Exchange transfusion and multidose activated charcoal following vancomycin overdose

Abstract

The inadvertent administration of a concentrated vancomycin solution to a 47 day-old premature male twin resulted in extremely high vancomycin levels and altered renal function. A 1.5 volume exchange transfusion did not change the measured vancomycin level. Multiple doses of oral activated charcoal, 1 g/kg, were administered beginning 5 h after the exchange transfusion. A calculated half-life of vancomycin before the exchange transfusion was 35 h. The half-life after the exchange transfusion and during charcoal administration was calculated to be 12 h. The only apparent adverse effect of this vancomycin overdose was reversible nephrotoxicity. The infant's hearing, tested by brainstem auditory responses, was normal. The higher volume of distribution of vancomycin in infants may preclude removing significant amounts of this drug by exchange transfusion. Gastrointestinal dialysis with activated charcoal warrants consideration in cases of vancomycin overdose in neonates.

How to use vancomycin optimally in neonates: remaining questions

“…Audiometric studies performed in 12 neonatal and pediatric patients receiving up to 21 days of vancomycin therapy showed no evidence of ototoxicity [55]. Even though an inadvertent overdose of vancomycin was given to a 47-day-old, premature infant, which resulted in extremely high concentrations, brainstem auditory evoked responses revealed that the infant's hearing was normal [56]. Moreover, De Hoog et al found that exposure to vancomycin was not associated with failure of automated auditory brainstem response in neonatal hearing screening [57].…”

Large Vancomycin Overdose in Two Premature Infants with Minimal Toxicity

“…parenteral overdose of vancomycin in attempts to minimize or avoid toxicity. [22][23][24][25][26][27] We report two premature infants who attained peak plasma vancomycin concentrations > 300 mg/mL following accidental overdose, and recovered uneventfully with no specific interventions to accelerate vancomycin clearance.…”

Treatment of paediatric vancomycin intoxication: a case report and review of the literature

“…A significant drawback of this therapy for children is the large extracorporeal blood volume required. Gastric dialysis with MDAC, which decreases the half-life of vancomycin, has also been successful in infants with decreased baseline renal function (see Supplementary Table T3; Cases 7 and 8) [15,16]. While cumbersome and time consuming, this approach can provide significant R V and a T 1/2 that is similar to that obtained with CRRT.…”

“…While cumbersome and time consuming, this approach can provide significant R V and a T 1/2 that is similar to that obtained with CRRT. Exchange transfusion with 1.5 blood volume equivalent was ineffective at clearing P Vanco in one reported case of vancomycin overdose [15]. …”