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Yang W, Zhang K, Chen Y, Fan Y, Zhang J. Is It Still Beneficial to Monitor the Trough Concentration of Vancomycin? A Quantitative Meta-Analysis of Nephrotoxicity and Efficacy. Antibiotics (Basel) 2024; 13:497. [PMID: 38927164 PMCID: PMC11200798 DOI: 10.3390/antibiotics13060497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
This study conducted a quantitative meta-analysis to investigate the association of vancomycin indicators, particularly area under the curve over 24 h (AUC24) and trough concentrations (Ctrough), and their relationship with both nephrotoxicity and efficacy. Literature research was performed in PubMed and Web of Science on vancomycin nephrotoxicity and efficacy in adult inpatients. Vancomycin Ctrough, AUC24, AUC24/minimum inhibitory concentration (MIC), nephrotoxicity evaluation and treatment outcomes were extracted. Logistic regression and Emax models were conducted, stratified by evaluation criterion for nephrotoxicity and primary outcomes for efficacy. Among 100 publications on nephrotoxicity, 29 focused on AUC24 and 97 on Ctrough, while of 74 publications on efficacy, 27 reported AUC24/MIC and 68 reported Ctrough. The logistic regression analysis indicated a significant association between nephrotoxicity and vancomycin Ctrough (odds ratio = 2.193; 95% CI 1.582-3.442, p < 0.001). The receiver operating characteristic curve had an area of 0.90, with a cut-off point of 14.55 mg/L. Additionally, 92.3% of the groups with a mean AUC24 within 400-600 mg·h/L showed a mean Ctrough of 10-20 mg/L. However, a subtle, non-statistically significant association was observed between the AUC24 and nephrotoxicity, as well as between AUC24/MIC and Ctrough concerning treatment outcomes. Our findings suggest that monitoring vancomycin Ctrough remains a beneficial and valuable approach to proactively identifying patients at risk of nephrotoxicity, particularly when Ctrough exceeds 15 mg/L. Ctrough can serve as a surrogate for AUC24 to some extent. However, no definitive cut-off values were identified for AUC24 concerning nephrotoxicity or for Ctrough and AUC24/MIC regarding efficacy.
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Affiliation(s)
- Wanqiu Yang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Kaiting Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yuancheng Chen
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China;
| | - Yaxin Fan
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
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Annasamudram A, Janyavula A, Elhessy A, Shrestha R, Gesheff M, Conway J. Local delivery of linezolid in the treatment of complex orthopedic bone and joint infections in patients with vancomycin allergy: a case series. J Bone Jt Infect 2024; 9:121-126. [PMID: 38779579 PMCID: PMC11106764 DOI: 10.5194/jbji-9-121-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/18/2024] [Indexed: 05/25/2024] Open
Abstract
Introduction: Osteomyelitis is a challenging bone infection associated with ischemia, trauma, or various surgical procedures (e.g., joint reconstruction). Treatment involves eradicating infected bone and soft tissue, local antibiotic delivery, and a 6-week course of antibiotics. Methicillin-resistant Staphylococcus aureus (MRSA) infections are common, and vancomycin is the standard treatment, but alternatives like linezolid are needed in vancomycin-resistant and vancomycin-allergic patients. Methods: A retrospective chart review was conducted on patients treated by the senior author between 2013 and 2021. The study included patients who received local delivery of linezolid for bone and/or joint infection with documented evidence of vancomycin allergy. Patient demographics, surgical details, linezolid delivery method, and outcomes were recorded. Clinical outcomes and subsequent procedures leading to infection eradication were documented. Results: A total of 13 patients were treated with linezolid-antibiotic-laden spacers with polymethyl methacrylate (PMMA) carrier. Nine patients were successfully treated using limb-salvage techniques and were still infection-free after a mean follow-up of 55.5 months. Conclusions: Linezolid-loaded bone cement is an option for managing chronic bone and joint infections, particularly MRSA, in patients with vancomycin allergy.
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Affiliation(s)
- Abhijith Annasamudram
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Aja Janyavula
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Ahmed H. Elhessy
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Raj Krishna Shrestha
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Martin Gesheff
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Janet D. Conway
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
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Ling J, Yang X, Dong L, Jiang Y, Zou S, Hu N. Utility of cystatin C and serum creatinine-based glomerular filtration rate equations in predicting vancomycin clearance: A population pharmacokinetics analysis in elderly Chinese patients. Biopharm Drug Dispos 2024; 45:58-68. [PMID: 38319316 DOI: 10.1002/bdd.2383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 11/14/2023] [Accepted: 01/18/2024] [Indexed: 02/07/2024]
Abstract
Renal function is an important factor affecting the pharmacokinetics of vancomycin. The renal function in elderly patients gradually decreases with age. An accurate estimated glomerular filtration rate (GFR) is essential in drug dosing. The study aimed to determine the most appropriate renal function estimation equations to describe vancomycin pharmacokinetics in elderly patients using population pharmacokinetic analysis. Data were obtained retrospectively from elderly patients aged ≥65 years who received vancomycin for infection from September 2016 to January 2022. Renal function was estimated using the Cockcroft-Gault equation (CG), Modification of Diet in Renal Disease equation (MDRD), three Chronic Kidney Disease Epidemiology Collaboration equations (CKD-EPIcys-scr , CKD-EPIscr , and CKD-EPIcys ) and two Berlin Initiative Study equations (BIS-1 and BIS-2). The CKD-EPIcys-scr and BIS-2 equations were based on cystatin C (Cys C) and serum creatinine (Scr). The others were based on Cys C or Scr. A nonlinear mixed effects model (NONMEM) was used to develop the population pharmacokinetic model. A total of 471 serum concentrations from 313 elderly patients were used to develop the population pharmacokinetic model. Weight and GFR were identified as significant covariates affecting the pharmacokinetics of vancomycin. Cys C and Scr-based GFR (CKD-EPIcys-scr and BIS-2) yielded significant improvement performance compared with the other equations in model building. The interindividual variability of CL was reduced from 49.4% to 23.6% and 49.4% to 23.7% in CKD-EPIcys-scr and BIS-2 based models, respectively. However, greater interindividual variabilities of CL (from 26.6% to 29.0%) were represented in the other five models which were based on either Cys C or Scr. The GFR estimated by EPIcys-scr and BIS-2 equations and vancomycin CL exhibited a good correlation (r = 0.834 and 0.833). In the external validation with 124 serum concentrations, the predictive performances of the CKD-EPIcys-scr and BIS-2 based models (the mean relative prediction errors were less than 1%, the mean relative absolute prediction errors were about 23%) were also superior to the other five models (the mean relative prediction errors were about 2%, the mean relative absolute prediction errors were greater than 25%) which are based on either Cys C or Scr. In this study, we determined that the equation used to estimate GFR can affect the population pharmacokinetic model fitting result. Population pharmacokinetics model with CKD-EPIcys-scr or BIS-2 can be used to optimize vancomycin dosage in elderly Chinese patients.
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Affiliation(s)
- Jing Ling
- Department of Pharmacy, The First People's Hospital of Changzhou/The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Xuping Yang
- Department of Pharmacy, The First People's Hospital of Changzhou/The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Lulu Dong
- Department of Pharmacy, The First People's Hospital of Changzhou/The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Yan Jiang
- Department of Pharmacy, The First People's Hospital of Changzhou/The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Sulan Zou
- Department of Pharmacy, The First People's Hospital of Changzhou/The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Nan Hu
- Department of Pharmacy, The First People's Hospital of Changzhou/The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
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Yang JJ, Brett J, Sordo A, Reuter SE, Stocker SL, Day RO, Roberts DM, Carland JE. The Influence of a Therapeutic Drug Monitoring Service on Vancomycin-Associated Nephrotoxicity. J Clin Pharmacol 2024; 64:19-29. [PMID: 37779493 DOI: 10.1002/jcph.2363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/29/2023] [Indexed: 10/03/2023]
Abstract
Vancomycin's widespread use as the mainstay antibiotic against methicillin-resistant Staphylococcus aureus infections is complicated by its narrow therapeutic index. Therapeutic drug monitoring using area under the concentration-time curve (AUC)-guided dosing is recommended to optimize therapy and prevent vancomycin-associated nephrotoxicity (VAN). In 2018, a consultative therapeutic drug monitoring Advisory Service (the Service) was piloted at an Australian hospital to enable AUC-guided vancomycin dosing. This study sought to compare the incidence of VAN pre- and post-Service implementation. A 4-year retrospective observational study of intravenous vancomycin therapy (greater than 48 hours) in adults (aged 18 years or older), spanning 3 years before and 1-year after implementation of the Service was undertaken. Nephrotoxicity was defined as an increase in serum creatinine concentrations of 26.5 μmol/L or greater or 50% or more from baseline, on 2 or more consecutive days. Univariate analysis was performed to compare patients before and after implementation, and with and without VAN. Independent factors associated with VAN were identified using a multivariate model. In total, 971 courses of vancomycin therapy, administered to 781 patients, were included: 764 courses (603 patients) before implementation and 207 courses (163 patients) after implementation. The incidence of VAN decreased by 5% after Service implementation (15% before implementation vs 10% after implementation; P = .075). Independent factors associated with VAN were sepsis, heart failure, solid-organ transplant, concomitant piperacillin-tazobactam, and average vancomycin AUC during therapy. In conclusion, there was a nonsignificant trend toward a reduced incidence of VAN after the Service. Larger prospective studies are needed to confirm the efficacy of the Service.
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Affiliation(s)
- Jennifer J Yang
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
| | - Jonathan Brett
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
| | - Anna Sordo
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Stephanie E Reuter
- UniSA Clinical & Health Sciences, University of South Australia, Adelaide, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
- School of Medical Sciences, UNSW Sydney, Sydney, NSW, Australia
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
- Drug Health Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Australia
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Tyler Pitcock C, Schadler A, Burgess DS, Burgess DR, Cotner SE, Van Hoose J, Gregory ER, Wallace KL. Association of vancomycin-induced acute kidney injury with trough versus AUC monitoring in patients receiving extended durations of therapy. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e225. [PMID: 38156206 PMCID: PMC10753493 DOI: 10.1017/ash.2023.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 12/30/2023]
Abstract
Objective Vancomycin therapy is associated with an increased risk of acute kidney injury (AKI). Previous studies suggest that area under the curve (AUC) monitoring reduces the risk of AKI, but literature is lacking to support this in patients receiving longer durations of vancomycin therapy. Design Retrospective cohort study. Method Patients ≥18 years old, admitted between August 2015 and July 2017 or October 2017 and September 2019, and received at least 14 days of intravenous (IV) vancomycin therapy were included in the study. Our primary outcome was the incidence of AKI between trough monitoring and AUC monitoring groups using Kidney Disease Improving Global Outcomes criteria. Secondary outcomes included inpatient mortality, median inpatient length of stay, and median intensive care unit length of stay. Results Overall, 582 patients were included in the study, with 318 patients included in the trough monitoring group and 264 included in the AUC monitoring group. The median duration of vancomycin therapy was 23 days (interquartile range, 16-39). Patients within the trough monitoring group had a higher incidence of AKI compared to the AUC monitoring group (45.6% vs 28.4%, p < 0.001). Furthermore, logistic regression analysis showed that AUC monitoring was associated with a 54% lower incidence of AKI (OR 0.46, 95% CI [0.31-0.69]). All-cause inpatient mortality was numerically higher in the trough monitoring group (12.9% vs 8.3%, p = 0.078). Conclusions In patients who received at least 14 days of IV vancomycin therapy, AUC monitoring was associated with a lower incidence of AKI.
