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Vancomycin-induced neutropenia during treatment of endocarditis in a pediatric patient
1Department of Pharmacy, University of California San Diego Medical Center.
Insights
Vancomycin therapy can cause reversible neutropenia in children, even with adjusted dosing. This drug-induced neutropenia, possibly immune-based, resolved after discontinuing vancomycin.
Area of Science:
- Pediatric Pharmacology
- Hematology
- Infectious Diseases
Background:
- Vancomycin is a critical antibiotic for treating serious infections in children.
- Neutropenia, a low white blood cell count, can increase infection risk.
- Drug-induced neutropenia is a known adverse effect of some medications.
Observation:
- A 2-year-old boy developed neutropenia during long-term vancomycin treatment for presumed endocarditis.
- His absolute neutrophil count (ANC) dropped significantly, reaching a nadir of 459 x 10(6) cells/L.
- Vancomycin serum levels remained within the therapeutic range throughout treatment.
Findings:
- Neutropenia resolved within 5 days of discontinuing vancomycin, with ANC returning to normal levels.
- The case suggests a potential link between vancomycin and neutropenia in pediatric patients, even with weight- and age-adjusted dosing.
- The mechanism is hypothesized to be immunologically mediated and not directly related to vancomycin concentrations.
Implications:
- Vancomycin should be considered a potential cause of neutropenia in children undergoing long-term therapy.
- Further research is needed to confirm vancomycin as the causative agent in pediatric neutropenia.
- Monitoring ANC is crucial in pediatric patients receiving prolonged vancomycin treatment.
Objective:
To report a case of reversible vancomycin-associated neutropenia occurring during long-term therapy with vancomycin using weight and age-adjusted dosing.
Case Summary:
A 2-year-old boy was started on vancomycin therapy for presumed endocarditis resulting from his ventriculoseptal defect. After 18 days of treatment, neutropenia with an absolute neutrophil count (ANC) of 990 x 10(6) cells/L was noted. The neutropenia progressed over the next 3 days and reached a nadir concentration of 459 x 10(6) cells/L. Vancomycin therapy was discontinued after 17 days (antibiotic day 20). A rise in the ANC occurred within 2 days of discontinuation. An improved ANC of 1672 x 10(6) cells/L occurred within 5 days. Vancomycin serum concentrations remained within an acceptable range: a peak of 30 micrograms/mL and a trough of 9 micrograms/mL.
Discussion:
Case reports in the literature of vancomycin-associated neutropenia in adults were briefly reviewed and compared. The onset and resolution and mechanism of vancomycin-induced neutropenia were studied. The potential relationship between vancomycin, weight-, and age-adjusted dosing and the occurrence of neutropenia in our pediatric patient was postulated.
Conclusions:
Vancomycin is identified as a possible cause of drug-induced neutropenia. More data are needed that clearly indicate vancomycin as the offending agent in children. The vancomycin-induced neutropenia is believed to be immunologically based and independent of drug concentrations.