The University of British Columbia, Vancouver, British Columbia, Canada.
Ann Pharmacother. 2011 May;45(5):629-38. doi: 10.1345/aph.1P583. Epub 2011 Apr 26.
To systematically evaluate the literature to determine whether vancomycin-induced neutropenia is dose- or duration-related and provide clinicians with feasible treatment alternatives.
A literature search of PubMed (1949-November 2010), MEDLINE (1950-November 2010), EMBASE (1980-November 2010), and International Pharmaceutical Abstracts (1970-November 2010) was performed using the terms vancomycin, neutropenia, and leukopenia. Citations from publications were reviewed for additional references.
Studies and case reports were included if they reported neutropenia with vancomycin administration and excluded if they did not describe vancomycin dosages and/or concentrations, or if neutropenia resolved while the patient was still receiving vancomycin. Cases with significant confounders and those in which authors provided minimal information about patients were also excluded.
Seven retrospective chart reviews (ie, case series) and 33 case reports were identified. Of these, 3 retrospective reviews and 26 case reports met inclusion criteria. To our knowledge, no prospective studies have assessed this clinical complication. Data suggest that vancomycin-induced neutropenia may not be completely related to daily dosages, total cumulative dosage, or supratherapeutic vancomycin concentrations. Furthermore, evidence suggests that neutropenia is more likely associated with therapy longer than 7 days, with the majority of episodes occurring beyond 20 days of therapy. Given these findings, a practical approach is to monitor white blood cell (WBC) count with a differential (including absolute neutrophil count) once a week in patients who are receiving vancomycin for more than 7 days.
Vancomycin-induced neutropenia is most likely associated with prolonged vancomycin exposure. Patients receiving vancomycin for longer than 7 days should have WBC count, differential, monitored weekly. Vancomycin should be discontinued if there is a high clinical suspicion of it causing neutropenia, and an alternative agent should be initiated. Prospective case-controlled studies are needed to better characterize this adverse event.
系统评估文献以确定万古霉素诱导性中性粒细胞减少症是否与剂量或时间有关，并为临床医生提供可行的治疗选择。
通过使用万古霉素、中性粒细胞减少症和白细胞减少症等术语，对 PubMed（1949 年-2010 年 11 月）、MEDLINE（1950 年-2010 年 11 月）、EMBASE（1980 年-2010 年 11 月）和国际药学文摘（1970 年-2010 年 11 月）进行了文献检索。查阅出版物中的参考文献以获取更多参考文献。
如果研究报告中提到了万古霉素治疗后发生中性粒细胞减少症，则将其纳入研究；如果研究报告未描述万古霉素剂量和/或浓度，或者患者在接受万古霉素治疗的同时中性粒细胞减少症已得到解决，则将其排除。还排除了存在明显混杂因素的病例和作者提供的患者信息极少的病例。
确定了 7 项回顾性图表审查（即病例系列）和 33 份病例报告。其中，有 3 项回顾性研究和 26 份病例报告符合纳入标准。据我们所知，尚无前瞻性研究评估这种临床并发症。数据表明，万古霉素诱导性中性粒细胞减少症可能与每日剂量、总累积剂量或超治疗性万古霉素浓度不完全相关。此外，有证据表明，中性粒细胞减少症更可能与治疗时间超过 7 天有关，大多数病例发生在治疗超过 20 天后。鉴于这些发现，一种实用的方法是，对于接受万古霉素治疗超过 7 天的患者，每周监测一次白细胞（WBC）计数和分类计数（包括绝对中性粒细胞计数）。如果高度怀疑万古霉素引起中性粒细胞减少症，应停止使用万古霉素，并开始使用替代药物。需要进行前瞻性病例对照研究以更好地描述这种不良事件。