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Affiliation(s)
- C. Tyler Pitcock
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Aric Schadler
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
- Department of Pediatrics, Kentucky Children’s Hospital, Lexington, KY, USA
| | - David S. Burgess
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Donna R. Burgess
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Sarah E. Cotner
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Jeremy Van Hoose
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Eric R. Gregory
- Department of Pharmacy Services, The University of Kansas Health System, Kansas City, KS, USA
| | - Katie L. Wallace
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
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Yoon S, Guk J, Lee SG, Chae D, Kim JH, Park K. Model-informed precision dosing in vancomycin treatment. Front Pharmacol 2023; 14:1252757. [PMID: 37876732 PMCID: PMC10593454 DOI: 10.3389/fphar.2023.1252757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/11/2023] [Indexed: 10/26/2023] Open
Abstract
Introduction: While vancomycin remains a widely prescribed antibiotic, it can cause ototoxicity and nephrotoxicity, both of which are concentration-associated. Overtreatment can occur when the treatment lasts for an unnecessarily long time. Using a model-informed precision dosing scheme, this study aims to develop a population pharmacokinetic (PK) and pharmacodynamic (PD) model for vancomycin to determine the optimal dosage regimen and treatment duration in order to avoid drug-induced toxicity. Methods: The data were obtained from electronic medical records of 542 patients, including 40 children, and were analyzed using NONMEM software. For PK, vancomycin concentrations were described with a two-compartment model incorporating allometry scaling. Results and discussion: This revealed that systemic clearance decreased with creatinine and blood urea nitrogen levels, history of diabetes and renal diseases, and further decreased in women. On the other hand, the central volume of distribution increased with age. For PD, C-reactive protein (CRP) plasma concentrations were described by transit compartments and were found to decrease with the presence of pneumonia. Simulations demonstrated that, given the model informed optimal doses, peak and trough concentrations as well as the area under the concentration-time curve remained within the therapeutic range, even at doses smaller than routine doses, for most patients. Additionally, CRP levels decreased more rapidly with the higher dose starting from 10 days after treatment initiation. The developed R Shiny application efficiently visualized the time courses of vancomycin and CRP concentrations, indicating its applicability in designing optimal treatment schemes simply based on visual inspection.
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Affiliation(s)
- Sukyong Yoon
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Brain Korea 21 Plus Project for Medical Science, Yonsei University, Seoul, Republic of Korea
| | - Jinju Guk
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Brain Korea 21 Plus Project for Medical Science, Yonsei University, Seoul, Republic of Korea
| | - Sang-Guk Lee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dongwoo Chae
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Ho Kim
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyungsoo Park
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Chung E, Seto W. Association between vancomycin therapeutic drug monitoring and clinical outcomes in treating neonatal sepsis. Int J Antimicrob Agents 2023; 62:106958. [PMID: 37633423 DOI: 10.1016/j.ijantimicag.2023.106958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Neonatal sepsis is commonly treated with vancomycin in the neonatal intensive care unit. Therapeutic drug monitoring of vancomycin is routinely used to personalise dosing to optimise effectiveness and avoid toxicity. OBJECTIVES This study aimed to define a target range by evaluating associations between vancomycin trough concentrations or area under the concentration time curve over 24 hours (AUC24h) and clinical outcomes in neonates. METHODS Neonates, who were admitted to the neonatal intensive care unit and received intravenous vancomycin, were included in this retrospective cohort study. For evaluating effectiveness, patients who received vancomycin for < 5 days were excluded. The AUC24h was estimated based on a study-derived population pharmacokinetic model. Primary outcomes were persistent/recurrent infections and mortality within 30 days. Secondary outcomes, including acute kidney injury (AKI), were also assessed. Logistic regression and classification and regression tree analyses were performed. RESULTS A total of 448 patients (123 patients for effectiveness analysis) were included. A vancomycin trough > 10 mg/L was associated with 70% lower odds of persistent/recurrent infections (adjusted OR 0.30, 95% CI 0.09-0.86; P = 0.023). Patients who took more than a day to reach target range had 1.4 times higher odds of persistent/recurrent infections or death (P = 0.04). A vancomycin trough > 15 mg/L was associated with a three times higher risk of AKI (P = 0.003). An AUC24h of 420-650 mg*h/L was also associated with the lowest risk of composite outcomes (adjusted OR 0.29, 95% CI 0.08-0.86; P = 0.025). CONCLUSION A vancomycin trough target range of 10-15 mg/L and achievement of this target within a day of treatment initiation were associated with the most optimal clinical outcomes in treating neonatal sepsis.
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Affiliation(s)
- Erin Chung
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
| | - Winnie Seto
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto Ontario, Canada
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Brothers KM, Parker DM, Taguchi M, Ma D, Mandell JB, Thurlow LL, Byrapogu VC, Urish KL. Dose optimization in surgical prophylaxis: sub-inhibitory dosing of vancomycin increases rates of biofilm formation and the rates of surgical site infection. Sci Rep 2023; 13:4593. [PMID: 36944677 PMCID: PMC10030625 DOI: 10.1038/s41598-023-30951-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/03/2023] [Indexed: 03/23/2023] Open
Abstract
Antibiotic stewardship is viewed as having great public health benefit with limited direct benefit to the patient at the time of administration. The objective of our study was to determine if inappropriate administration of antibiotics could create conditions that would increase the rates of surgical infection. We hypothesized that sub-MIC levels of vancomycin would increase Staphylococcus aureus growth, biofilm formation, and rates of infection. S. aureus MRSA and MSSA strains were used for all experiments. Bacteria were grown planktonically and monitored using spectrophotometry. Quantitative agar culture was used to measure planktonic and biofilm bacterial burden. A mouse abscess model was used to confirm phenotypes in vivo. In the planktonic growth assay, increases in bacterial burden at ¼ MIC vancomycin were observed in USA300 JE2 by 72 h. Similar findings were observed with ½ MIC in Newman and SH1000. For biofilm formation, USA300 JE2 at ¼ and ½ MIC vancomycin increased biofilm formation by approximately 1.3- and 2.3-fold respectively at 72 h as compared to untreated controls. Similar findings were observed with Newman and SH1000 with a 2.4-fold increase in biofilm formation at ½ MIC vancomycin. In a mouse abscess model, there was a 1.2-fold increase with sub-MIC vancomycin at 3 days post infection. Our study showed that Sub-optimal vancomycin dosing promoted S. aureus planktonic growth and biofilm formation, phenotypic measures of bacterial virulence. This phenotype induced by sub-MIC levels of vancomycin was also observed to increase rates of infection and pathogenesis in our mouse model. Risks of exposure to sub-MIC concentrations with vancomycin in surgical procedures are greater as there is decreased bioavailability in tissue in comparison to other antibiotics. This highlights the importance of proper antibiotic selection, stewardship, and dosing for both surgical prophylaxis and treatment of infection.
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Affiliation(s)
- Kimberly M Brothers
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dana M Parker
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Masashi Taguchi
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedic Surgery, Ageo Medical Clinic, 3133 Haraichi, Ageo-Shi, Saitama, Japan
| | - Dongzhu Ma
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan B Mandell
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lance L Thurlow
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC, USA
| | - Venkata C Byrapogu
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Arthritis and Arthroplasty Design Group, and The Bone and Joint Center, Department of Orthopaedic Surgery, Department of Bioengineering, Department of Biomedical Engineering, and Clinical and Translational Science Institute, Magee Womens Hospital of the University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, 15219, USA.
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Altowayan WM, Mobark MA, ALharbi A, Alduhami AA, Rabbani SI. The influence of vancomycin on renal functions, the predictors and associated factors for nephrotoxicity. PLoS One 2023; 18:e0284223. [PMID: 37068067 PMCID: PMC10109467 DOI: 10.1371/journal.pone.0284223] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 03/27/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Vancomycin has been widely used in the last six decades to treat methicillin-resistant S. aureus (MRSA) and other resistant gram-positive infections. The risk of vancomycin toxicity increases with the utilization of higher doses while treating the resistant form of bacterial infections. Nephrotoxicity is one of the major complications reported to be a hinderance in the prognosis of vancomycin therapy. OBJECTIVES This hospital-based study aimed to highlight the influence of vancomycin on renal function with special emphasis on identifying the predictors and augmenting factors for nephrotoxicity. METHODOLOGY A cross-sectional, unicentric, hospital-based study was conducted at King Fahad Specialist Hospital (KFSH) in Qassim region in Saudi Arabia (KSA). It included 319 hospitalized patients who received vancomycin at intermittent doses (15 to 30 mg/kg IV per day) based on the diseased state. Data regarding vancomycin dose, frequency, duration and data of renal function tests and type of admission were analysed to evaluate their influence on the renal function using parameters such as blood urea, serum creatinine levels and creatinine clearance. One-way ANOVA and Spearman correlation test were used in the analysis of data. RESULTS Both male and female patients treated with vancomycin had significantly (p<0.05) elevated blood urea and serum creatinine levels compared to baseline levels while creatinine clearance was non-significantly varied. Increasing age, increasing body weight, higher vancomycin dose and trough levels, increased vancomycin frequency and duration, critically ill patients and site of infection were factors associated with significant (p<0.05) increases in blood urea and serum creatinine levels with reduction in creatinine clearance. CONCLUSION Data suggested that vancomycin treatment reduced the renal function in patients and indicated its association with several predictors and confounding factors. The findings of the study might assist in identifying the patients under risk from the vancomycin-induced nephrotoxicity and in designing the preventive strategies to reduce such complications.
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Affiliation(s)
- Waleed M Altowayan
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraydah, Saudi Arabia
| | - Mugahid A Mobark
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraydah, Saudi Arabia
- Department of Pathology, Faculty of Medicine, University of Kordofan, El-Obeid, Sudan
| | - Abdulmajed ALharbi
- Clinical Pharmacy, King Fahad Specialist Hospital, Buraydah, Qassim, Saudi Arabia
| | - Abdullah Ali Alduhami
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraydah, Saudi Arabia
| | - Syed Imam Rabbani
- Department of Pharmacology and Toxicology, College of Pharmacy, Qassim University, Buraydah, Saudi Arabia
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Duan R, Wang P. Rapid and Simple Approaches for Diagnosis of Staphylococcus aureus in Bloodstream Infections. Pol J Microbiol 2022; 71:481-489. [PMID: 36476633 PMCID: PMC9944965 DOI: 10.33073/pjm-2022-050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/01/2022] [Indexed: 12/13/2022] Open
Abstract
Staphylococcus aureus is an important causative pathogen of bloodstream infections. An amplification assay such as real-time PCR is a sensitive, specific technique to detect S. aureus. However, it needs well-trained personnel, and costs are high. A literature review focusing on rapid and simple methods for diagnosing S. aureus was performed. The following methods were included: (a) Hybrisep in situ hybridization test, (b) T2Dx system, (c) BinaxNow Staphylococcus aureus and PBP2a, (d) Gram staining, (e) PNA FISH and QuickFISH, (f) Accelerate PhenoTM system, (g) MALDI-TOF MS, (h) BioFire FilmArray, (i) Xpert MRSA/SA. These rapid and simple methods can rapidly identify S. aureus in positive blood cultures or direct blood samples. Furthermore, BioFire FilmArray and Xpert MRSA/SA identify methicillin-resistant S. aureus (MRSA), and the Accelerate PhenoTM system can also provide antimicrobial susceptibility testing (AST) results. The rapidity and simplicity of results generated by these methods have the potential to improve patient outcomes and aid in the prevention of the emergence and transmission of MRSA.
