Review of vancomycin-induced renal toxicity: an update

Comparison of acute kidney injury and clinical prognosis of vancomycin monotherapy and combination therapy with beta-lactams in the intensive care unit

Antibiotics induced acute kidney injury (AKI) risk in critically ill patients is not well known. This study aimed to evaluate the AKI development and clinical outcomes in critically ill adult patients treated with vancomycin (VAN) or combined with piperacillin-tazobactam (TZP) or meropenem (MEM). This was a retrospective study on critically ill adult patients who were given VAN, TZP or MEM and maintained for at least 48 h. The risk of AKI development and clinical outcomes were compared using the simple analysis and multivariate logistic regression. Three hundred forty patients were eligible. The incidence of any AKI was significantly higher in patients treated with VAN + TZP than those with VAN + MEM or VAN alone (52.7% vs. 27.7% vs. 25.7%; p < .0001). The adjusted odds of AKI increased 2.43-fold in VAN + TZP versus VAN, but not different in VAN + MEM versus VAN. However, AKI duration and recovery rate were not statistically different. In addition, all-cause death within 30 days after AKI onset was not significantly associated with antibiotic regimens. AKI incidence is higher in critically ill patients administered with VAN + TZP than those with VAN + MEM or VAN. However, no obvious evidence was found to prove that antibiotic-induced AKI leads to poor clinical outcomes.

Real-world effectiveness of infection prevention interventions for reducing procedure-related cardiac device infections: Insights from the veterans affairs clinical assessment reporting and tracking program

OBJECTIVE

To measure the association between receipt of specific infection prevention interventions and procedure-related cardiac implantable electronic device (CIED) infections.

DESIGN

Retrospective cohort with manually reviewed infection status.

SETTING

Setting: National, multicenter Veterans Health Administration (VA) cohort.

PARTICIPANTS

Sampling of procedures entered into the VA Clinical Assessment Reporting and Tracking-Electrophysiology (CART-EP) database from fiscal years 2008 through 2015.

METHODS

A sample of procedures entered into the CART-EP database underwent manual review for occurrence of CIED infection and other clinical/procedural variables. The primary outcome was 6-month incidence of CIED infection. Measures of association were calculated using multivariable generalized estimating equations logistic regression.

RESULTS

We identified 101 procedure-related CIED infections among 2,098 procedures (4.8% of reviewed sample). Factors associated with increased odds of infections included (1) wound complications (adjusted odds ratio [aOR], 8.74; 95% confidence interval [CI], 3.16-24.20), (2) revisions including generator changes (aOR, 2.4; 95% CI, 1.59-3.63), (3) an elevated international normalized ratio (INR) &gt;1.5 (aOR, 1.56; 95% CI, 1.12-2.18), and (4) methicillin-resistant Staphylococcus colonization (aOR, 9.56; 95% CI, 1.55-27.77). Clinically effective prevention interventions included preprocedural skin cleaning with chlorhexidine versus other topical agents (aOR, 0.41; 95% CI, 0.22-0.76) and receipt of β-lactam antimicrobial prophylaxis versus vancomycin (aOR, 0.60; 95% CI, 0.37-0.96). The use of mesh pockets and continuation of antimicrobial prophylaxis after skin closure were not associated with reduced infection risk.

CONCLUSIONS

These findings regarding the real-world clinical effectiveness of different prevention strategies can be applied to the development of evidence-based protocols and infection prevention guidelines specific to the electrophysiology laboratory.

Gentamicin and Vancomycin Interference on Results of Clinical Chemistry Parameters on Abbott Architect c8000

CONTEXT.—

Gentamicin and vancomycin are nephrotoxic antibiotics. Little is known about the influence of drug concentrations on results of clinical chemistry tests.

OBJECTIVE.—

To investigate gentamicin and vancomycin interference on results of 33 commonly measured biochemistry tests.

DESIGN.—

The study was carried out in the University Department of Chemistry, Medical School University Hospital Sestre Milosrdnice (Zagreb, Croatia). For each drug, 10 aliquots of pooled serum were prepared. In order to cover toxic concentrations, pool serum samples were spiked with drugs to obtain 0 to 50 μg/mL of gentamicin and 0 to 200 μg/mL of vancomycin. Biochemistry tests were measured in duplicate on the Architect c8000 analyzer, and drug concentrations were measured on Architect i2000 SR (both Abbott Laboratories, Abbott Park, Illinois). For each tested concentration, bias was calculated against the initial measurement. Acceptance criteria were defined as measurement uncertainty of the commercial control with the value close to the measured range of the pool sample.

RESULTS.—

For gentamicin, all bias values were below established criteria. For vancomycin, significant changes were observed for potassium, direct bilirubin, and immunoglobulin A. Significant bias was already detected at low vancomycin concentration (2.98 μg/mL) for direct bilirubin (bias = 9.7%; acceptable = 8%). Potassium bias at the highest vancomycin concentration (204.4 μg/mL) exceeded acceptance criteria (bias = 4.5%; acceptable = 4%). For immunoglobulin A, no apparent trend was observed, and bias is attributed to increased method imprecision.

CONCLUSIONS.—

Gentamicin did not interfere with the results of clinical chemistry tests. Direct bilirubin concentration is falsely increased in the presence of vancomycin, and potassium is affected at high concentrations.

Incidence of Acute Kidney Injury in Critically Ill Patients Receiving Vancomycin with Concomitant Piperacillin-Tazobactam, Cefepime, or Meropenem

Critically ill patients are frequently treated with empirical antibiotic therapy, including vancomycin and β-lactams. Recent evidence suggests an increased risk of acute kidney injury (AKI) in patients who received a combination of vancomycin and piperacillin-tazobactam (VPT) compared with patients who received vancomycin alone or vancomycin in combination with cefepime (VC) or meropenem (VM), but most studies were conducted predominately in the non-critically ill population. A retrospective cohort study that included 2,492 patients was conducted in the intensive care units of a large university hospital with the primary outcome being the development of any AKI. The rates of any AKI, as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, were 39.3% for VPT patients, 24.2% for VC patients, and 23.5% for VM patients (P < 0.0001 for both comparisons). Similarly, the incidences of stage 2 and stage 3 AKI were also significantly higher for VPT patients than for the patients in the other groups. The rates of stage 2 and stage 3 AKI, respectively, were 15% and 6.6% for VPT patients, 5.8% and 1.8% for VC patients, and 6.6% and 1.3% for VM patients (P < 0.0001 for both comparisons). In multivariate analysis, the use of vancomycin in combination with piperacillin-tazobactam was found to be an independent predictor of AKI (odds ratio [OR], 2.161; 95% confidence interval [CI], 1.620 to 2.883). In conclusion, critically ill patients receiving the combination of VPT had the highest incidence of AKI compared to critically ill patients receiving either VC or VM.

