Description Of The Patient Case: The Patient Is A 26-Year-Ol

Description Of The Patient Casethe Patient Is A 26 Year Old Male Who

The patient is a 26-year-old male who presented to the emergency room (ER) with worsening right elbow bursitis. He initially visited the ER two days prior for the same issue, during which a drainage procedure was performed, removing only 1cc of fluid, and he was started on oral Keflex (cephalexin). Fluid obtained during the procedure was sent for culture to identify potential infective organisms. Since the initial visit, the patient's symptoms worsened, with increased pain and spreading erythema around the elbow. He also reported intermittent numbness and tingling in the fingers of his right hand. The patient returned to the ER due to concerns about a possible advancing infection.

He denied experiencing systemic symptoms such as fever or chills, and reported no tobacco or alcohol use. Despite the initial antibiotic therapy, the patient’s condition did not improve, indicating possible resistance or inadequate response to oral antibiotics. The prescribed dose of Keflex was 500 mg taken orally four times daily (QID) for five days. Given the persistence and progression of his symptoms, inpatient management was initiated, including intravenous (IV) vancomycin therapy.

Factors Influencing Pharmacokinetics and Pharmacodynamics in the Patient

In the inpatient setting, the patient received a loading dose of vancomycin at 1.5 grams IV, followed by maintenance doses of 1 gram IV every 12 hours, calculated at 15 mg/kg dosing based on his weight. During the initial infusion, the patient developed a mild adverse reaction characterized by a pruritic rash on the abdomen—commonly associated with vancomycin infusion reactions. This reaction was managed successfully with oral diphenhydramine (Benadryl), which was administered preemptively before subsequent doses. The infusion rate was slowed to mitigate symptoms, illustrating the importance of infusion rate adjustment in managing vancomycin-related adverse effects.

One critical factor affecting the patient's reaction was the rate of IV infusion. Vancomycin infusion reactions are often attributed to “Red Man Syndrome,” which is caused by non-IgE mediated degranulation of mast cells and basophils, leading to histamine release (Rivera & Ryan, 2022). This syndrome presents with flushing, hypotension, and pruritus and can be prevented or reduced by slowing the infusion rate and pretreating with antihistamines. Evidence also suggests gender differences in the susceptibility to Red Man Syndrome, with male patients being more predisposed than females (Alvarez-Arango et al., 2021). Furthermore, racial disparities have been observed, with White patients more likely to experience this reaction compared to non-White patients, underscoring the importance of personalized care based on patient demographics.

A Personalized Plan of Care for the Patient

Considering the patient's response to vancomycin and the risk of infusion-related reactions, a personalized plan of care emphasizes vigilant monitoring for adverse effects, appropriate dose adjustments, and premedication strategies. Continuation of vancomycin at 1 gram IV every 12 hours was deemed necessary for adequate coverage against suspected resistant organisms based on the clinical picture. To minimize the risk of Red Man Syndrome, the infusion duration was extended to 120 minutes, allowing for a more gradual administration of the drug, which has been shown to significantly reduce the incidence and severity of infusion reactions (Rosenthal & Burchum, 2021).

Pre-treatment with 50 mg of oral diphenhydramine was implemented before each vancomycin infusion to further prevent hypersensitivity reactions. Moreover, close monitoring of vital signs and patient symptoms during administration was established to promptly identify and manage any reactions. Education was provided to the patient regarding potential allergic or adverse reactions and instructions to report symptoms such as rash, itching, or difficulty breathing immediately.

This approach reflects an individualized and evidence-based strategy, balancing the need for effective antimicrobial therapy with the patient's safety and tolerability. Pharmacists and clinicians should also consider other factors such as renal function, as vancomycin pharmacokinetics can be significantly affected by renal clearance, impacting serum drug levels and toxicity risk. Therapeutic drug monitoring (TDM) was scheduled to guide dosing adjustments throughout treatment.

Conclusion

Managing complex infections such as severe bursitis with suspicion of resistant organisms requires a comprehensive understanding of pharmacokinetic and pharmacodynamic principles. Individual patient factors, including gender, race, and response to therapy, influence the likelihood of adverse reactions like Red Man Syndrome. Tailoring care through infusion rate adjustment, premedication, and regular monitoring enhances treatment efficacy while minimizing adverse events. This case illustrates the importance of a personalized approach to antibiotic therapy, integrating current evidence with patient-specific considerations to optimize outcomes and ensure safety.

References

• Alvarez-Arango, S., Michelle, O. S., Sequist, T. D., & Burk, C. M. (2021). Vancomycin infusion reaction — moving beyond “Red man syndrome”. The New England Journal of Medicine, 384(14). https://doi.org/10.1056/NEJMc2103420
• Rivera, C. G., & Ryan, K. L. (2022). Call to Pharmacists: End Use of “Red Man Syndrome”. Annals of Pharmacotherapy, 56(1), 102–103.
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