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Clinical Summary

Vancomycin has activity against gram-positive bacteria with little to no activity against gram-negative bacteria or mycobacteria. It is poorly absorbed after oral administration, although it may be used orally for treatment of pseudomembranous colitis. Intravenous administration is the most common route. This is well tolerated with minimal burning at the site of the intravenous line; however, rapid infusion may occasionally cause degranulation of mast cells and basophils. As a result, the patient experiences erythematous flushing, particularly of the face and neck, hence the name “red man syndrome.” Tachycardia and hypotension may occasionally be seen.

Management and Disposition

Slowing the intravenous infusion usually resolves the flushing. Increasing the dilution of vancomycin in solution may also assist with preventing the flushing. Diphenhydramine has been used for treatment and may be used as a pretreatment.


  1. The differential diagnosis for flushing includes scombroid poisoning, disulfiram reactions, niacin, and hydroxocobalamin infusions.

  2. Concomitant administration of aminoglycoside with vancomycin may increase the risk of nephrotoxicity.

FIGURE 17.62

Red Man Syndrome. Facial and neck flushing are manifestations that may be seen with red man syndrome from intravenous vancomycin infusion. (Photo contributor: R. Jason Thurman, MD.)

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