Swift Cure of a Chronic Wound Infected With Multiresistant Staphylococcus aureus in an Elderly Patient With Stage 5 Renal Disease

We present a case of a 91-year-old female with stage 5 renal disease, diabetes type 2, and considerable weakness, suffering from a 2-month-old wound infected by a multiresistant Staphylococcus aureus. The wound measured 7 cm in length, 5 cm in width, and 1.5 cm in depth, having purulent white edges and exudates exceeding the size of the wound. The systemic antibiotic use was opposing to improve the patient's clinical condition due to underlying nephrotoxicity that may have deteriorated renal failure and resistance of the infecting pathogen. The halogenated taurine (Tau) derivatives N-chlorotaurine (NCT) and N-bromotaurine (NBrT) with potent anti-inflammatory and antimicrobial efficacy were alternatively employed as combination topical treatment to provide a therapeutic solution. Each agent was applied separately with an interval of 5 minutes as a 1% spray in aqueous solution every 30 minutes during the day for 3 days. This treatment was very well tolerated and led to rapid disappearance of the purulent exudate, rapid epithelialization, and complete healing. To avoid relapse, the application was continued 4 times daily for a further 4 days. No complications occurred in the course of treatment. This case report confirms the therapeutic efficacy of NCT in chronic purulent wounds. NBrT is well tolerated, too, and can be used in combination with NCT in emergency clinical settings. Its potential as a single agent should be investigated in further studies. Advancement of wound closure by these agents proved to be life-saving for this patient. Further molecular research is needed to identify mechanisms that promote wound healing.

Impact of 13-valent pneumococcal conjugate vaccination on invasive pneumococcal disease in children under 15 years old in Madrid, Spain, 2007 to 2016: The HERACLES clinical surveillance study

Streptococcus pneumoniae is a major cause of morbidity and mortality worldwide. Using the data from the HERACLES clinical surveillance study (2007-2016), we describe the population impact of the 13-valent pneumococcal conjugate vaccine (PVC13) on invasive pneumococcal disease (IPD) in children <15 years of age in the Community of Madrid, Spain. After six years of the inclusion of PCV13 in the vaccination calendar (2010-2016), and despite changes in the Regional Immunization Programme that limited its availability, the net benefit incidence rate (IR) of IPD fell by 70.1% (IRR 0.3 [95% CI: 0.22-0.4]; p ≤ 0.001), mainly due to a significant reduction (91%) in the PCV13 serotypes (IRR 0.09 [95% CI: 0.05-0.16], p ≤ 0.001). Furthermore, no significant changes were detected in the IR of IPD caused by non-PCV13 serotypes. The IRs of the aggressive, resistant and most prevalent serotype in the analysed population, the 19A serotype, dramatically decreased from the beginning to the end of the study (98%) [IRR 0.03 (95% CI: 0.00-0.19), p ≤ 0.001], to its almost total disappearance. Remarkably, this reduction led to a pronounced decline in the percentage of cefotaxime-resistant isolates and the incidence of meningitis cases. Assessment of the clinical impact revealed a reduction in the number of all clinical presentations of IPD, confirming the effectiveness of the PCV13. Finally, PCV13 detected by PCR is predicted to have a stronger impact than the one based on culture methods, which can overlook more than 20% of cases of IPD, mainly pleural empyemas.

Vancomycin-Associated Acute Kidney Injury in Critically Ill Adolescent and Young Adult Patients

BACKGROUND

Risk factors for the development of vancomycin-associated acute kidney injury (AKI) have been evaluated in both pediatric and adult populations; however, no previous studies exist evaluating this in the critically ill adolescent and young adult patients.

OBJECTIVE

Identify the incidence of AKI and examine risk factors for the development of AKI in critically ill adolescents and young adults on vancomycin.

METHODS

This retrospective review evaluated the incidence of AKI in patients 15 to 25 years of age who received vancomycin, while admitted to an intensive care unit. Acute kidney injury in this population was defined as an increase in serum creatinine by 0.5 mg/dL or 50% from baseline. Patients who developed AKI were evaluated for specific risk factors compared to those who did not develop AKI.

RESULTS

A total of 50 patients (20 developed AKI) were included in the study. There was no difference in vancomycin daily dose or duration of vancomycin therapy. Maximum vancomycin trough (31.15 mg/dL vs 12.5 mg/dL, P = .006), percentage of patients with concurrent nephrotoxic medication (95% vs 60%, P = .012) and concurrent vasopressor (55% vs 23%, P = .029) were higher in those who developed AKI. Percentage of patients who underwent a procedure while on vancomycin (35% vs 6.7%, P = .021) was also higher within the AKI group.

CONCLUSIONS

Vancomycin-associated AKI occurred in 40% of critically ill adolescent and young adult patients. These patients may be more likely to develop vancomycin-associated AKI if they had undergone a procedure, as well as in the presence of high vancomycin trough levels, concurrent nephrotoxic agents, and concurrent vasopressor therapy.

The Effectiveness of a Vancomycin Dosing Guideline in the Neonatal Intensive Care Unit for Achieving Goal Therapeutic Trough Concentrations

Concern for bacterial resistance and treatment failure with vancomycin trough concentrations < 10 μg/mL have led guidelines to increase goal concentrations. There is a paucity of data evaluating vancomycin dosage necessary to achieve goals in the neonatal intensive care unit (NICU). We aimed to evaluate the implementation of a new vancomycin dosing guideline in improving trough target attainment. This retrospective study evaluated neonates in the NICU treated with vancomycin between January 2009 and December 2015. Therapeutic trough concentration attainment (10-20 μg/mL) was compared between neonates receiving vancomycin per old versus new dosing guidelines. Vancomycin trough concentrations, modeled pharmacodynamic target attainment, and nephrotoxicity were compared between groups. A total of 212 vancomycin trough concentrations (n = 91 old and n = 121 new guideline) were evaluated in 182 unique neonates. The mean ± standard deviation trough concentration achieved was 18.0 ± 7.3 μg/mL vs 8.9 ± 4.8 μg/mL in the new and old guidelines, respectively (P < .01). The new guideline resulted in a higher percentage of neonates achieving trough concentrations of 10 to 20 μg/mL (62% vs 29%; P < .01) and decreased the percentage of neonates with subtherapeutic trough concentrations (9% vs 69%; P < .01). Pharmacokinetic modeling identified postmenstrual age, days of life, and urine output as predictors of vancomycin clearance and resultant trough and area under the curve values (P < .01 for all). Trough concentrations >10 μg/mL ensured area under the curve /minimum inhibitory concentration >400 in >90% of neonates when bacteria minimum inhibitory concentration was ≤ 1 μg/mL. Nephrotoxicity was similar between groups (8.3% vs 7.7%; P = .99). In conclusion, a vancomycin nomogram designed to achieve trough concentration of 10 to 20 μg/mL improves pharmacodynamic target attainment in neonates in the NICU.

