Red man syndrome (RMS) is an anaphlylactoid reaction caused by the rapid infusion of the glycopeptide antibiotic Vancomycin (see this link) RMS consists of a pruritic erythematous rash to the face, neck, and upper torso which may also involve the extremities to a lesser degree. Symptoms may include weakness, angioedema, and chest or back pain. RMS is caused by Vancomycin through the direct and non immune mediated release of histamine from mast cells and basophils. The amount of histamine release is generally related to the dose of Vancomycin infused and the rate of infusion. RMS is generally associated with more rapid infusion rates but can be seen following slower infusion rates and after several days of transfusion.
RMS most frequently occurs with IV vancomycin but may rarely occur from oral or intraperitoneal vancomycin. It usually is related to a rapid infusion rate of vancomycin (1 gram in less than 1 hour).
Current treatment recommendations are to administer vancomycin at a rate no faster than 1 gram/hour or 10 mg/min. RMS most often begins 4 to 10 minutes from the start of the first dose of IV vancomycin. It may occur later during the infusion or begin shortly after dose completion. RMS may occur from later doses as far out as 7 days.
The increased incidence of methicillin/oxacillin-resistant Staphylococcus aureus, multiresistant Staphylococcus epidermidis, penicillin-resistant Streptococcus pneumoniae, and metronidazole-resistant Clostridium difficile has led to an increase in the use of vancomycin.
It is commonly used as IV or topical prophylaxis against Cutibacterium.
There are case studies of RMS occurring from other antibiotics such as rifampin, cefepime, teicoplanin, ciprofloxacin, and amphotericin B.
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