Vancomycin-Induced Thrombocytopenia: A Narrative Review

Abstract

Thrombocytopenia has been reported as an adverse reaction of numerous drugs. Vancomycin is often overlooked as a culprit but has been associated with several cases of thrombocytopenia that were not well described in the literature. A literature search was conducted to find reports of thrombocytopenia induced by vancomycin. Biomedical databases including 'PubMed', 'Scopus', and 'Web of Science' were searched using terms 'vancomycin', 'platelet', 'pancytopenia', 'thrombocytopenia', and 'bleeding'. English language articles published before July 2015 were included. Thirty-nine papers including 29 case reports (30 cases), five observational studies, two clinical trials, two letters, and one case series remained for final analysis. The main route of administration was intravenous infusion. This adverse reaction seems to be duration dependent with the mean time to platelet nadir count of 8 days in reported cases. The interval may be significantly shorter in re-exposure to the drug. Platelet nadir counts ranged from 2000 to 100,000/mL in patients who experienced bleeding. Vancomycin-specific antibodies were detected in 13 of 17 patients who were tested in the case reports. Based on the Naranjo Adverse Drug Reaction Probability Scale, reaction was 'definite', 'probable', and 'possible' in 1, 15, and 14 patients, respectively. Among 30 cases, vancomycin was discontinued in 29 patients and platelets returned to normal counts within 5-6 days in 17 of them; in one patient, vancomycin was not discontinued, but platelet count recovered 11 days after the nadir time. Transfusion might be recommended if severe thrombocytopenia and bleeding occurs. Intravenous immunoglobulins, corticosteroids, rituximab, and plasma exchange should be reserved for patients with resistant thrombocytopenia and severe bleeding as mentioned in a number of reports.

<p>Vancomycin in ICU Patients with Gram-Positive Infections: Initial Trough Levels and Mortality</p>

“…28 A recent review shows an association between the highest trough level of vancomycin and thrombocytopenia. 29 However, the platelet counts might be a surrogate of organ dysfunction or disease severity. 30 Aubron et al 31 indicated that peak and trough concentration was lower in patients with severe organ dysfunction.…”

Drug-Induced Thrombocytopenia Secondary to Commonly Used Antibiotics in Total Joint Arthroplasty

“…Platelet transfusion is not indicated owing to continued immune destruction of the platelets in the presence of the offending agent [3]. However, transfusion can be considered in cases of severe bleeding and platelet counts less than 20 Â 10 3 /mm 3 [2] and can be effective when performed after discontinuation of the causative agent [15].…”

“…There is no gold standard regarding testing for VIT currently; however, the standard antibiotic-induced immune thrombocytopenia (AIT) clinical and laboratory criteria are generally recommended for suspected cases. Management has typically consisted of discontinuation of the causative medication, with transfusion being the next most commonly used treatment in the case of severe bleeding and some studies estimating transfusion rates as high as 2 of 3 patients [2]. Other treatments including corticosteroids, immunoglobulins, and plasma exchange have been used; however, none of these were clinically superior in a large retrospective series of 30 patients with VIT [10].…”

“…Currently, the incidence of DITP has been reported as roughly 10 cases per 1 million patients [2]. While surgical prophylaxis for other surgeries appears to have significant precedent, the severity of and devastating consequences from infection in arthroplasty have led to continued debate regarding the selection, duration, and type of antibiotics used prophylactically.…”

“…Drug-induced thrombocytopenia (DITP) is an adverse reaction that has been reported with more than 300 medications, most commonly due to drug-dependent platelet antibodies that produce a response from the reticuloendothelial system [1,2]. Previous research has shown that DITP is an underrecognized clinical problem that can lead to severe bleeding complications [3].…”