Clinical and Procedural Evaluation of a Pharmacy Pharmacokinetic Consult Service

PURPOSE

Though previous studies have shown benefit with pharmacist-managed dosing of antibiotics, many institutions still do not offer such services. Our objective was to determine and report novel outcomes associated with the implementation of a pharmacist-managed pharmacokinetic/pharmacodynamic consult service and to assess the impact of direct pharmacist involvement in therapeutic drug monitoring.

METHODS

Retrospective cohort study of patients who received vancomycin or an aminoglycoside in the medical intensive care unit from January 5, 2013, to January 6, 2015, divided into 2 groups: before/after implementation of the consult service on January 6, 2014.

RESULTS

Nine-hundred sixty-two patients were included. Groups were similar at baseline. There were fewer critical values after implementation of the consult service (40.8% vs 27.3%, P < .001). The intervention group had significantly more vancomycin troughs within therapeutic range (15.4% vs 32.8%, P = .019). Time from order entry to medication administration was shorter when pharmacists entered the medication order, although this difference was nonsignificant (103 minutes vs 77 minutes, P = .054).

CONCLUSION

Implementation of a pharmacist-managed dosing and monitoring program led to significantly decreased rates of critical value drug concentrations and increased rates of therapeutic concentrations, with a 25% (NS) decreased time-to-antibiotic administration, therefore demonstrating the additive value of the pharmacist-managed over pharmacist-monitored approach.

Management of community-acquired bacterial pneumonia in adults: Limitations of current antibiotics and future therapies

Community-acquired bacterial pneumonia (CABP) is one of the leading causes of morbidity and mortality in India and worldwide. Evidence indicates that Gram-positive, Gram-negative, and atypical bacteria are encountered with near-equal frequency. Despite guideline recommendations and antibiotic options for the management of CABP, burden of morbidity and mortality is high, which is attributable to a variety of factors. Failure of empirical therapy, probably because of insufficient microbial coverage, increasing bacterial resistance, and adverse effects of existing treatments, underlies the unsuccessful treatment of CABP, especially in India. Multiple novel therapies that have entered clinical development phases have potential to address some of these issues. This article discusses the current treatment guidelines in CABP, management limitations, and emerging potential treatment options in the management of CABP.

Elevated Vancomycin Trough Levels in a Tertiary Health System: Frequency, Risk Factors, and Prognosis

OBJECTIVE

To investigate the frequency of, risk factors for, and outcomes after elevated levels of vancomycin.

PATIENTS AND METHODS

We identified hospitalizations among 21,285 individuals in which intravenous vancomycin was given between August 29, 2007, and October 10, 2014. We investigated frequency and risk factors for elevated vancomycin levels (trough levels >30 mg/L) as well as associations with subsequent acute kidney injury (AKI), length of stay, and in-hospital mortality.

RESULTS

Among the 21,285 patients, the mean age was 62.9 years, and 10,478 (49.2%) were female. Trough levels of vancomycin were checked in 7422 patients, and 755 elevated levels were detected. Compared with patients with trough levels checked but no elevated levels found, those with elevated levels had longer duration of vancomycin therapy (median, 6.0 days vs 3.4 days; P<.001) and slightly higher doses (mean, 1.72 g vs 1.58 g; P<.001). Patients with higher body mass index or lower estimated glomerular filtration rate had more elevated levels. In propensity-matched analyses, patients had higher risk of incident AKI after elevated levels compared with patients without elevated levels (hazard ratio, 1.55; 95% CI, 1.09-2.20; P=.02), as well as longer subsequent length of stay (relative risk, 1.14; 95% CI, 1.02-1.28; P=.03) but similar in-hospital mortality.

CONCLUSION

In this study, elevated vancomycin levels were common, particularly in patients with higher body mass index and lower estimated glomerular filtration rate, and were associated with greater subsequent AKI and length of stay.

Parenterally administered vancomycin in 29 dogs and 7 cats (2003-2017)

Background

Vancomycin is commonly used to treat resistant bacterial infections in people. Reported adverse effects of vancomycin in people include acute kidney injury (AKI), neutropenia, and systemic allergic reaction. Given the increased incidence of vancomycin‐resistant bacterial infections in people, support is growing for restriction of vancomycin.

Objectives

To evaluate the use of intravenous (IV) vancomycin in a university teaching hospital and to describe potential adverse effects.

Animals

Twenty‐nine dogs and 7 cats.

Methods

Medical records of dogs and cats treated with IV vancomycin at the Foster Hospital for Small Animals between January 2003 and October 2017 were reviewed. Information recorded included signalment, infection source, vancomycin dosing, potential adverse effects, and outcome.

Results

Vancomycin was used to treat infections from a range of sources with a variety of dosing intervals. The most common bacterial isolates susceptible to vancomycin included Enterococcus sp. (11/36, 30.6%), methicillin‐resistant Staphylococcus aureus (8/36, 22.2%), and methicillin‐resistant Staphylococcus pseudintermedius (2/36, 5.6%). AKI occurred in 6 of 36 patients (16.7%) during vancomycin treatment but could not definitively be attributed to vancomycin treatment in any patients because of illness severity, additional nephrotoxic treatments, or both. Neutropenia or allergic reaction was not documented in any animal. In 2 of 36 patients (5.6%), susceptibility data documented an infection that was only susceptible to vancomycin. Most patients survived to discharge (25/36, 69.4%).

Conclusions and Clinical Importance

Adverse effects attributable to vancomycin were infrequent in dogs and cats. In most cases, there were potential alternative effective antimicrobials or lack of susceptibility data to support vancomycin treatment.

Pharmacokinetics of Vancomycin in Patients with Different Renal Function Levels

There are many determinants of vancomycin clearance, but these have not been analyzed separately in populations with different levels of renal function, which could be why some important factors have been missed. The aim of our study was to compare the pharmacokinetic parameters and factors that may affect vancomycin pharmacokinetics in groups of patients with normal renal function and in those with chronic kidney failure. The study used a population pharmacokinetic modeling approach, based on plasma vancomycin concentrations and other data from 78 patients with chronic kidney failure and 32 patients with normal renal function. The model was developed using NONMEM software and validated by bootstrapping. The final model for patients with impaired kidney function was described by the following equation: CL (L/h) = 0.284 + 0.000596 x DD + 0.00194 x AST, and that for the patients with normal kidney function by: CL (L/h) = 0.0727 + 0.205 x FIB. If our results are confirmed by new studies on two similar populations, these factors could be considered when dosing vancomycin in patients with chronically damaged kidneys, as well as in patients with normal kidneys who frequently require high doses of vancomycin.