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Affiliation(s)
- Rui Duan
- Department of Laboratory Medicine and Blood Transfusion, The First People’s Hospital of Jingmen, Jingmen, Hubei Province, China
| | - Pei Wang
- Department of Laboratory Medicine and Blood Transfusion, The First People’s Hospital of Jingmen, Jingmen, Hubei Province, China, E-mail:
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11
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Alakeel YS, Alanazi GA, Alawbathani BS, Alshutwi KI, Alahmed YS. Vancomycin dosing required to achieve a therapeutic level in children post-surgical correction of congenital heart disease. Medicine (Baltimore) 2022; 101:e30145. [PMID: 36254077 PMCID: PMC9575798 DOI: 10.1097/md.0000000000030145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The vancomycin dosing range for safe and effective treatment remains uncertain for children who had corrective surgery for a congenital heart disease (CHD). We aimed to determine the vancomycin dosing requirements for this subgroup of patients. This prospective cohort study included children younger than 14 years old with CHD who received intravenous vancomycin for at least 3 days at the Pediatric Cardiology section of King Abdulaziz Medical City, Riyadh. In total, 140 pediatric patients with CHD were included with a median age of 0.57 years (interquartile range 0.21-2.2). The mean vancomycin total daily dose (TDD), 37.71 ± 6.8 mg/kg/day, was required to achieve a therapeutic trough concentration of 7-20 mg/L. The patient's age group and the care setting were significant predictors of the vancomycin dosing needs. Neonates required significantly lower doses of 34 ± 6.03 mg/kg/day (P = .002), and young children higher doses of 43.97 ± 9.4 mg/kg/day (P = .003). The dosage requirements were independent of the type of cardiac lesion, cardiopulmonary surgery exposure, sex, and BMI percentile. However, the patients in the pediatric cardiac ward required higher doses of vancomycin 41.08 ± 7.06 mg/kg/day (P = .039). After the treatment, 11 (8.5%) patients had an elevated Scr, and 3 (2.3%) patients developed AKI; however, none of the patients' sociodemographic factors or clinical variables, or vancomycin therapy characteristics was significantly associated with the renal dysfunction. Overall, the vancomycin TDD requirements are lower in pediatric post-cardiac surgery compared to non-cardiac patients and are modulated by several factors.
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Affiliation(s)
- Yousif S. Alakeel
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- * Correspondence: Yousif S. Alakeel, PharmD, MPH, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia (e-mail: )
| | - Ghadah A. Alanazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Bushra S. Alawbathani
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Kadi I. Alshutwi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yazeed S. Alahmed
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pediatrics, College of Medicine, Qassim University, Qassim, Saudi Arabia
- Division of Pediatric Cardiology, Cardiac Sciences, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
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12
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Ghasemiyeh P, Vazin A, Zand F, Haem E, Karimzadeh I, Azadi A, Masjedi M, Sabetian G, Nikandish R, Mohammadi-Samani S. Pharmacokinetic assessment of vancomycin in critically ill patients and nephrotoxicity prediction using individualized pharmacokinetic parameters. Front Pharmacol 2022; 13:912202. [PMID: 36091788 PMCID: PMC9449142 DOI: 10.3389/fphar.2022.912202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/15/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction: Therapeutic drug monitoring (TDM) and pharmacokinetic assessments of vancomycin would be essential to avoid vancomycin-associated nephrotoxicity and obtain optimal therapeutic and clinical responses. Different pharmacokinetic parameters, including trough concentration and area under the curve (AUC), have been proposed to assess the safety and efficacy of vancomycin administration. Methods: Critically ill patients receiving vancomycin at Nemazee Hospital were included in this prospective study. Four blood samples at various time intervals were taken from each participated patient. Vancomycin was extracted from plasma samples and analyzed using a validated HPLC method. Results: Fifty-three critically ill patients with a total of 212 blood samples from June 2019 to June 2021 were included in this study. There was a significant correlation between baseline GFR, baseline serum creatinine, trough and peak concentrations, AUCτ, AUC24h, Cl, and Vd values with vancomycin-induced AKI. Based on trough concentration values, 66% of patients were under-dosed (trough concentration <15 μg/ml) and 18.9% were over-dosed (trough concentration ≥20 μg/ml). Also, based on AUC24h values, about 52.2% were under-dosed (AUC24h < 400 μg h/ml), and 21.7% were over-dosed (AUC24h > 600 μg h/ml) that emphasizes on the superiority of AUC-based monitoring approach for TDM purposes to avoid nephrotoxicity occurrence. Conclusion: The AUC-based monitoring approach would be superior in terms of nephrotoxicity prediction. Also, to avoid vancomycin-induced AKI, trough concentration and AUCτ values should be maintained below the cut-off points.
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Affiliation(s)
- Parisa Ghasemiyeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmaceutics, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Afsaneh Vazin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- *Correspondence: Soliman Mohammadi-Samani, ; Afsaneh Vazin,
| | - Farid Zand
- Anesthesiology and Critical Care Research Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elham Haem
- Department of Biostatistics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Iman Karimzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Azadi
- Department of Pharmaceutics, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mansoor Masjedi
- Department of Anesthesiology, Faculty of Medicine, Shiraz University of Medical Science, Shiraz, Iran
| | - Golnar Sabetian
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Nikandish
- Anesthesiology and Critical Care Research Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soliman Mohammadi-Samani
- Department of Pharmaceutics, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- *Correspondence: Soliman Mohammadi-Samani, ; Afsaneh Vazin,
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13
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Vancomycin Therapeutic Drug Monitoring (TDM) and Its Association with Clinical Outcomes: A Retrospective Cohort. J Infect Public Health 2022; 15:589-593. [DOI: 10.1016/j.jiph.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/13/2022] [Accepted: 04/17/2022] [Indexed: 01/05/2023] Open
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The association of high Vancomycin trough concentration with acute kidney injury during combination therapy of Piperacillin/Tazobactam and Vancomycin. Pract Lab Med 2022; 29:e00266. [PMID: 35111893 PMCID: PMC8789664 DOI: 10.1016/j.plabm.2022.e00266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/05/2021] [Accepted: 01/14/2022] [Indexed: 11/24/2022] Open
Abstract
Background Co-administration of Piperacillin/Tazobactam (PIPC/TAZ) and Vancomycin (VCM) as an antibiotic therapy for severe infectious diseases increases the risk of nephrotoxicity. We retrospectively investigated the utility of monitoring VCM trough concentration in early stage of developing acute kidney injury (AKI) on this combination therapy. Methods We enrolled all infectious disease patients who were managed with concurrent PIPC/TAZ and VCM. The record of dosage and the administration interval of each antibiotic and its clinical parameters, as well as the VCM trough concentrations, blood culture for bacteria, and serum creatinine values, were collected. VCM trough concentration was measured during the initial 48–72 h of VCM administration. Nephrotoxicity was evaluated as the degree of AKI. Results A total of 47 patients fulfilling the criteria were registered, and AKI developed in 10 patients. There was no statistical difference between the AKI and non-AKI groups with regard to age, height, weight, basal creatinine level, body surface area, body mass index, PIPC/TAZ dose, VCM dose, gender, artificial management, and death within around 30 days. The VCM trough level was increased significantly in the AKI group (mean [standard deviation {SD}]: 25.9 [7.8] μg/mL) compared to that in the non-AKI group (mean [SD]: 15.7 [6.9] μg/mL) (p = 0.003). During the clinical course, renal function returned to normal levels in three out of four AKI stage 2 patients, whereas only partial recovery was achieved in all AKI stage 3 patients. Conclusions A high VCM trough concentration may have an influence on the occurrence of AKI during combination therapy of PIPC/TAZ and VCM. Careful monitoring of VCM trough concentration will be required to prevent AKI progression.
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15
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Yamaguchi R, Kani H, Yamamoto T, Tanaka T, Suzuki H. Development of a decision flowchart to identify the patients need high-dose vancomycin in early phase of treatment. J Pharm Health Care Sci 2022; 8:3. [PMID: 34983684 PMCID: PMC8725522 DOI: 10.1186/s40780-021-00231-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/05/2021] [Indexed: 12/29/2022] Open
Abstract
Background The standard dose of vancomycin (VCM, 2 g/day) sometimes fails to achieve therapeutic concentration in patients with normal renal function. In this study, we aimed to identify factors to predict patients who require high-dose vancomycin (> 2 g/day) to achieve a therapeutic concentration and to develop a decision flowchart to select these patients prior to VCM administration. Methods Patients who had an estimated creatinine clearance using the Cockcroft–Gault equation (eCCr) of ≥50 mL/min and received intravenous VCM were divided into 2 cohorts: an estimation set (n = 146, from April to September 2016) and a validation set (n = 126, from October 2016 to March 2017). In each set, patients requiring ≤2 g/day of VCM to maintain the therapeutic trough concentration (10–20 μg/mL) were defined as standard-dose patients, while those who needed > 2 g/day were defined as high-dose patients. Univariate and multivariate logistic regression analysis was performed to identify the predictive factors for high-dose patients and decision tree analysis was performed to develop decision flowchart to identify high-dose patients. Results Among the covariates analyzed, age and eCCr were identified as independent predictors for high-dose patients. Further, the decision tree analysis revealed that eCCr (cut off value = 81.3 mL/min) is the top predictive factor and is followed by age (cut off value = 58 years). Based on these findings, a decision flowchart was constructed, in which patients with eCCr ≥81.3 mL/min and age < 58 years were designated as high-dose patients and other patients were designated as standard-dose patients. Subsequently, we applied this decision flowchart to the validation set and obtained good predictive performance (positive and negative predictive values are 77.6 and 84.4%, respectively). Conclusion These results suggest that the decision flowchart constructed in this study provides an important contribution for avoiding underdosing of VCM in patients with eCCr of ≥50 mL/min. Supplementary Information The online version contains supplementary material available at 10.1186/s40780-021-00231-w.
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Affiliation(s)
- Ryo Yamaguchi
- Department of Pharmacy, The University of Tokyo Hospital, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroko Kani
- Department of Pharmacy, The University of Tokyo Hospital, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takehito Yamamoto
- Department of Pharmacy, The University of Tokyo Hospital, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. .,The Education Center for Clinical Pharmacy, Graduate School of Pharmaceutical Sciences, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Takehiro Tanaka
- Department of Pharmacy, The University of Tokyo Hospital, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroshi Suzuki
- Department of Pharmacy, The University of Tokyo Hospital, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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16
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Vancomycin-decorated microbubbles as a theranostic agent for Staphylococcus aureus biofilms. Int J Pharm 2021; 609:121154. [PMID: 34624449 DOI: 10.1016/j.ijpharm.2021.121154] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/20/2022]
Abstract
Bacterial biofilms are a huge burden on our healthcare systems worldwide. The lack of specificity in diagnostic and treatment possibilities result in difficult-to-treat and persistent infections. The aim of this in vitro study was to investigate if microbubbles targeted specifically to bacteria in biofilms could be used both for diagnosis as well for sonobactericide treatment and demonstrate their theranostic potential for biofilm infection management. The antibiotic vancomycin was chemically coupled to the lipid shell of microbubbles and validated using mass spectrometry and high-axial resolution 4Pi confocal microscopy. Theranostic proof-of-principle was investigated by demonstrating the specific binding of vancomycin-decorated microbubbles (vMB) to statically and flow grown Staphylococcus aureus (S. aureus) biofilms under increasing shear stress flow conditions (0-12 dyn/cm2), as well as confirmation of microbubble oscillation and biofilm disruption upon ultrasound exposure (2 MHz, 250 kPa, and 5,000 or 10,000 cycles) during flow shear stress of 5 dyn/cm2 using time-lapse confocal microscopy combined with the Brandaris 128 ultra-high-speed camera. Vancomycin was successfully incorporated into the microbubble lipid shell. vMB bound significantly more often than control microbubbles to biofilms, also in the presence of free vancomycin (up to 1000 µg/mL) and remained bound under increasing shear stress flow conditions (up to 12 dyn/cm2). Upon ultrasound insonification biofilm area was reduced of up to 28%, as confirmed by confocal microscopy. Our results confirm the successful production of vMB and support their potential as a new theranostic tool for S. aureus biofilm infections by allowing for specific bacterial detection and biofilm disruption.
