Vancomycin infusion reaction


  • Also known as Vancomycin Flushing Syndrome or "Red Man Syndrome"[1]
  • Anaphylactoid reaction after the rapid infusion of Vancomycin
    • Predominantly seen in intravenous infusions, may occur via oral administration in patients with impaired kidney function
    • Vancomycin triggers the direct release of histamine from mast cells and basophils
    • Different from anaphylaxis in that reaction is not IgE-Mediated, does not preclude future administration
  • Related to the rate of infusion
    • Should be administered at a rate no faster than 10mg/minute (minimum of 1g over 100 minutes)
    • Increased incidence when co-administering with opioids, radiocontrast dye, and some muscle relaxers

Clinical Features

Rash found in Vancomycin Infusion Reaction.

Differential Diagnosis

Erythematous rash



  • Typically not needed


  • Clinical
    • Rule out from Anaphylaxis
    • Assess presence/degree of angioedema
  • Mild cases include pruritis and erythema
  • Moderate to severe cases include hypotension, angioedema, chest pain and dyspnea


  • Immediately stop transfusion
  • Supportive care
    • IV H1/H2 blockers
    • IVF for transient hypotension, if hypotension prolonged consider anaphylaxis
  • In mild cases, infusion may be restarted after symptom resolution (typically ~20 minutes)
  • In moderate to severe cases, consider pre-medicating after an hour or switching to an alternative antibiotic
  • If patients require rapid infusion of vancomycin, consider pre-medication with diphenhydramine and cimetidine.


  • No observation period needed after resolution of symptoms
  • Important to education patient to avoid future diagnosis of vancomycin allergy

See Also

External Links


  1. Alvarez-Arango, S, Ogunwole, SM, Sequist, TD, Burk, CM, Blumenthal, KG. Vancomycin infusion reaction—moving beyond “red man syndrome.” N Engl J Med. 2021;384:1283-1286. doi:10.1056/NEJMp2031891
  • Martel TJ, Jamil RT, King KC. Vancomycin Flushing Syndrome. [Updated 2023 Jan 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
  • Sivagnanam S, Deleu D. Red man syndrome. Crit Care. 2003 Apr;7(2):119-20. doi: 10.1186/cc1871. Epub 2002 Dec 23. PMID: 12720556; PMCID: PMC270616.