Vancomycin associated acute kidney injury in pediatric patients

INTRODUCTION

Vancomycin associated acute kidney injury (vAKI) is a well known complication in pediatric patients. Identification and characterization of the incidence and risk factors for vAKI in the pediatric population would assist clinicians in potentially preventing or mitigating vAKI.

METHODS AND MATERIALS

A 6 year retrospective cohort study was designed. Patients were included if they were < 19 years of age, received vancomycin as inpatients, and had a baseline SCr and one other SCr drawn during and up to 72 hours after the discontinuation of vancomycin. Data collection included patient demographics, vancomycin doses and length of therapy, vancomycin serum concentrations, and concomitant medications. The Kidney Disease Improving Global Outcomes (KDIGO) criteria were used to characterize acute kidney injury. Descriptive statistical methods were used and ordinal logistic regression was employed to determine variables significantly associated with vAKI.

RESULTS

A total of 7,095 patients met study criteria (55.4% male, median age 4.1 years (IQR 0.67-11.2 years)). Mechanical ventilation was used in 7.9% (n = 563) and mortality was 4.9% (n = 344). A total of 153 concomitant medications were identified. A median of 5 (IQR 3-7) SCr values were obtained and median SCr prior to vancomycin was 0.39 (IQR 0.28-0.57) mg/dL (CrCl 134±58 mL/min/1.73m2). Vancomycin was administered for a median of 2 (IQR 1-3) days (14.9±1.6 mg/kg/dose). vAKI was present in 12.2% (n = 862: KDIGO stage 1 (8.30%, n = 589), KDIGO stage 2 (1.94%, n = 138) KDIGO stage 3 (1.89%, n = 134)). Mean vancomycin serum concentration at 6-8 hours after a dose for patients with vAKI (10.7±8.9 mg/L) was significantly, but not clinically different for patients with no vAKI (7.5±6.3 mg/L). (p<0.05) Ordinal logistic regression identified total dose of vancomycin, vancomycin administration in the intensive care unit, and concomitant medication administration as significant for vAKI. In particular, concomitant administration of several different medications, including nafcillin, clindamycin, and acetazolamide, were noted for strong associations with vAKI. (p<0.05).

CONCLUSIONS

Moderate to severe acute kidney injury due to vancomycin is infrequent in children and associated with concomitant medication use and total dose of vancomycin. Serum vancomycin concentrations are not useful predictors of vAKI in the pediatric population.

Preoperative antibiotics and cardiovascular implantable electronic device infection: A cohort study in veterans

BACKGROUND

Cefazolin is used as standard preoperative prophylaxis for a variety of surgical procedures that involve the skin. In contrast, vancomycin is recommended for a minority of patients, specifically those with an IgE-mediated allergy to beta-lactams and considered in patients with known colonization with methicillin-resistant Staphylococcus aureus or at high risk for such. Vancomycin, however, has been overprescribed, has nephrotoxicity risk, and may be less effective due to its inferior coverage of methicillin-susceptible S. aureus and lack of Gram-negative coverage. This study was performed to assess whether vancomycin use was associated with an increased incidence of cardiovascular implantable electronic device infection (CIEDI) as compared to that of cefazolin or other antistaphylococcal beta-lactam antibiotics.

METHODS

The VA Informatics and Computing Infrastructure database, which included all veterans who underwent CIED placement or revision between 2008 and 2015, was used. A logistic regression model was constructed to estimate the adjusted odds of CIEDI.

RESULTS

Overall, 10,454 CIED procedures were included, and 98% of them were performed in men with a mean age of 71 ± 12 years. The logistic regression analysis showed that vancomycin use alone or in combination with other antibiotics was associated with an increased risk of CIEDI (odds ratio 2.99 [1.76-5.06], P-value < 0.001), after controlling for other effects.

CONCLUSIONS

Our study revealed that among patients who received surgical site infection prophylaxis for CIED placement or revision, there was: (1) an unanticipated high rate of vancomycin use, and (2) a threefold increase in the incidence of subsequent CIEDI among vancomycin recipient.

MRSA colonization status as a predictor of clinical infection: A systematic review and meta-analysis

BACKGROUND

Vancomycin is often used as empiric therapy for methicillin-resistant Staphylococcus aureus (MRSA), but can be associated with clinically important adverse events including renal failure. MRSA colonization swabs are primarily used for infection control; their use as a diagnostic test to inform the decision to add empiric vancomycin therapy has not been well elucidated.

METHODS

We performed a Medline and Embase systematic review for peer-reviewed studies reporting the diagnostic accuracy of using MRSA colonization status to predict MRSA infections. Meta-analysis was performed using Cochrane guidelines. Grey literature was excluded.

FINDINGS

29 studies were included involving 24225 patients. In cases where the pathogen is not known to be S. aureus, specificities were greater than 85% for bacteremia, lower respiratory tract infections, skin and soft tissue infections (SSTI), and all infections pooled together. Sensitivities ranged between 54.0% and 77.5%. In cases where the pathogen is known to be S. aureus, we found studies on bacteremia and SSTI and arrived at pooled estimates of sensitivities ranging between 56.6% and 56.9%, and of specificities greater than 91%. Most importantly, for most infections in settings where the prevalence of MRSA as a causative organism is below 15%, the negative predictive value of a negative MRSA colonization swab exceeds 90%.

INTERPRETATIONS

In settings of low-moderate MRSA prevalence, negative MRSA screening swabs may prevent unnecessary vancomycin use. More research is needed to assess if this strategy can mitigate the cost of screening in areas with a low MRSA colonization rate.

Extremely high levels of vancomycin can cause severe renal toxicity

Vancomycin has usually been associated with nephrotoxicity. Generally, this toxicity is presented as proximal tubular cells injury with or without necrosis and as acute interstitial nephritis. However, development of both lesions is uncommonly described in literature. We present a case of vancomycin-induced nephrotoxicity resulting in both acute interstitial nephritis and tubular cells damage confirmed by renal biopsy. Peak and trough levels of 77.11 and 63.60 μg/mL, respectively, were obtained at the first plasma determination. After 8 more plasma determinations and several hemodialysis sessions, vancomycin levels were undetectable 1 month after therapy was stopped. To our knowledge, this is the case report with the highest vancomycin trough levels developing both lesions and describing total vancomycin washout after a biopsy-proven vancomycin toxicity. In conclusion, early vancomycin therapeutic drug monitoring should be performed in order to avoid toxicities where, as seen in our patient, antibiotic exposure could last around 1 month after last dose administration.