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17
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Krueger KM, LaCloche L, Buros Stein A, Kates R, Murray M, Angarone MP. Risk Factors Associated With Nephrotoxicity During Outpatient Intravenous Vancomycin Administration. J Pharm Technol 2021; 38:10-17. [DOI: 10.1177/87551225211054378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Many studies have described an association between intravenous vancomycin and nephrotoxicity; however, the majority have evaluated incidence and risk factors among hospitalized patients. Outpatient administration of intravenous antibiotics is a growing practice and presents its own set of unique challenges. Objective: The aim of this study was to identify risk factors for vancomycin-associated nephrotoxicity in the outpatient setting. Methods: A case-control study of patients who received intravenous vancomycin through an Outpatient Parenteral Antimicrobial Therapy (OPAT) program was conducted. Patients were identified who developed an acute kidney injury (AKI) during treatment. The primary outcome was the incidence of AKI during treatment. Results: A total of 37 out of 130 patients (28.5%) met the criteria for AKI. AKI was more likely to occur in patients with a longer duration of therapy, higher maximum trough concentration, co-administration of a fluoroquinolone or metronidazole, and those who received another potentially nephrotoxic medication. Co-administration of a fluoroquinolone (OR = 5.96, P = 0.009, [CI: 1.59, 24.38]), any nephrotoxic medication (OR = 11.17, P < 0.001, [CI 3.14, 51.23]), and a higher maximum vancomycin trough (OR = 1.29, P < 0.001, [CI 1.17, 1.44]) were all indicative of a higher odds of an AKI. Conclusion: In this cohort, vancomycin-associated nephrotoxicity was common during outpatient intravenous antibiotic therapy. Co-administration of a fluoroquinolone, any nephrotoxic medication, and a higher maximum vancomycin trough were associated with AKI development. Further study is needed to determine how this impacts long-term clinical outcomes and what measures can be taken to reduce nephrotoxicity risk.
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Affiliation(s)
- Karen M. Krueger
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa LaCloche
- Infectious Diseases Center, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Amy Buros Stein
- Office of Research and Sponsored Programs, Midwestern University College of Pharmacy, Glendale, AZ, USA
| | - Ryan Kates
- Northwestern Medicine Specialty Pharmacy, Chicago, IL, USA
| | - Milena Murray
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Chicago, IL, USA
| | - Michael P. Angarone
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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18
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Hong TS, Briscese K, Yuan M, Deshpande K, Aleksunes LM, Brunetti L. Renoprotective Effects of Melatonin against Vancomycin-Related Acute Kidney Injury in Hospitalized Patients: a Retrospective Cohort Study. Antimicrob Agents Chemother 2021; 65:e0046221. [PMID: 34152824 PMCID: PMC8370200 DOI: 10.1128/aac.00462-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 06/20/2021] [Indexed: 12/15/2022] Open
Abstract
Vancomycin is associated with nephrotoxicity, and the mechanism may in part be related to oxidative stress. In vitro and preclinical studies suggest that melatonin supplementation decreases oxidative stress. The objective of this study was to evaluate concomitant use of melatonin and vancomycin and the incidence of acute kidney injury (AKI). We performed a retrospective cohort study at a large community medical center. All consecutive patients admitted to the medical center between January 2016 and September 2020 who received vancomycin therapy alone or concomitantly with melatonin as part of ordinary care were considered for inclusion. The primary endpoint was the development of AKI, defined as an absolute increase in serum creatinine of ≥0.3 mg/dl or a ≥50% increase in serum creatinine. All data were analyzed using descriptive statistics. A multivariable logistic regression was constructed to account for potential confounding variables. We identified a total of 303 adult patients meeting inclusion and exclusion criteria treated with vancomycin, 101 of which received melatonin concomitantly. Overall baseline characteristics were similar between the two groups except for the incidence of bacteremia/sepsis. After controlling for the vancomycin area under the curve, baseline creatinine clearance, and intensive care unit admission in a multivariable logistic regression analysis, melatonin use was associated with a 63% decrease in AKI (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.14 to 0.96; P = 0.041). Melatonin use was associated with a significant reduction in vancomycin-related AKI. Although this was a retrospective study with a small sample size, given the magnitude of the difference seen, further large prospective studies are warranted.
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Affiliation(s)
- Thomas S. Hong
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Kelsey Briscese
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Marshall Yuan
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Kiran Deshpande
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Lauren M. Aleksunes
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Luigi Brunetti
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
- Robert Wood Johnson University Hospital—Somerset, Somerville, New Jersey, USA
- Center of Excellence in Pharmaceutical Translational Research and Education, Piscataway, New Jersey, USA
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19
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Cusumano JA, Klinker KP, Huttner A, Luther MK, Roberts JA, LaPlante KL. Towards precision medicine: Therapeutic drug monitoring-guided dosing of vancomycin and β-lactam antibiotics to maximize effectiveness and minimize toxicity. Am J Health Syst Pharm 2021; 77:1104-1112. [PMID: 32537644 DOI: 10.1093/ajhp/zxaa128] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The goal of this review is to explore the role of antimicrobial therapeutic drug monitoring (TDM), especially in critically ill, obese, and older adults, with a specific focus on β-lactams and vancomycin. SUMMARY The continued rise of antimicrobial resistance prompts the need to optimize antimicrobial dosing. The aim of TDM is to individualize antimicrobial dosing to achieve antibiotic exposures associated with improved patient outcomes. Initially, TDM was developed to minimize adverse effects during use of narrow therapeutic index agents. Today, patient and organism complexity are expanding the need for precision dosing through TDM services. Alterations of pharmacokinetics and pharmacodynamics (PK/PD) in the critically ill, obese, and older adult populations, in conjunction with declining organism susceptibility, complicate attainment of therapeutic targets. Over the last decade, antimicrobial TDM has expanded with the emergence of literature supporting β-lactam TDM and a shift from monitoring vancomycin trough concentrations to monitoring of the ratio of area under the concentration (AUC) curve to minimum inhibitory concentration (MIC). PK/PD experts should be at the forefront of implementing precision dosing practices. CONCLUSION Precision dosing through TDM is expanding and is especially important in populations with altered PK/PD, including critically ill, obese, and older adults. Due to wide PK/PD variability in these populations, TDM is vital to maximize antimicrobial effectiveness and decrease adverse event rates. However, there is still a need for studies connecting TDM to patient outcomes. Providing patient-specific care through β-lactam TDM and transitioning to vancomycin AUC/MIC monitoring may be challenging, but with experts at the forefront of this initiative, PK-based optimization of antimicrobial therapy can be achieved.
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Affiliation(s)
- Jaclyn A Cusumano
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
| | | | - Angela Huttner
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Megan K Luther
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Brisbane, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
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20
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Huang X, Yu Z, Wei X, Shi J, Wang Y, Wang Z, Chen J, Bu S, Li L, Gao F, Zhang J, Xu A. Prediction of vancomycin dose on high-dimensional data using machine learning techniques. Expert Rev Clin Pharmacol 2021; 14:761-771. [PMID: 33835879 DOI: 10.1080/17512433.2021.1911642] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Despite therapeutic vancomycin is regularly monitored, its dose requirements vary considerably between individuals. Various innovative vancomycin dosing strategies have been developed for dose optimization; however, the utilization of individual factors and extensibility is insufficient. We aimed to develop an optimal dosing algorithm for vancomycin based on the high-dimensional data using the proposed variable engineering and machine-learning methods. METHODS This study proposed a variable engineering process that automatically generates second-order variable interactions. We performed an initial examination of independent variables and interactive variables using eXtreme Gradient Boosting. The vancomycin dose prediction model was established based on the derived variables. RESULTS Based on the evaluation of the model performance in the validation cohort, our algorithm accounted for 67.5% of variations in the vancomycin doses. Subgroup analysis showed better performance in patients with medium and high body weight (with the ideal predictive percentage of 72.7% and 73.7%), and low and medium levels of serum creatinine (with the ideal predictive percentage of 77.8% and 73.1%) than in other groups. CONCLUSION The new vancomycin dose prediction model is potentially useful for patients whose population profiles are similar to those of our patients and yielded desired reference of clinical indicators with specific breakpoints.
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Affiliation(s)
- Xiaohui Huang
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ze Yu
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Xin Wei
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Junfeng Shi
- Department of Nephrology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yu Wang
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Zeyuan Wang
- Beijing Medicinovo Technology Co. Ltd., Beijing, China.,School of Computer Science, The University of Sydney, Sydney, Australia
| | - Jihui Chen
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shuhong Bu
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lixia Li
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fei Gao
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Jian Zhang
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ajing Xu
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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21
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Kunming P, Can C, Zhangzhang C, Wei W, Qing X, Xiaoqiang D, Xiaoyu L, Qianzhou L. Vancomycin Associated Acute Kidney Injury: A Longitudinal Study in China. Front Pharmacol 2021; 12:632107. [PMID: 33762952 PMCID: PMC7982802 DOI: 10.3389/fphar.2021.632107] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/01/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Vancomycin-associated acute kidney injury (VA-AKI) is a recognizable condition with known risk factors. However, the use of vancomycin in clinical practices in China is distinct from other countries. We conducted this longitudinal study to show the characteristics of VA-AKI and how to manage it in clinical practice. Patients and Methods: We included patients admitted to hospital, who received vancomycin therapy between January 1, 2016 and June 2019. VA-AKI was defined as a patient having developed AKI during vancomycin therapy or within 48 h following the withdrawal of vancomycin therapy. Results: A total of 3719 patients from 7058 possible participants were included in the study. 998 patients were excluded because of lacking of serum creatinine measurement. The incidence of VA-AKI was 14.3%. Only 32.3% (963/2990) of recommended patients performed therapeutic drug monitoring of vancomycin. Patients with VA-AKI were more likely to concomitant administration of cephalosporin (OR 1.55, 95% CI 1.08–2.21, p = 0.017), carbapenems (OR 1.46, 95% CI 1.11–1.91, p = 0.006) and piperacillin-tazobactam (OR 3.12, 95% CI 1.50–6.49, p = 0.002). Full renal recovery (OR 0.208, p = 0.005) was independent protective factors for mortality. Compared with acute kidney injury stage 1, AKI stage 2 (OR 2.174, p = 0.005) and AKI stage 3 (OR 2.210, p = 0.005) were independent risk factors for fail to full renal recovery. Conclusion: Lack of a serum creatinine measurement for the diagnosis of AKI and lack of standardization of vancomycin therapeutic drug monitoring should be improved. Patient concomitant with piperacillin-tazobactam are at higher risk. Full renal recovery was associated with a significantly reduced morality.
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Affiliation(s)
- Pan Kunming
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Chen Can
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Chen Zhangzhang
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Wu Wei
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Xu Qing
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Ding Xiaoqiang
- Department of Nephrology, Zhongshan Hospital Fudan University, Shanghai, China
| | - Li Xiaoyu
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Lv Qianzhou
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
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Acute Renal Failure After the First Stage of a 2-Stage Exchange for Periprosthetic Joint Infection. J Arthroplasty 2021; 36:717-721. [PMID: 32893061 DOI: 10.1016/j.arth.2020.08.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/27/2020] [Accepted: 08/13/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Two-stage exchange using antibiotic-loaded spacers is a common approach in treating periprosthetic joint infections. Acute kidney injury (AKIN) can be a systemic complication of this procedure. This study investigates the prevalence of AKIN and identifies potential risk factors. METHODS This is a single-center retrospective analysis of patients undergoing 2-stage exchange using a spacer in 285 patients treated between 2010 and 2017. Risk factors were evaluated using parametric and nonparametric analyses and a multivariate, binary logistic regression model. RESULTS Thirty-three percent of patients (95/285) developed an AKIN postoperatively. Twenty-four percent (23/95) of these patients had an acute on chronic kidney failure with a previously impaired renal function. In multivariate analysis, a higher age (hazard ratio [HR], 1.034; 95% confidence interval [CI], 1-1.068; P = .046) and a higher baseline creatinine level (HR, 1.94; 95% CI, 1.237-3.052; P = .004) were risk factors for AKIN. Treatment with vancomycin in the spacer or systemically was not associated with AKIN while a high vancomycin blood level (HR, 1.91; 95% CI, 0.913-3.992; P = .086) and fungal infections were (HR, 3.482; 95% CI, 0.968-12.521; P = .056). Furthermore, in univariate analysis, a higher median Charlson comorbidity index (4 vs 3, P = .007), a lower preoperative hemoglobin (10.9 vs 11.7 g/dL, P = .008), and a higher number of blood transfusions (1 vs 0, P = .004) were associated with AKIN. CONCLUSION AKIN is common in patients undergoing 2-stage exchange. Associated patient factors, particularly in patients with chronic renal dysfunction, should be optimized. The general use of glycopeptide antibiotics was no risk factor for AKIN.
