Severe thrombocytopenia caused by vancomycin in the intensive care unit: a case report and systematic review
Guanru Wang 1a, 2†, Xiaoxiao Li 1a, 2†, Qinggang Ge1b, Chao Li 1b, Na He 1a,2, Peng Yao 2, Chuhui Wang1a, 2, Min Yi 1b, Zongyu Wang1b, Luwen Shi 2*, and Rongsheng Zhao1a, 2*
1 a Department of Pharmacy, b Department of Intensive Care Unit, Peking University Third Hospital, Beijing 100191, China
2 Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
*Correspondence: Lu-wen Shi MHPE, Email: Shilu@bjmu.edu.cn, Add: 38 Xueyuan Rd., Haidian District, Beijing, P. R. China (100191), Tel: 86-10-82265740
Rong-sheng Zhao Ph.D., Email: zhaorongsheng@bjmu.edu.cn, Add: 49 North Garden Rd., Haidian District, Beijing, P. R. China (100191), Tel: 86-10-82265810
† These authors contributed equally to this work.
Acknowledgments : We sincerely thank the patient for willing to share his therapy information and thank the multidisciplinary therapy team for offering the profound skill and high-quality patient care.
Conflicts of Interest : The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Abstract : Thrombocytopenia can cause substantial morbidity and mortality in critically ill patients. There are multiple etiology factors and various mechanisms associated with thrombocytopenia, of which drug-induced thrombocytopenia (DITP) deserves attention. Herein, we describe a case of severe thrombocytopenia during intensive care unit (ICU) hospitalization that was probable to be associated with vancomycin. In addition, clinical studies evaluating thrombocy-topenia caused by vancomycin were systematically reviewed and 6 studies with acceptable quality were included and analyzed. By revealing the process of identifying this case of DITP and re-viewing relevant clinical studies, a risk alert of vancomycin related severe hematotoxicity should be focused on.
Keywords: Vancomycin; thrombocytopenia; adverse drug reaction; critically illness; systematic review
Thrombocytopenia is defined as a platelet count below the lower limit of normal (<150 × 109/L for adults). Degrees of thrombocytopenia can be further subdivided into mild (100 × 109/L to 150 × 109/L), moderate (5 × 109/L to 9.9 × 109/L), and severe (under 5 × 109/L). In the setting of immune thrombocytopenia, a platelet count <3 × 109/L is considered to represent severe thrombocytopenia.1 Thrombocytopenia can cause substantial morbidity and mortality in critically ill patients. The incidence of thrombocytopenia in adult critically ill patients can reach 8.3% to 67.6%.2 Meanwhile, thrombocytopenia is associated to significantly increased bleeding and blood transfusion and even mortality events.3,4
There are multiple etiology factors and various mechanisms that can cause thrombocytopenia, and clinical decision-making is quite complicated. Common causes of thrombocytopenia are bone marrow suppression, primary hematological diseases, autoimmune diseases, severe infections and medications. As an increasingly cause of isolated thrombocytopenia, drug-induced thrombocytopenia (DITP) can be attributed to foods and herbal remedies besides medications.5Among the intensive care unit (ICU) patients with new-onset thrombocytopenia, medications cause can account for 16%.6 DITP is an important clinical problem for physicians, of which drug-dependent anti-body-mediated platelet destruction is one of the main mechanisms. The most implicated medications include quinine, sulfamethoxazole, penicillin and linezolid, etc.7 Vancomycin is used for gram-positive cocci infections, especially in methicillin-resistant staphylococcus aureus (MRSA) infection.8 Severe renal impairment, hypersensitivity reactions and infusion-related reactions caused by vancomycin have been widely recognized in clinical practice, while adverse reactions such as agranulocytosis and thrombocytopenia are rare and can easily be ignored.
Herein, we present a case with probable vancomycin-induced severe thrombocytopenia during ICU hospitalization. We aim to provide evidence-based references for the diagnosis and treatment of vancomycin-induced thrombocytopenia in critically ill patients.