Serum trough level as a postmarketing quality measure of generic vancomycin products

BACKGROUND

The vancomycin trough level (VTL) is the most widely used pharmacokinetic parameter for monitoring its clinical efficacy. Whether the VTL is affected in patients receiving different vancomycin products has not previously been determined.

METHODS

From 2005 to 2015, five vancomycin products, including the innovator (designated as VAN-Lilly) and four generic versions (designated as VAN-A, VAN-B, VAN-C and VAN-D), were sequentially used in a teaching hospital. The initial VTLs were compared between patients who received different vancomycin products after propensity score (PS) weighting and matching for clinical covariates.

RESULTS

Among 8735 patients with initial VTL levels available for analysis, a significant association was identified between the VTL and different vancomycin products in children aged 1 month to 12 years (P < 0.0001). The PS weighting analysis in the paediatric group disclosed children on VAN-C had higher VTL compared to those on other four products (P = 0.0008). PS matching analysis revealed that children who received VAN-C had significantly higher VTLs than those who received VAN-Lily (P = 0.0001), VAN-A (P = 0.0008), VAN-B (P = 0.0002) or VAN-D (P = 0.0015). Furthermore, the coefficient of variation of the VTL was much greater in patients who received VAN-C than in those who received the other four versions, suggesting an unstable quality of this product.

CONCLUSION

A generic version of vancomycin generated significantly higher concentrations and greater variation of VTLs than the innovator and other generic vancomycin products in children. The VTL can serve as an indicator to monitor the quality of vancomycin products after marketing.

Fatty acid conjugated pyridinium cationic amphiphiles as antibacterial agents and self-assembling nano carriers

Most of the bacteria are on the verge of becoming resistant to available potential antibiotics. Novel approaches to combat these drug resistant bacteria are turning out to be crucial. This study aimed to synthesize novel fatty acid based cationic amphiphiles (FCA) that would serve as nano-drug carrier having intrinsic antibacterial activity. Three fatty acids oleic acid, linoleic acid and linolenic acid based cationic amphiphiles were synthesized and evaluated for antibacterial activity and cytotoxicity. The application in the delivery of vancomycin (VCM) was demonstrated using oleic based cationic amphiphilic (OCA). OCA was self-assembled in aqueous media to prepare VCM loaded OCA vesicles. The particle size, polydispersity index, zeta potential and entrapment efficiency were found to be 132.9 ± 2.5 nm, 0.167 ± 0.02, 18.9 ± 1.2 mV and 61.24 ± 1.8% respectively. The images from transmission electron microscopy (TEM) revealed that the vesicles were spherical and bilayered. The release of VCM from OCA vesicles was sustained throughout the studied period of 72 h. From in vitro studies, a significant antibacterial activity was observed for all three FCAs and it was found that, VCM loaded OCA vesicles displayed indifference and synergism against Gram positive methicillin susceptible and resistant staphylococcus aureus respectively (MRSA). In contrast to minimum inhibitory concentration (MIC) of VCM against Gram negative Escherichia coli (E. coli) and Pseudomonas aeruginosa (P. aeruginosa), the synthesized FCAs were more potent against both the strains, further there was no synergism observed against either of the strains when VCM was encapsulated in OCA vesicles. The synergism against MRSA was further confirmed in in vivo studies using mouse infection model. These findings therefore suggest that, FCAs can make promising nano-carrier systems for the delivery of antibiotics to treat infections caused by multi drug resistant bacteria.

Biopsy-proven vancomycin-induced acute kidney injury: a case report and literature review

Background

Vancomycin is the first-line antibiotic for methicillin-resistant Staphylococcus aureus and coagulase-negative strains. The risk of vancomycin-induced acute kidney injury increases with plasma vancomycin levels. Vancomycin-induced acute kidney injury is histologically characterized by acute interstitial nephritis and/or acute tubular necrosis. However, only 12 biopsy-proven cases of vancomycin-induced acute kidney injury have been reported so far, as renal biopsy is rarely performed for such cases. Current recommendations for the prevention or treatment of vancomycin-induced acute kidney injury are drug monitoring of plasma vancomycin levels using trough level and drug withdrawal. Oral prednisone and high-flux haemodialysis have led to the successful recovery of renal function in some biopsy-proven cases.

Case presentation

We present the case of a 41-year-old man with type 1 diabetes mellitus, who developed vancomycin-induced acute kidney injury during treatment for Fournier gangrene. His serum creatinine level increased to 1020.1 μmol/L from a baseline of 79.6 μmol/L, and his plasma trough level of vancomycin peaked at 80.48 μg/mL. Vancomycin discontinuation and frequent haemodialysis with high-flux membrane were immediately performed following diagnosis. Renal biopsy showed acute tubular necrosis and focal acute interstitial nephritis, mainly in the medullary rays (medullary ray injury). There was no sign of glomerulonephritis, but mild diabetic changes were detected. He was discharged without continuing haemodialysis (serum creatinine level, 145.0 μmol/L) 49 days after initial vancomycin administration.

Conclusions

This case suggests that frequent haemodialysis and renal biopsy could be useful for the treatment and assessment of vancomycin-induced acute kidney injury, particularly in high-risk cases or patients with other renal disorders.

Protective Effects of DHA-PC against Vancomycin-Induced Nephrotoxicity through the Inhibition of Oxidative Stress and Apoptosis in BALB/c Mice

The clinical use of glycopeptide antibiotic vancomycin is usually accompanied by nephrotoxicity, limiting its application and therapeutic efficiency. The aim of this study was to investigate the protection of DHA-enriched phosphatidylcholine (DHA-PC) against nephrotoxicity using a model of vancomycin-induced male BALB/c mice with renal injury by measuring death curves, histological changes, and renal function indexes. The addition of DHA in DHA and DHA-PC groups were 300 mg/kg per day on the basis of human intake level in our study. Results indicated that DHA-PC could dramatically extend the survival time of mice, while traditional DHA and PC had no significant effects. Moreover, oral administration of DHA-PC exhibited better effects on reducing vancomycin-induced increases of blood urea nitrogen, creatinine, cystatin C, and kidney injury molecule-1 levels than traditional DHA and PC. DHA-PC significantly delayed the development of vancomycin-induced renal injury, including tubular necrosis, hyaline casts, and tubular degeneration. A further mechanistic study revealed that the protective effect of DHA-PC on vancomycin-mediated toxicity might be attributed to its ability to inhibit oxidative stress and inactivate mitogen-activated protein kinase (MAPK) signaling pathways, which was associated with upregulation of Bcl-2 and downregulation of caspase-9, caspase-3, cytochrome-c, p38, and JNK. These findings suggest that DHA-PC may be acted as the dietary supplements or functional foods against vancomycin-induced nephrotoxicity.