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23
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Yasu T, Konuma T, Oiwa-Monna M, Kato S, Isobe M, Takahashi S, Tojo A. Lower vancomycin trough levels in adults undergoing unrelated cord blood transplantation. Leuk Lymphoma 2020; 62:348-357. [PMID: 33100069 DOI: 10.1080/10428194.2020.1834096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Vancomycin (VCM) is frequently used for neutropenic patients undergoing cord blood transplantation (CBT). We retrospectively examined the relationship between VCM trough levels and the efficacy and toxicity in 122 adult patients undergoing CBT in our institute. The median initial dose of VCM based on body weight was 9.1 mg/kg/dose (range, 6.0-22.6 mg/kg/dose). The median initial trough level of VCM for all patients was 4.50 µg/mL (range, 1.20-24.05 µg/mL), at a median of 3 days (range, 2-6 days) after VCM administration. The cumulative incidence of acute kidney injury (AKI) was 19% at 30 days after VCM administration. A higher median trough level of VCM during the first 7 days was significantly associated with the development of AKI in the multivariate analysis (Hazard ratio: 1.28, p = .026). These data suggest that a lower VCM trough level may be safe in adult patients undergoing CBT under therapy with nephrotoxic drugs.
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Affiliation(s)
- Takeo Yasu
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan.,Department of Medicinal Therapy Research, Pharmaceutical Education and Research Center, Meiji Pharmaceutical University, Tokyo, Japan
| | - Takaaki Konuma
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Maki Oiwa-Monna
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Seiko Kato
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Masamichi Isobe
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Satoshi Takahashi
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Arinobu Tojo
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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24
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Gaggl M, Pate V, Stürmer T, Kshirsagar AV, Layton JB. The comparative risk of acute kidney injury of vancomycin relative to other common antibiotics. Sci Rep 2020; 10:17282. [PMID: 33057027 PMCID: PMC7560595 DOI: 10.1038/s41598-020-73687-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 09/17/2020] [Indexed: 01/09/2023] Open
Abstract
The glycopeptide antibiotic vancomycin is a mainstay in the treatment of Gram-positive infection. While its association with acute kidney injury (AKI) has waxed and waned, recent data suggest nephrotoxicity, even as mono-therapy. Our study aimed to evaluate the 2-week risk of AKI after at least 3 days of intravenous vancomycin mono-therapy initiated within 5 days of hospitalization compared to other intravenous antibiotics used for similar indications. We used a new user-active comparator study design and identified patients with a first hospitalization during which they received vancomycin or comparator, from commercial claims based in the United States. We estimated incidence rates, hazard ratios using adjusted cox-regression models, and standardized mortality/morbidity ratio weighted cox-regression models. In the 32,997 patients vancomycin was used in 17% of patients and 129 cases of AKI were observed. Overall incidence of AKI was 9.3 (95% CI 0.78-1.22) per 100 person-years. The adjusted hazard ratio for vancomycin versus all other comparators was 0.74 (95% CI 0.45-1.21). Separate models for respective comparators resulted in hazard ratios below the null, except for vancomycin vs. cefazolin. Intravenous vancomycin mono-therapy does not increase the risk of AKI compared to other intravenous antibiotics used for similar indication in this cohort of hospitalized patients.
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Affiliation(s)
- Martina Gaggl
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, USA.
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria.
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, USA
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, USA
| | - Abhijit V Kshirsagar
- Division of Nephrology and Hypertension, UNC Kidney Center, University of North Carolina, Chapel Hill, NC, USA
| | - J Bradley Layton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, USA
- RTI Health Solutions, Research Triangle Park, NC, USA
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CSF levels of myelin basic protein in pediatric patients with ventriculoperitoneal shunt infection. Cent Eur J Immunol 2020; 45:48-55. [PMID: 32425679 PMCID: PMC7226547 DOI: 10.5114/ceji.2020.94682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/03/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Hydrocephalus is a common disorder of the central nervous system (CNS) in the pediatric population. Surgical treatment options involve ventriculoperitoneal shunt (VPS) placement. VPS infection is the most common complication of surgically treated hydrocephalus in pediatric patients [1, 2],which may lead to neuronal damage. Myelin basic protein (MBP) has been proposed as a marker of neuronal injury in a variety of contexts, and MBP levels in the cerebrospinal fluid (CSF) may be used to assess the severity of neuronal damage [1, 3, 4]. Therefore, the aim of this study was to evaluate the CSF level of myelin basic protein (MBP) in a group of pediatric patients with VPS infection. Material and methods Thirty CSF samples were collected from pediatric patients with VPS infection. CSF levels of MBP were measured at three time points, marked by contamination detection, obtention of the first sterile CSF culture, and VPS shunt implantation. The collected data were compared with those of the control group composed of children with active congenital hydrocephalus and valid CSF values. Results The MBP level in the study group was higher than the corresponding control values in the second and third measurements. The highest MBP level was reached in the study group in the second and third measurements. Conclusions The lack of normalization of MBP level in the CSF of children with shunt infection could be connected with ongoing brain damage. It takes longer than the normalization of CSF protein level and pleocytosis. The delay is associated with a prolonged reaction of the immunological system.
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Bellos I, Daskalakis G, Pergialiotis V. Relationship of vancomycin trough levels with acute kidney injury risk: an exposure–toxicity meta-analysis. J Antimicrob Chemother 2020; 75:2725-2734. [DOI: 10.1093/jac/dkaa184] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/05/2020] [Accepted: 04/13/2020] [Indexed: 02/06/2023] Open
Abstract
AbstractObjectivesNephrotoxicity represents a major complication of vancomycin administration, leading to high rates of morbidity and treatment failure. The aim of this meta-analysis was to evaluate the association between trough levels and risk of renal impairment, by defining an exposure–toxicity relationship and assessing its accuracy in predicting the development of acute kidney injury (AKI).MethodsMedline, Scopus, CENTRAL, Clinicaltrials.gov and Google Scholar databases were systematically searched from inception. Studies examining the effects of trough levels on nephrotoxicity risk in adult patients were deemed eligible.ResultsThe meta-analysis was based on 60 studies, including 13 304 patients. The development of AKI was significantly linked to both higher initial [standardized mean difference (SMD): 0.82; 95% CI: 0.65–0.98] and maximum (SMD: 1.06; 95% CI: 0.82–1.29) trough levels. Dose–response analysis indicated a curvilinear relationship between trough levels and nephrotoxicity risk (χ2 = 127.1; P value < 0.0001). A cut-off of 15 mg/L detected AKI with a sensitivity of 62.6% (95% CI: 55.6–69.2) and a specificity of 65.5% (95% CI: 58.9–71.6), while applying a 20 mg/L threshold resulted in a sensitivity of 42.9% (95% CI: 34–52.2) and a specificity of 82.5% (95% CI: 73.9–88.8).ConclusionsThe present findings suggest that the development of vancomycin-induced AKI is significantly associated with higher initial and maximum trough levels. An exposure–response relationship was defined, indicating that increasing trough levels correlate with a significant rise of nephrotoxicity risk. Future studies should verify the effectiveness of individualized pharmacokinetic tools that would enable the attainment of trough level targets and minimize the risk of renal toxicity.
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Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Daskalakis
- First Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
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27
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AUC- vs. Trough-Guided Monitoring of Vancomycin in Infants. Indian J Pediatr 2020; 87:359-364. [PMID: 31984471 DOI: 10.1007/s12098-019-03162-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 12/17/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Improving vancomycin therapy with therapeutic drug monitoring is recommended. Over the past few years, a few studies have demonstrated that trough concentrations may not be the optimal parameter for monitoring vancomycin concentration and Area under the curve (AUC) should be used instead. In this study authors evaluate two methods to estimate the AUC. The first method is based on linear regression using only a trough concentration. The second method uses a simplified two-sample equation-based strategy to estimate the AUC. METHODS Data from 70 infant patients were collected retrospectively from their medical records at King Saud University Medical City. The prediction accuracy for vancomycin therapy monitoring was optimized by comparing the two methods for the AUC calculation, the simple linear regression and simplified two-sample equation-based strategy. RESULTS The target AUC > 400 μg × h/ml was achieved in 10%, 71%, and 100% of patients with trough concentration ranges of 5-10, 10-15, and > 15 μg/ml, respectively. There was a strong correlation between the predicted and observed AUC calculated using the simplified two-sample equation-based strategy (R2 = 0.91, bias = -3.9%, precision =12%). CONCLUSIONS The target AUC > 400 μg × h/ml can be achieved at trough concentrations <15 μg/ml in most patients. Targeting trough concentrations >15 can lead to overdoing and increase risk of nephrotoxicity. The authors recommend estimating the AUC using the simplified two-sample equation strategy for more precise dosing of vancomycin. Using AUC-guided dosing instead of the trough-guided approach can prevent over dosing and reduce the risk of nephrotoxicity.
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28
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Brunetti L, Song JH, Suh D, Kim HJ, Seong YH, Lee DS, Lee SM, Suh DC. The risk of vancomycin toxicity in patients with liver impairment. Ann Clin Microbiol Antimicrob 2020; 19:13. [PMID: 32234065 PMCID: PMC7110653 DOI: 10.1186/s12941-020-00354-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/25/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The influence of liver disease on the pharmacokinetic profile, the risk of acute kidney injury, and excessive drug exposure in patients treated with vancomycin was examined. METHODS A retrospective cohort study was performed with patients discharged from a medical center between January 2011 and June 2018 who received vancomycin therapy. Patients were stratified according to liver dysfunction (no to mild liver dysfunction (NMLD) and moderate to severe liver dysfunction (MSLD) based on the Child-Pugh score. The risk of acute kidney injury was compared between patients who were stratified by the attainment of a target serum trough concentration (10 mg/dL to 20 mg/dL) and the vancomycin ratio formed between the area under the curve and minimum inhibitory concentration. The impact of liver dysfunction and a daily dose of vancomycin on the risk of acute kidney injury and vancomycin AUC:MIC > 600 were tested using logistic regression with and without adjusting for the study variables. RESULTS A total of 408 patients empirically treated with vancomycin were included in this study (237 with NMLD and 171 with MSLD). Mean vancomycin trough concentrations (17.5 ± 8.4 mg/dL versus 15.3 ± 5.2 mg/dL, p = 0.0049) and AUC:MIC ratios (549.4 ± 217.2 versus 497.5 ± 117.3, 0.0065) were significantly higher in the MSLD group when compared to the NMLD group, respectively. Vancomycin clearance was also lower in the MSLD group and corresponded to a longer half-life. The proportion of patients who developed acute kidney injury was greater in patients with MSLD when compared to NMLD (7.6% versus 3.8%, respectively; p = 0.0932); however, the difference was statistically insignificant. Furthermore, supratherapeutic serum trough concentrations and AUC:MIC ratios were more common in the MSLD group versus the NMLD group (27.5% versus 13.9%, p = 0.0007 and 28.7% versus 17.3%, respectively; p = 0.0063). CONCLUSIONS MSLD correlates with an increased risk of supratherapeutic vancomycin exposure. Although patients with MSLD had a higher risk of acute kidney injury, the difference was not significant.
