteriostatic against Clostridium difficile
  • Mechanism of resistance
    • not susceptible to beta-lactamases
    • D-Ala-D-Ala mutation to D-Ala-D-Lac, preventing vancomycin from binding
  • Clinical use
    • gram-positive rods and cocci
      • especially methicillin-resistant Staphylococcus aureus (MRSA)
      • ampicillin-resistant Enterococcus
    • Clostridium difficile (oral dose)
    • often reserved for serious infections
  • Adverse effects
    • ROTN
      • Red man syndrome
        • pretreat with antihistamines and slow infusion rate
        • vancomycin directly causes degranulation of mast cells and histamine release 
        • characterized by a pruritic, erythematous rash of the face, neck, and upper trunk within minutes to days of vancomycin exposure
      • Ototoxicity
      • Thrombophlebitis
      • Nephrotoxicity
        • must be renally dosed in patients with renal impairment
    • DRESS syndrome
      • Drug Reaction with Eosinophilia and Systemic Symptoms
 

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