Branched High Molecular Weight Glycopolypeptide With Broad-Spectrum Antimicrobial Activity for the Treatment of Biofilm Related Infections

There are few therapeutic options to simultaneously tackle Staphylococcus aureus and Pseudomonas aeruginosa, two of the most relevant nosocomial and antibiotic-resistant pathogens responsible for implant, catheters and wound severe infections. The design and synthesis of polymers with inherent antimicrobial activity have gained increasing attention as a safe strategy to treat multi-drug-resistant microbes. Here, we tested the activity of a new polymeric derivative with glycopolypeptide architecture (PAA-VC) bearing l-arginine, vancomycin, and colistin as side chains acting against multiple targets, which give rise to a broad spectrum antimicrobial activity favorably combining specific and nonspecific perturbation of the bacterial membrane. PAA-VC has been tested against planktonic and established biofilms of reference strains S. aureus ATCC 25923 and P. aeruginosa ATCC 15442 and susceptible or antibiotic resistant clinical isolates of the above-mentioned microorganisms. MIC values observed for the conjugate (48-190 and 95-190 nM for P. aeruginosa and S. aureus strains, respectively) showed higher efficacy if compared with the free vancomycin (MICs within 1.07-4.28 μM) and colistin (MICs within 0.63-1.33 μM). Additionally, being highly biocompatible (IC₅₀ > 1000, 430, and 250 μg mL^-1 for PAA-VC, vancomycin and colistin respectively) high-dosage can be adopted for the eradication of infections in patients. This positively influences the anti-biofilm activity of the conjugate leading to a quasi-total eradication of established clinically relevant biofilms (inhibition >90% at 500 μg mL^-1). We believe that the in vitro presented data, especially the activity against established biofilms of two relevant pathogens, the high biocompatibility and the good mucoadhesion properties, would allow the use of PAA-VC as promising candidate to successfully address emerging infections.

Retracted Article: PVT1 knockdown alleviates vancomycin-induced acute kidney injury by targeting miR-124 via inactivation of NF-κB signaling

Acute kidney injury (AKI) is a serious threat for human health and life. High dose of vancomycin (VAN) can give rise to AKI. The roles and molecular basis of long noncoding RNA plasmacytoma variant translocation 1 (PVT1) in VAN-induced AKI have been poorly defined till now. Protein levels of p65, phosphorylated p65 (p-p65), NF-κB inhibitor alpha (IκBα), phosphorylated IκBα (p-IκBα), Bcl-2 and Bax were measured by western blot assay. RNA levels of PVT1 and microRNA-124 (miR-124) were determined by RT-qPCR assay. HK-2 cell apoptosis was detected by an Annexin V-FITC apoptosis detection assay. Kidney functions were assessed by blood urea nitrogen (BUN) level, serum creatinine (Scr) level, histopathologic analysis, and TUNEL assay. Bioinformatical analysis, luciferase reporter assay, RIP and RNA pull down assays were performed to explore whether PVT1 could interact with miR-124. PVT1 was highly expressed in VAN-induced AKI models. Functional analysis revealed that PVT1 knockdown ameliorated VAN-induced AKI in vivo. Further exploration manifested that PVT1 directly interacted with miR-124. Moreover, the silencing of PVT1 abated VAN-induced HK-2 cell apoptosis in vitro, while this effect was reversed by the miR-124 inhibitor. Also, VAN treatment resulted in the reduction of miR-124 expression and the activation of NF-κB signaling in HK-2 cells. The inhibition of NF-κB alleviated VAN-induced HK-2 cell apoptosis. PVT1 activated NF-κB signaling by targeting miR-124 in VAN-induced HK-2 cells. PVT1 knockdown lessened VAN-induced AKI by targeting miR-124 via inactivating the NF-κB signaling, elucidating the critical roles and molecular basis of PVT1 in VAN-induced AKI and highlighting the diagnostic and therapeutic values of PVT1 in AKI.

PVT1 was highly expressed in the kidneys of VAN-induced AKI mice.

Vancomycin Plus Piperacillin-Tazobactam and Acute Kidney Injury in Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

The objective of this systematic review and meta-analysis was to assess acute kidney injury with combination therapy of vancomycin plus piperacillin-tazobactam, in general, adult patients and in critically ill adults. Rates of acute kidney injury, time to acute kidney injury, and odds of acute kidney injury were compared with vancomycin monotherapy, vancomycin plus cefepime or carbapenem, or piperacillin-tazobactam monotherapy.

DATA SOURCES

Studies were identified by searching Pubmed, Embase, Web of Science, and Cochrane from inception to April 2017. Abstracts from selected conference proceedings were manually searched.

STUDY SELECTION

Articles not in English, pediatric studies, and case reports were excluded.

DATA EXTRACTION

Two authors independently extracted data on study methods, rates of acute kidney injury, and time to acute kidney injury. Effect estimates and 95% CIs were calculated using the random effects model in RevMan 5.3.

DATA SYNTHESIS

Literature search identified 15 published studies and 17 conference abstracts with at least 24,799 patients. The overall occurrence rate of acute kidney injury was 16.7%, with 22.2% for vancomycin plus piperacillin-tazobactam and 12.9% for comparators. This yielded an overall number needed to harm of 11. Time to acute kidney injury was faster for vancomycin plus piperacillin-tazobactam than vancomycin plus cefepime or carbapenem, but not significantly (mean difference, -1.30; 95% CI, -3.00 to 0.41 d). The odds of acute kidney injury with vancomycin plus piperacillin-tazobactam were increased versus vancomycin monotherapy (odds ratio, 3.40; 95% CI, 2.57-4.50), versus vancomycin plus cefepime or carbapenem (odds ratio, 2.68; 95% CI, 1.83-3.91), and versus piperacillin-tazobactam monotherapy (odds ratio, 2.70; 95% CI, 1.97-3.69). In a small subanalysis of 968 critically ill patients, the odds of acute kidney injury were increased versus vancomycin monotherapy (odds ratio, 9.62; 95% CI, 4.48-20.68), but not significantly different for vancomycin plus cefepime or carbapenem (odds ratio, 1.43; 95% CI, 0.83-2.47) or piperacillin-tazobactam monotherapy (odds ratio, 1.35; 95% CI, 0.86-2.11).