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Affiliation(s)
- Luigi Brunetti
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Piscataway, NJ, USA.,Department of Pharmacy, RWJ Barnabas Health-Robert Wood Johnson University Hospital Somerset, Somerville, NJ, USA
| | - Jong Hwa Song
- Department of Pharmacy Administration, Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - David Suh
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Heui Jae Kim
- Department of Pharmacy Administration, Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Yeon Hee Seong
- Department of Pharmacy Administration, Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Dae Song Lee
- Department of Pharmacy Administration, Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Seung-Mi Lee
- Department of Pharmacy, College of Pharmacy, Daegu Catholic University, Gyeongsan-si, Gyeongsangbuk-do, South Korea.
| | - Dong-Churl Suh
- Department of Pharmacy Administration, Chung-Ang University College of Pharmacy, Seoul, South Korea.
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29
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Caplin JD, García AJ. Implantable antimicrobial biomaterials for local drug delivery in bone infection models. Acta Biomater 2019; 93:2-11. [PMID: 30654212 DOI: 10.1016/j.actbio.2019.01.015] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/07/2019] [Accepted: 01/10/2019] [Indexed: 01/05/2023]
Abstract
Increased use of implantable biomedical devices demonstrates their potential in treating a wide variety of ailments and disorders in bone trauma and orthopaedic, reconstructive, and craniofacial applications. However, the number of cases involving implant failure or malfunction due to bacterial infection have also increased in recent years. Implanted devices can facilitate the growth of bacteria as these micro-organisms have the potential to adhere to the implant and grow and develop to form biofilms. In an effort to better understand and mitigate these occurrences, biomaterials containing antimicrobial agents that can be released or presented within the local microenvironment have become an important area of research. In this review, we discuss critical factors that regulate antimicrobial therapy to sites of bone infection, such as key biomolecular considerations and platforms for delivery, as well as current in vivo models and current advances in the field. STATEMENT OF SIGNIFICANCE: This review outlines the important factors that are taken into consideration for the development of biomaterials for local delivery of therapeutics to the site of bone infections. An overview of important criteria for development of this model (such as type of bone defect, antimicrobial therapeutic, and delivery vehicle) are provided, along with current research that utilizes these considerations. Additionally, this review highlights recent clinical trials that have utilized antimicrobial therapeutics for treatment of osteomyelitis.
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30
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Selby AR, Hall RG. Utilizing the Patient Care Process to Minimize the Risk of Vancomycin-Associated Nephrotoxicity. J Clin Med 2019; 8:E781. [PMID: 31159415 PMCID: PMC6616424 DOI: 10.3390/jcm8060781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 05/28/2019] [Accepted: 05/29/2019] [Indexed: 12/28/2022] Open
Abstract
Vancomycin-associated acute kidney injury (AKI) is a popular topic in the medical literature with few clear answers. While many studies evaluate the risk of AKI associated with vancomycin, few data are high quality and/or long in duration of follow-up. This review takes the clinician through an approach to evaluate a patient for risk of AKI. This evaluation should include patient assessment, antibiotic prescription, duration, and monitoring. Patient assessment involves evaluating severity of illness, baseline renal function, hypotension/vasopressor use, and concomitant nephrotoxins. Evaluation of antibiotic prescription includes evaluating the need for methicillin-resistant Staphylococcus aureus (MRSA) coverage and/or vancomycin use. Duration of therapy has been shown to increase the risk of AKI. Efforts to de-escalate vancomycin from the antimicrobial regimen, including MRSA nasal swabs and rapid diagnostics, should be used to lessen the likelihood of AKI. Adequate monitoring includes therapeutic drug monitoring, ongoing fluid status evaluations, and a continual reassessment of AKI risk. The issues with serum creatinine make the timely evaluation of renal function and diagnosis of the cause of AKI problematic. Most notably, concomitant piperacillin-tazobactam can increase serum creatinine via tubular secretion, resulting in higher rates of AKI being reported. The few studies evaluating the long-term prognosis of AKI in patients receiving vancomycin have found that few patients require renal replacement therapy and that the long-term risk of death is unaffected for patients surviving after the initial 28-day period.
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Affiliation(s)
- Ashley R Selby
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center Jerry H. Hodge School of Pharmacy, Dallas, TX 75235, USA.
- VA North Texas Health Care System, Dallas, TX 75216, USA.
| | - Ronald G Hall
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center Jerry H. Hodge School of Pharmacy, Dallas, TX 75235, USA.
- VA North Texas Health Care System, Dallas, TX 75216, USA.
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
- Dose Optimization and Outcomes Research (DOOR) Program, Dallas, TX 75235, USA.
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31
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Jhaveri R. The Time Has Come to Stop Using Vancomycin as Part of Empiric Therapy for Meningitis. J Pediatric Infect Dis Soc 2019; 8:92-93. [PMID: 30380088 DOI: 10.1093/jpids/piy105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/16/2018] [Indexed: 11/13/2022]
Affiliation(s)
- Ravi Jhaveri
- Division of Pediatric Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine
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32
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Risk factors for vancomycin nephrotoxicity and time course of renal function during vancomycin treatment. Eur J Clin Pharmacol 2019; 75:859-866. [PMID: 30770940 DOI: 10.1007/s00228-019-02648-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Vancomycin (VCM) is used for the treatment of methicillin-resistant Staphylococcus aureus. Although the risk factors for VCM nephrotoxicity have been evaluated, the time course of renal function during VCM treatment is unknown. We assessed risk factors for VCM nephrotoxicity and how renal function varied over time. METHODS We conducted a retrospective analysis of patients receiving intravenous VCM treatment between June 2015 and August 2017 at Tokyo Women's Medical University, Medical Center East. VCM nephrotoxicity was defined as an increase in serum creatinine levels > 50%. We performed multivariate logistic regression analysis to assess risk factors for VCM nephrotoxicity. The time course of renal function with VCM nephrotoxicity was compared and stratified by risk factors for VCM nephrotoxicity. Clinical course of VCM nephrotoxicity and VCM trough concentration were assessed. RESULTS In total, 42 (17.3%) of 243 patients developed VCM nephrotoxicity. Risk factors for VCM nephrotoxicity were VCM trough concentration > 20 μg/mL and concomitant use of renal hypoperfusion medications (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, loop/thiazide diuretics, and non-steroidal anti-inflammatory drugs). Although time course of renal function stratified by renal hypoperfusion medications was comparable, the time course of renal function significantly deteriorated in patients with loop/thiazide diuretics. Focusing on patients continuing VCM treatment, VCM nephrotoxicity recovered in 40% of the patients and VCM trough concentration improved to 10-20 μg/mL in 75% of the patients. CONCLUSIONS VCM trough concentration > 20 μg/mL and concomitant use of renal hypoperfusion medications are associated with VCM nephrotoxicity. Recovery of VCM nephrotoxicity was poor compared to the improvement of VCM trough concentration.
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Gyamlani G, Potukuchi PK, Thomas F, Akbilgic O, Soohoo M, Streja E, Naseer A, Sumida K, Molnar MZ, Kalantar-Zadeh K, Kovesdy CP. Vancomycin-Associated Acute Kidney Injury in a Large Veteran Population. Am J Nephrol 2019; 49:133-142. [PMID: 30677750 DOI: 10.1159/000496484] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/21/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND To determine the association of vancomycin with acute kidney injury (AKI) in relation to its serum concentration value and to examine the risk of AKI in patients treated with vancomycin when compared with a matched cohort of patients receiving non-glycopeptide antibiotics (linezolid/daptomycin). METHODS From a cohort of > 3 million US veterans with baseline estimated glomerular filtration rate ≥60 mL/min/1.73 m2, we identified 33,527 patients who received either intravenous vancomycin (n = 22,057) or non-glycopeptide antibiotics (linezolid/daptomycin, n = 11,470). We examined the association of the serum trough vancomycin level recorded within the first 48 h of administration with subsequent AKI in all patients treated with vancomycin and association of vancomycin vs. non-glycopeptide antibiotics use with the risk of incident AKI. RESULTS The overall multivariable adjusted ORs of AKI stages 1, 2, and 3 in patients on vancomycin vs. non-glycopeptides were 1.1 (1.1-1.2), 1.2 (1-1.4), and 1.4 (1.1-1.7), respectively. When examined in strata divided by vancomycin trough level, the odds of AKI were similar or lower in patients receiving vancomycin compared to non-glycopeptide antibiotics as long as serum vancomycin levels were ≤20 mg/L. However, in patients with serum vancomycin levels > 20 mg/L, the ORs of AKI stages 1, 2, and 3 in patients on vancomycin vs. non-glycopeptide antibiotics were 1.5 (1.4-1.7), 1.9 (1.5-2.3), and 2.7 (2-3.5), respectively. CONCLUSIONS Vancomycin use is associated with a higher risk of AKI when serum levels exceed > 20 mg/L.
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Affiliation(s)
- Geeta Gyamlani
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Praveen K Potukuchi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- IHOP, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Oguz Akbilgic
- Center for Biomedical Informatics, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Melissa Soohoo
- Division of Nephrology, University of California, Irvine, California, USA
| | - Elani Streja
- Division of Nephrology, University of California, Irvine, California, USA
| | - Adnan Naseer
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, Tennessee, USA
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA,
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA,
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Sharma M, Braekevelt K, Kale-Pradhan P, Szpunar S, Khatib R. Are Blacks at Higher Risk for Vancomycin-Related Acute Kidney Injury? J Pharm Pract 2019; 33:592-597. [PMID: 30669919 DOI: 10.1177/0897190018800093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Black individuals have a higher lifetime risk of acute kidney injury (AKI) and chronic kidney disease than whites. Vancomycin has a potential for nephrotoxicity. The objective of this study was to determine whether the incidence of AKI among patients being treated with vancomycin differs by race. METHODS Retrospective study of adult (3 ≥18 years) inpatients who were on vancomycin for 348 hours between January 2012 and December 2014. Data on demographics, comorbid conditions, clinical characteristics, vancomycin dose, duration, and nephrotoxic drugs were collected. Patients with a creatinine clearance <30 mL/min or undergoing dialysis were excluded. RESULTS We identified 1130 patients during the study period; 48.1% (544) were black. The overall incidence of AKI was 8.2% (10.1% blacks, 6.5% whites; P = .03). Independent predictors of AKI included black race (P = .011); higher Charlson score (P = .006); higher body mass index (BMI; P = .002); higher vancomycin trough level (P < .0001); and sepsis/systemic inflammatory response syndrome (<.0001), pneumonia (P = .001) or gastrointestinal/genitourinary (P = .025) as the source of infection. CONCLUSION The incidence of vancomycin-related AKI was higher in blacks, independent of other risk factors. Based on our study, vancomycin trough levels and renal function need to be closely monitored in blacks.
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Affiliation(s)
- Mamta Sharma
- Infection Prevention and Control, Ascension, St John Hospital & Medical Center, Detroit, MI, USA
| | | | - Pramodini Kale-Pradhan
- Department of Pharmacy Practice, Wayne State University, Ascension, St John Hospital & Medical Center, Detroit, MI, USA
| | - Susan Szpunar
- Biomedical Investigations and Research, Department of Medical Education, Ascension, St John Hospital & Medical Center, Grosse Pointe Woods, MI, USA
| | - Riad Khatib
- Department of Infectious Diseases, Ascension, St John Hospital & Medical Center, Detroit, MI, USA
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Al-Obaidy SSM, Halbus AF, Greenway GM, Paunov VN. Boosting the antimicrobial action of vancomycin formulated in shellac nanoparticles of dual-surface functionality. J Mater Chem B 2019. [DOI: 10.1039/c8tb03102a] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We demonstrate a strong enhancement of the antimicrobial action of vancomycin encapsulated in shellac nanocarriers with cationic surface functionality which concentrate on the microbial cell membranes.
