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.