CONCLUSIONS

The combination of vancomycin plus piperacillin-tazobactam increased the odds of acute kidney injury over vancomycin monotherapy, vancomycin plus cefepime or carbapenem, and piperacillin-tazobactam monotherapy. Limited data in critically ill patients suggest the odds of acute kidney injury are increased versus vancomycin monotherapy, and mitigated versus the other comparators. Further research in the critically ill population is needed.

Comparison of Acute Kidney Injury During Treatment with Vancomycin and either Piperacillin-Tazobactam or Meropenem

CONTEXT

Empiric antibiotics are often required in hospitalized patients with serious infections who may be septic and at risk for drug resistant organisms. The purpose of this study was to evaluate the observed incidence of acute kidney injury (AKI) in a sample of adult patients receiving either piperacillin-tazobactam and vancomycin or meropenemvancomycin for at least 72 hours.

METHODS

Single-center, retrospective matched cohort at a 200-bed Regional Community Medical Center. Adult patients were included in the sample if they were without preexisting renal dysfunction and admitted over an 18-month time period to receive either the combination of piperacillin-tazobactam and vancomycin or meropenem-vancomycin. Sample patients were evaluated for AKI. This condition was defined by the authors as an increase in serum creatinine of 0.5mg/ml or an increase of 50% above baseline during the duration of antibiotic treatment.

RESULTS

A total of 266 patients receiving either combination of antibiotics were evaluated for AKI. The incidence of AKI was significantly higher in the piperacillin-tazobactam and vancomycin group (n = 74/292, 25%) compared with the meropenem-vancomycin group (n=8/74, 9.5%, p=0.008).

CONCLUSIONS

The results of this study suggest that the combination of piperacillin-tazobactam and vancomycin is associated with an increased incidence of AKI. Higher vancomycin trough concentrations were associated with increased risk for development of AKI.

Glomerular filtration drug injury: In vitro evaluation of functional and morphological podocyte perturbations

The kidney is an organ that plays a major role in the excretion of numerous compounds such as drugs and chemicals. However, a great number of pharmacological molecules are nephrotoxic, affecting the efficiency of the treatment and increasing morbidity or mortality. Focusing on glomerular filtration, we propose in this study a simple and reproducible in vitro human model that is able to bring to light a functional podocyte injury, correlated with morphologic/phenotypic changes after drug exposure. This model was used for the evaluation of paracellular permeability of FITC-dextran molecules as well as FITC-BSA after different treatments. Puromycin aminonucleoside and adriamycin, compounds known to induce proteinuria in vivo and that serve here as positive nephrotoxic drug controls, were able to induce an important increase in fluorescent probe passage through the cell monolayer. Different molecules were then evaluated for their potential effect on podocyte filtration. Our results demonstrated that a drug effect could be time dependent, stable or scalable and relatively specific. Immunofluorescence studies indicated that these functional perturbations were due to cytoskeletal perturbations, monolayer disassembly or could be correlated with a decrease in nephrin expression and/or ZO-1 relocation. Taken together, our results demonstrated that this in vitro human model represents an interesting tool for the screening of the renal toxicity of drugs.

MBD2 upregulates miR-301a-5p to induce kidney cell apoptosis during vancomycin-induced AKI

Despite DNA methylation occurred in acute kidney injury (AKI), how it influenced progression of AKI remains unclear. Methyl-CpG-binding domain protein 2 (MBD2), a protein readers of methylation, was used to analyze the impact of DNA methylation on vancomycin (VAN)-induced AKI. Here, in cultured human kidney tubular epithelial cells (HK-2), we show that knockdown of MBD2 by siRNA attenuated VAN-induced apoptosis, caspase activity, and the expression of BAX and cleaved caspase 3. Interestingly, knockdown of MBD2 by siRNA was associated with the suppression of miR-301a-5p. Mechanistic studies confirmed MBD2 binds to these methylated CpG elements of miR-301a-5p promoter, and then activates miR-301a-5p promoter by suppressing methylation. Furthermore, anti-miR-301a-5p significantly blocked VAN-induced apoptosis and caspase activity in HK-2 cells, which was accompanied by downregulation of p53, and upregulation of MITF, HDGF and MDM-4 together. The latter genes were further identified as target genes of miR-301a-5p, and silencing of MDM-4 promoted p53 accumulation. In vivo, mice with MBD2 knockout (MBD2-KO) were counteracted to VAN-induced AKI, indicated by the analysis of renal function, histology, apoptosis and inflammation. MBD2-KO also significantly suppressed the expression of miR-301a-5p, p53, BAX and cleaved caspase 3, and restored the expression of MDM-4, MITF and HDGF. Finally, in vivo inhibition of miR-301a-5p also ameliorated VAN-induced AKI. Together, these results show the novel MBD2/miR-301a-5p/MITF, HDGF and MDM-4/p53 pathway in VAN-induced AKI.

The Whole Price of Vancomycin: Toxicities, Troughs, and Time

Vancomycin is a glycopeptide antibiotic that is active against Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus. Nephrotoxicity, which is usually reversible, is the most serious common adverse effect of vancomycin. Vancomycin-associated nephrotoxicity prolongs hospital stays, imposes a need for additional antibiotics and, in rare circumstances, dialysis treatment, and increases medical costs and mortality. Risk factors for nephrotoxicity include the dose and duration of vancomycin treatment, serum trough concentration, patient characteristics, and concomitant receipt of nephrotoxins. Contemporary guidelines recommend targeting vancomycin trough concentrations of ≥10 mg/L to prevent resistance and trough concentrations of 15-20 mg/L to optimize outcomes. There is significant correlation between vancomycin trough serum concentrations and the incidence of vancomycin-associated nephrotoxicity; however, evidence of an association between trough concentrations and efficacy is less convincing. Routine monitoring of serum vancomycin concentrations consumes time and limited healthcare resources and may not be cost effective. The use of alternative antibacterial agents that do not require monitoring would free up pharmacy resources. This time could then be devoted to initiatives such as pharmacist-led antibiotic stewardship programs that are known to reduce antibiotic use and promote improved patient outcomes.

Vascular Graft Impregnation with Antibiotics: The Influence of High Concentrations of Rifampin, Vancomycin, Daptomycin, and Bacteriophage Endolysin HY-133 on Viability of Vascular Cells

Background

Rifampin-soaked synthetic prosthetic grafts have been widely used for prevention or treatment of vascular graft infections (VGIs).