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Affiliation(s)
- Saba S. M. Al-Obaidy
- Department of Chemistry and Biochemistry
- University of Hull
- Hull
- UK
- Department of Chemistry
| | - Ahmed F. Halbus
- Department of Chemistry and Biochemistry
- University of Hull
- Hull
- UK
- Department of Chemistry
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Patel N, Huang D, Lodise T. Potential for Cost Saving with Iclaprim Owing to Avoidance of Vancomycin-Associated Acute Kidney Injury in Hospitalized Patients with Acute Bacterial Skin and Skin Structure Infections. Clin Drug Investig 2018; 38:935-943. [PMID: 30105549 DOI: 10.1007/s40261-018-0686-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Vancomycin is the most prescribed antibiotic for hospitalized adults with skin and skin structure infections. Vancomycin is associated with acute kidney injury. Iclaprim is an antibiotic under development for the treatment of patients with acute bacterial skin and skin structure infections and is not associated with acute kidney injury. This economic model sought to determine the potential cost saving with iclaprim owing to avoidance of vancomycin-associated acute kidney injury among hospitalized patients with acute bacterial skin and skin structure infections. MATERIALS AND METHODS A hospital cost-minimization model was developed to estimate the overall cost impact of replacing empiric vancomycin with iclaprim among hospitalized adult patients with skin and skin structure infections. The structural model included: vancomycin acquisition; vancomycin assay; incidence of vancomycin-associated acute kidney injury; excess hospital length of stay if acute kidney injury occurred; frequency/cost of specialty physician consults after occurrence of acute kidney injury; and probability/cost of acute dialysis as a result of acute kidney injury. Iclaprim treatment duration was 7 days and iclaprim acquisition cost was varied to determine the upper end of the daily iclaprim price that still conferred cost savings relative to vancomycin. Duration of hospitalization for iclaprim was assumed to be the same as patients with no acute kidney injury. RESULTS Based on the overall acute kidney injury rate (9.2%), the neutral acquisition price threshold for iclaprim vs. vancomycin was US$1373.47/regimen. Across various subpopulations where acute kidney injury risk ranged between 9.2 and 16.7%, the daily iclaprim acquisition cost that still conferred cost savings was up to US$300/day. CONCLUSIONS Iclaprim has the potential to reduce the economic burden of acute bacterial skin and skin structure infections in hospitalized patients at risk for vancomycin-associated acute kidney injury when iclaprim acquisition is US$300/day or less.
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Affiliation(s)
- Nimish Patel
- Pharmacy Practice, Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY, 12208-3492, USA
| | - David Huang
- Motif BioSciences, Inc., 125 Park Avenue, 25th Floor, New York, NY, 10017, USA
| | - Thomas Lodise
- Pharmacy Practice, Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY, 12208-3492, USA.
- IDRx Solutions LLC, 11 Mohagany Drive, Albany, NY, 12208, USA.
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Ho AL, Cannon JGD, Mohole J, Pendharkar AV, Sussman ES, Li G, Edwards MSB, Cheshier SH, Grant GA. Topical vancomycin surgical prophylaxis in pediatric open craniotomies: an institutional experience. J Neurosurg Pediatr 2018; 22:710-715. [PMID: 30141749 DOI: 10.3171/2018.5.peds17719] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 05/30/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVETopical antimicrobial compounds are safe and can reduce cost and complications associated with surgical site infections (SSIs). Topical vancomycin has been an effective tool for reducing SSIs following routine neurosurgical procedures in the spine and following adult craniotomies. However, widespread adoption within the pediatric neurosurgical community has not yet occurred, and there are no studies to report on the safety and efficacy of this intervention. The authors present the first institution-wide study of topical vancomycin following open craniotomy in the pediatric population.METHODSIn this retrospective study the authors reviewed all open craniotomies performed over a period from 05/2014 to 12/2016 for topical vancomycin use, SSIs, and clinical variables associated with SSI. Topical vancomycin was utilized as an infection prophylaxis and was applied as a liquid solution following replacement of a bone flap or after dural closure when no bone flap was reapplied.RESULTSOverall, 466 consecutive open craniotomies were completed between 05/2014 and 12/2016, of which 43% utilized topical vancomycin. There was a 1.5% SSI rate in the nontopical cohort versus 0% in the topical vancomycin cohort (p = 0.045). The number needed to treat was 66. There were no significant differences in risk factors for SSI between cohorts. There were no complications associated with topical vancomycin use.CONCLUSIONSRoutine topical vancomycin administration during closure of open craniotomies can be a safe and effective tool for reducing SSIs in the pediatric neurosurgical population.
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Affiliation(s)
- Allen L Ho
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - John G D Cannon
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - Jyodi Mohole
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - Arjun V Pendharkar
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - Eric S Sussman
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - Gordon Li
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - Michael S B Edwards
- 1Department of Neurosurgery, Stanford University School of Medicine; and.,2Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital Stanford, Stanford, California
| | - Samuel H Cheshier
- 1Department of Neurosurgery, Stanford University School of Medicine; and.,2Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital Stanford, Stanford, California
| | - Gerald A Grant
- 1Department of Neurosurgery, Stanford University School of Medicine; and.,2Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital Stanford, Stanford, California
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Relationship Between Initial Vancomycin Trough Levels and Early-Onset Vancomycin-Associated Nephrotoxicity in Critically Ill Patients. Ther Drug Monit 2018; 40:109-114. [PMID: 29095798 DOI: 10.1097/ftd.0000000000000459] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Appropriate initial dosing of vancomycin (VCM) is important in improving survival and in preventing nephrotoxicity in critically ill patients, but the potential relationship between initial VCM trough levels and early-onset nephrotoxicity remains unclear. We examined the relationship between initial VCM trough levels and early-onset VCM-associated nephrotoxicity. METHODS We performed a retrospective study of patients who had therapeutic drug monitoring of VCM with initial trough levels within 4 days after the beginning of VCM administration. We excluded patients who received renal replacement therapy from 2 days before to 7 days after the beginning of VCM administration, were younger than 18 years, or had renal dysfunction before the beginning of VCM administration. Early-onset VCM-associated nephrotoxicity was defined as an increase in serum creatinine level of ≥0.5 mg/dL (44.2 μmol/L) or 50% above baseline for 2 or more consecutive days within 7 days after the beginning of VCM administration. RESULTS Among 109 enrolled patients, 13 patients had early-onset VCM-associated nephrotoxicity. Its incidence rate was 31.3% in patients with initial trough levels of ≥20g/mL, which was significantly higher than 6.3% in patients with initial trough levels of <10 mg/L. Multiple logistic regression analysis demonstrated that early-onset VCM-associated nephrotoxicity was associated with initial trough levels of ≥20 mg/L (odds ratio, 5.0; 95% confidence interval, 1.3-19.1) and with vasopressor use (odds ratio, 5.0; 95% confidence interval, 1.3-19.1). Kaplan-Meier analysis showed that the probability of nonnephrotoxicity for patients with initial VCM trough levels of ≥20 mg/L was lower compared with patients with trough levels of <15 mg/L. CONCLUSIONS Initial trough levels of ≥20 mg/L but not ≥15 mg/L were associated with early-onset VCM-associated nephrotoxicity in critically ill patients. Future prospective studies are needed to examine outcomes in critically ill patients achieving initial VCM trough levels of 15-20 mg/L.
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Moffett BS, Morris J, Kam C, Galati M, Dutta A, Akcan-Arikan A. Vancomycin associated acute kidney injury in pediatric patients. PLoS One 2018; 13:e0202439. [PMID: 30281600 PMCID: PMC6169857 DOI: 10.1371/journal.pone.0202439] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/02/2018] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Brady S. Moffett
- Texas Children's Hospital, Department of Pharmacy, Houston, Texas, United States of America
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States of America
| | - Jennifer Morris
- Texas Children's Hospital, Department of Pharmacy, Houston, Texas, United States of America
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States of America
| | - Charissa Kam
- Texas Children's Hospital, Department of Pharmacy, Houston, Texas, United States of America
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States of America
| | - Marianne Galati
- Texas Medical Center Library, Houston, Texas, United States of America
| | - Ankhi Dutta
- Texas Children's Hospital, Department of Pharmacy, Houston, Texas, United States of America
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States of America
| | - Ayse Akcan-Arikan
- Texas Children's Hospital, Department of Pharmacy, Houston, Texas, United States of America
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States of America
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Butler-Laporte G, De L'Étoile-Morel S, Cheng MP, McDonald EG, Lee TC. MRSA colonization status as a predictor of clinical infection: A systematic review and meta-analysis. J Infect 2018; 77:489-495. [PMID: 30102944 DOI: 10.1016/j.jinf.2018.08.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 08/02/2018] [Accepted: 08/04/2018] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Guillaume Butler-Laporte
- Division of Infectious Diseases, Department of Medicine, McGill University Health Center, Montréal, Canada.
| | - Samuel De L'Étoile-Morel
- Division of Internal Medicine, Department of Medicine, McGill University Health Center, Montréal, Canada
| | - Matthew P Cheng
- Division of Infectious Diseases, Department of Medicine, McGill University Health Center, Montréal, Canada
| | - Emily G McDonald
- Division of Internal Medicine, Department of Medicine, McGill University Health Center, Montréal, Canada; Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, Canada
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Center, Montréal, Canada; Division of Internal Medicine, Department of Medicine, McGill University Health Center, Montréal, Canada; Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, Canada
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Butler-Laporte G, Cheng MP, McDonald EG, Lee TC. Screening swabs surpass traditional risk factors as predictors of MRSA bacteremia. BMC Infect Dis 2018; 18:270. [PMID: 29890954 PMCID: PMC5996459 DOI: 10.1186/s12879-018-3182-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/03/2018] [Indexed: 11/24/2022] Open
Abstract
Background Consideration to add empiric MRSA therapy with vancomycin is a common clinical dilemma. However, vancomycin overuse has important adverse events. MRSA colonization screening is commonly performed for infection control. We hypothesized that in cases of S. aureus bacteremia, a score based on patient level factors and MRSA colonization could predict the risk of MRSA infection and inform the need for empiric coverage. Methods Using modern machine learning statistical methods (LASSO regression and random forests), we designed a predictive score for MRSA infection based on patient level characteristics, and MRSA colonization as measured by screening done 30 days before infection (30-Day criteria), or at any time before infection (Ever-Positive criteria). Patient factors (age, sex, number of previous admissions, and other medical comorbidities) were obtained through our electronic records. Results With random forests, MRSA colonization largely surpassed all other factors in terms of accuracy and discriminatory power. Using LASSO regression, MRSA colonization was the only factor with MRSA infection predictive power with odds ratio of 10.3 (min: 5.99, max: 16.1) and 8.14 (min: 6.01, max: 14.8) for the 30-Day and Ever-Positive criteria, respectively. Further, patient comorbidities were not adequate predictors of MRSA colonization. Conclusions In an era of community acquired MRSA, colonization status appears to be the only independent and reliable predictor of MRSA infection in cases of S. aureus bacteremia. A clinical approach based on a patient’s known MRSA colonization status and on local susceptibility patterns may be appropriate. Electronic supplementary material The online version of this article (10.1186/s12879-018-3182-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Guillaume Butler-Laporte
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, 1001 Boulevard Décarie, room E05. 1917, Montreal, Quebec, H4A 3J1, Canada.