This in vitro study investigated the effect of the antibiotics daptomycin and vancomycin and the new recombinant bacteriophage endolysin HY-133 on vascular cells, as potential alternatives compared to rifampin.

Material/Methods

Primary human ECs, vascular smooth muscle cells (vSMC), and fibroblasts were cultivated in 96-well plates and incubated with rifampin, daptomycin, vancomycin, and endolysin HY-133 for 24 h. Subsequently, after washing, cell viability was determined by measuring mitochondrial ATP concentration. Antibiotics were used in their corresponding minimum and maximum serum concentrations, in decimal multiples and in maximum soaking concentration. The experiments were performed in triplicate.

Results

The 10-fold max serum concentrations of rifampin, daptomycin, and vancomycin did not influence viability of EC and vSMC (100 μg/ml, p>0.170). Higher concentrations of rifampin (>1 mg/ml) significantly (p<0.001) reduced cell viability of all cell types. For the other antibiotics, high concentrations (close to maximum soaking concentration) were most cytotoxic for EC and vSMC and fibroblasts (p<0.001). Endolysin did not display any cytotoxicity towards vascular cells.

Conclusions

Results of this in vitro study show the high cytotoxicity of rifampin against vascular cells, and may re-initiate the discussion about the benefit of prophylactic pre-soaking in high concentrations of rifampin. Further studies are necessary to determine the influence of rifampin on the restoration of vessel functionality versus its prophylactic effect against VGIs. Future use of recombinant phage endolysins for alternative prophylactic strategies needs further investigations.

Cilastatin attenuates vancomycin-induced nephrotoxicity via P-glycoprotein

BACKGROUND

Oxidative stress is one of the main pathogenic mechanisms in vancomycin-induced nephrotoxicity (VIN). Some studies suggest proximal renal tubular cell necrosis by vancomycin accumulation as a mechanism of nephrotoxicity, and other studies demonstrate that cilastatin has protective effects against drug-induced nephrotoxicity. We investigated whether cilastatin regulates p-gp expression and whether cilastation prevents VIN.

MATERIALS AND METHODS

We conducted an in vitro study using an immortalized proximal tubule epithelial cell line from a normal adult human kidney (HK-2) and an in vivo study using male C57BL/6J mice.

RESULTS

Vancomycin showed dose-dependent toxicity in the HK-2 cells, and cilastatin attenuated VIN. Vancomycin provoked the reactive oxygen species in a dose-dependent pattern on DCF-DA. Caspase 3/7 activity showed a dose-dependent increase at 6h. We confirmed apoptosis by Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay at 24h (vancomcyin 2mM). Cilastatin attenuated vancomycin-induced ROS production and apoptosis, and it also attenuated vancomycin-induced P-gp suppression. In vivo, vancomycin (400mg/kg, 600mg/kg IP, 7days) induced acute kidney injury, as demonstrated by elevated blood urea nitrogen and creatinine. Histological examination of the sections indicated greater tubular damage in the vancomycin-treated kidney compared with the control. TUNEL-positive cells decreased significantly in the mouse kidney with cilastatin and vancomycin. Bax/Bcl-2 ratio were significantly increased in the vancomycin-treated kidney. Cilastatin 300mg/kg treatment significantly decreased the vancomycin concentrations in the blood and kidney.

CONCLUSION

Our study showed that mechanism of VIN might be involved, at least in part, in suppressing P-gp function, and cilastatin attenuated VIN.

Effect of perioperative sodium bicarbonate administration on renal function following cardiac surgery for infective endocarditis: a randomized, placebo-controlled trial

Background

Patients with infective endocarditis (IE) have an elevated risk of renal dysfunction because of extensive systemic inflammation and use of nephrotoxic antibiotics. In this randomized, placebo-controlled trial, we investigated whether perioperative sodium bicarbonate administration could attenuate postoperative renal dysfunction in patients with IE undergoing cardiac surgery.

Methods

Seventy patients randomly received sodium chloride (n = 35) or sodium bicarbonate (n = 35). Sodium bicarbonate was administered as a 0.5 mmol/kg loading dose for 1 h commencing with anesthetic induction, followed by a 0.15 mmol/kg/h infusion for 23 h. The primary outcome was peak serum creatinine (SCr) level during the first 48 h postoperatively. The incidence of acute kidney injury, SCr level, estimated glomerular filtration rate, and major morbidity endpoints were assessed postoperatively.

Results

The peak SCr during the first 48 h postoperatively (bicarbonate vs. control: 1.01 (0.74, 1.37) mg/dl vs. 0.88 (0.76, 1.27) mg/dl, P = 0.474) and the incidence of acute kidney injury (bicarbonate vs. control: 29% vs. 23%, P = 0.584) were similar in both groups. The postoperative increase in SCr above baseline was greater in the bicarbonate group than in the control group on postoperative day 2 (0.21 (0.07, 0.33) mg/dl vs. 0.06 (0.00, 0.23) mg/dl, P = 0.028) and postoperative day 5 (0.23 (0.08, 0.36) mg/dl vs. 0.06 (0.00, 0.23) mg/dl, P = 0.017).

Conclusions

Perioperative sodium bicarbonate administration had no favorable impact on postoperative renal function and outcomes in patients with IE undergoing cardiac surgery. Instead, it was associated with possibly harmful renal effects, illustrated by a greater increase in SCr postoperatively, compared to control.

Trial registration

ClinicalTrials.gov, NCT01920126. Registered on 31 July 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1591-z) contains supplementary material, which is available to authorized users.

p53 activates miR-192-5p to mediate vancomycin induced AKI

Pathogenic role of p53 in AKI remains controversial and the underlying mechanism is unclear. Here, we tested whether the inhibition of p53 may ameliorate vancomycin (VAN) induced acute kidney injury (AKI). Mice with p53 knock out (p53-KO) were resistant to VAN induced AKI, indicated by the analysis of renal function, histology, and apoptosis. Mechanistically, AKI was associated with the upregulation of several known p53 target genes, including Bax and p21, and this association was attenuated in p53-KO mice. Furthermore, the expression of miR-192-5p was significantly decreased in the p53-KO kidney tissues. In human renal tubular epithelial cell line (HK-2), VAN induced p53 accumulation and miR-192-5p expression. Both apoptosis of HK-2 cells and expression of miR-192-5p were also suppressed by pifithrin-α. Anti-miR-192-5p significantly blocked VAN-induced apoptosis and caspase activity in HK-2 cells. Consistently, in vivo inhibition of miR-192-5p also suppressed VAN induced AKI. Thus, we provided clinical and genetic evidence that p53 was associated with the development of VAN induced AKI through upregulation of miR-192-5p.