| | - Matthew P Cheng
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, 1001 Boulevard Décarie, room E05. 1917, Montreal, Quebec, H4A 3J1, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, 1001 Boulevard Décarie, room E05. 1917, Montreal, Quebec, H4A 3J1, Canada.,Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Quebec, Canada
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Park SJ, Lim NR, Park HJ, Yang JW, Kim MJ, Kim K, In YW, Lee YM. Evaluation of risk factors for vancomycin-induced nephrotoxicity. Int J Clin Pharm 2018; 40:1328-1334. [PMID: 29744794 DOI: 10.1007/s11096-018-0634-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 04/04/2018] [Indexed: 11/30/2022]
Abstract
Background Vancomycin is a glycopeptide antibiotic of choice for the treatment of serious infections caused by multi-resistant Gram-positive bacteria. However, vancomycin-associated nephrotoxicity (VAN) often limits its use. Previous data suggested a few risk factors of VAN, including higher mean vancomycin trough level, higher daily doses, old age, long duration of vancomycin therapy, and concomitant nephrotoxins. Objective To evaluate the incidence and risk factors of VAN and determine whether higher vancomycin trough concentrations were associated with a greater risk for VAN. Settings A retrospective, observational, single-center study at the 1960-bed university-affiliated tertiary care hospital (Samsung Medical Center), Seoul, Korea. Method A retrospective analysis of adult patients who received vancomycin parenterally in a tertiary care medical center from March 1, 2013 to June 30, 2013 was performed. We excluded patients with a baseline serum creatinine level > 2 mg/dL and those who had a history of end-stage renal disease and dialysis at baseline. The clinical characteristics were compared between patients with nephrotoxicity and those without nephrotoxicity to identify the risk factors associated with VAN. Main outcome measure Incidence of VAN and VAN-associated risk factors were analyzed. Results Of the 315 vancomycin-treated patients, nephrotoxicity occurred in 15.2% of the patients. In multivariate analysis, higher vancomycin trough concentrations of > 20 mg∕L (OR 9.57, 95% CI 2.49-36.83, p < 0.01) and intensive care unit (ICU) residence (OR 2.86, 95% CI 1.41-5.82, p < 0.01) were independently associated with VAN. Conclusion Our findings suggest that higher vancomycin trough levels and ICU residence might be associated with a greater risk for VAN. More careful monitoring of vancomycin serum trough levels and patient status might facilitate the timely prevention of VAN.
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Affiliation(s)
- So Jin Park
- Samsung Medical Center, Gangnam-gu, Seoul, Republic of Korea
| | - Na Ri Lim
- Samsung Medical Center, Gangnam-gu, Seoul, Republic of Korea
| | - Hyo Jung Park
- Samsung Medical Center, Gangnam-gu, Seoul, Republic of Korea.
| | - Jae Wook Yang
- Samsung Medical Center, Gangnam-gu, Seoul, Republic of Korea
- Department of Pharmaceutical Sciences, Sahmyook University, Seoul, Korea
| | - Min-Ji Kim
- Samsung Medical Center, Gangnam-gu, Seoul, Republic of Korea
- Statistics and Data center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Kyunga Kim
- Samsung Medical Center, Gangnam-gu, Seoul, Republic of Korea
- Statistics and Data center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Yong Won In
- Samsung Medical Center, Gangnam-gu, Seoul, Republic of Korea
| | - Young Mee Lee
- Samsung Medical Center, Gangnam-gu, Seoul, Republic of Korea
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Woldu H, Guglielmo BJ. Incidence and Risk Factors for Vancomycin Nephrotoxicity in Acutely Ill Pediatric Patients. J Pharm Technol 2018; 34:9-16. [PMID: 34860973 DOI: 10.1177/8755122517747088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Particularly with the current increased vancomycin dosing trends, the true risk of the agent's nephrotoxicity is not well characterized and remains of concern. Objective: To determine the incidence of vancomycin nephrotoxicity in acutely ill hospitalized children and to secondarily characterize the risk factors for this complication. Methods: A single-center retrospective cohort study conducted at UCSF Benioff Children's Hospital from June 2012 to June 2015. Inpatients 3 months to <19 years who received intravenous vancomycin for ≥48 hours were included. The primary outcome was incidence of nephrotoxicity, defined as an increase in serum creatinine by ≥50% from baseline. Univariate and multivariate analyses were conducted to identify risk factors for vancomycin nephrotoxicity. Results: A total of 291 patients (272 nonnephrotoxic and 19 nephrotoxic) were included in the analysis. Of the 19 patients, 12 (4.1%) were found to have moderate to severe toxicity. The median duration of therapy was 3 (3-5) and 4 (3-6) days for the group with "no nephrotoxicity" and "nephrotoxicity," respectively. The mean time for the serum creatinine to return to normal in patients with nephrotoxicity was 5.1 days. In the multivariate analysis, only final trough concentration ≥15mg/dL (odds ratio = 3.49, 95% confidence interval = 1.2-10.1; P = .021) and receipt of piperacillin/tazobactam (odds ratio = 3.14, 95% confidence interval = 1.02-9.6; P = .046) were significantly associated with nephrotoxicity. Conclusion: The rate of moderate to severe vancomycin-associated nephrotoxicity in acutely ill children is relatively uncommon and reversible. Kidney injury is associated with increased vancomycin trough concentrations and concomitant receipt of nephrotoxins, particularly piperacillin/tazobactam.
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Affiliation(s)
- Henock Woldu
- University of California, San Francisco, CA, USA
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Abstract
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.
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Affiliation(s)
- Meghan N Jeffres
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, 12850 E. Montview Blvd. V20-1212, Aurora, CO, 80045, USA.
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Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin. Clin Orthop Relat Res 2017; 475:1767-1774. [PMID: 28401341 PMCID: PMC5449331 DOI: 10.1007/s11999-017-5302-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In total joint arthroplasty (TJA), vancomycin is used as perioperative antibiotic prophylaxis in patients with penicillin allergy or in patients colonized with methicillin-resistant Staphylococcus aureus (MRSA). Although vancomycin dosing should be weight-based (15 mg/kg), not all surgeons are aware of this; a fixed 1-g dose is instead frequently administered. QUESTIONS/PURPOSES (1) Is there a difference in the risk of periprosthetic joint infection (PJI) in patients receiving vancomycin or cefazolin prophylaxis after primary TJA? (2) What proportion of patients is adequately dosed with vancomycin? (3) Compared with actual fixed dosing, does weight-based dosing result in a greater proportion of patients staying above the recommended 15-mg/L level at the beginning and end of surgery? (4) Are patients overdosed with vancomycin at greater risk of developing nephrotoxicity and acute kidney injury? METHODS A single-institution, retrospective study was performed on 1828 patients undergoing primary TJAs who received vancomycin prophylaxis between 2008 and 2014. During the same period, 5810 patients underwent primary TJA and received cefazolin monotherapy. A chart review was performed to obtain patient characteristics, antibiotic dose and timing of administration, and microbiology data. Adequate vancomycin dosing was defined as 15 mg/kg and within the 125-mg range. Vancomycin levels were calculated at the beginning and end of surgery using pharmacokinetic equations. Levels of 15 mg/L were considered adequate. Logistic regression, chi square tests, and analysis of variance were performed. RESULTS Among primary TJAs, patients receiving vancomycin had a higher rate of PJI (32 of 1828 [2%]) compared with patients receiving cefazolin prophylaxis (62 of 5810 [1%]; adjusted odds ratio, 1.587 [1.004-2.508]; p = 0.048). Ten percent of PJIs in the vancomycin underdosed group (two of 20) was caused by MRSA, and no patients with adequate dosing or overdosing of vancomycin developed PJI with MRSA. Of all procedures in which vancomycin monotherapy was used, 28% (518 of 1828) was adequately dosed according to weight-based dosage recommendations. Furthermore, 94% (1726 of 1828) of patients received a fixed 1-g dose of vancomycin, of whom 64% (1105 of 1726) were underdosed. All patients had vancomycin infusion initiated within 2 hours before incision. A weight-based protocol would have resulted in fewer patients having unacceptably low vancomycin levels (< 15 mg/L) compared with those with actual fixed dosing, both for the beginning of surgery at the time of incision (zero of 1828 [0%] versus 471 of 1828 [26%]; odds ratio, 0.001 [0.000-0.013]; p < 0.001) and at the end of surgery (33 of 1828 [2%] versus 746 of 1828 [41%]; odds ratio, 0.027 [0.019-0.038]; p < 0.001). Between the vancomycin dosage groups, there were no differences in the rate of nephrotoxicity (underdosed: 12 of 1130 [1%], adequately dosed: five of 518 [1%], overdosed: four of 180 [2%], p = 0.363) and acute kidney injury (underdosed: 28 of 1130 [2%], adequately dosed: 10 of 518 [2%], overdosed: six of 180 [3%], p = 0.561). CONCLUSIONS The majority of patients given vancomycin prophylaxis are underdosed according to the weight-based dosage recommendations, and MRSA did not occur in patients who were adequately dosed with vancomycin. Surgeons should thus ensure that their patients are adequately dosed with vancomycin using the recommendation of 15 mg/kg and that the dose of vancomycin is administered in a timely fashion. Furthermore, and based on the findings of this study, we have moved toward limiting the utilization of vancomycin prophylaxis for patients undergoing elective arthroplasty at our institution. LEVEL OF EVIDENCE Level III, therapeutic study.
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Impact of Higher Vancomycin Troughs on Vancomycin-Induced Nephrotoxicity. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2017. [DOI: 10.1097/ipc.0000000000000496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Reducing acute kidney injury due to vancomycin in trauma patients. J Trauma Acute Care Surg 2017; 81:352-7. [PMID: 27192471 DOI: 10.1097/ta.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Supratherapeutic vancomycin trough levels are common after trauma and associated with both increased acute kidney injury (AKI) and mortality. We sought to limit the adverse effects of vancomycin in trauma patients through more frequent trough monitoring. METHODS Beginning in January 2011, trauma patients treated with vancomycin had trough levels (VT) monitored daily until steady state was reached. Trauma patients admitted from January 2011 to May 2015 (POST) were compared with those admitted from January 2006 to December 2010 (PRE). Inclusion criteria required administration of intravenous vancomycin, admission serum creatinine (SCr), and SCr within 72 hours of highest VT. Acute kidney injury was defined as an increase in SCr of at least 0.3 mg/dL or 50% from admission to post-vancomycin administration. Those in the POST group were prospectively followed up until discharge or death. RESULTS Two hundred sixty-three patients met inclusion criteria in the PRE-phase and 115 in the POST-phase. The two groups were similar in age, gender, race, body mass index, pre-existing comorbidities, admission systolic blood pressure, Glasgow Coma Scale, and head Abbreviated Injury Scale. Injury Severity Score was higher in the POST cohort (18 PRE vs. 25 POST, p < 0.001). Compared with PRE, the POST cohort had lower rates of supratherapeutic VT (>20 mg/L) (34.6% PRE vs. 22.6% POST, p = 0.02) and AKI (30.4% PRE vs. 19.1% POST, p = 0.026). After adjusting for confounders, the POST group had a significantly lower risk of AKI with an adjusted odds ratio of 0.457 (p = 0.027). There was a trend toward decreased mortality in the POST cohort, but this did not reach significance (10% PRE vs. 5.2% POST, p = 0.162). CONCLUSIONS A reduction in AKI was observed in trauma patients with daily vancomycin trough levels monitored until steady state. Increased awareness regarding closer surveillance of VT in trauma patients may limit the incidence of vancomycin-related nephrotoxicity. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Filippone EJ, Kraft WK, Farber JL. The Nephrotoxicity of Vancomycin. Clin Pharmacol Ther 2017; 102:459-469. [PMID: 28474732 PMCID: PMC5579760 DOI: 10.1002/cpt.726] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/07/2017] [Accepted: 04/28/2017] [Indexed: 12/13/2022]
Abstract
Vancomycin use is often associated with nephrotoxicity. It remains uncertain, however, to what extent vancomycin is directly responsible, as numerous potential risk factors for acute kidney injury frequently coexist. Herein, we critically examine available data in adult patients pertinent to this question. We review the pharmacokinetics/pharmacodynamics of vancomycin metabolism. Efficacy and safety data are discussed. The pathophysiology of vancomycin nephrotoxicity is considered. Risk factors for nephrotoxicity are enumerated, including the potential synergistic nephrotoxicity of vancomycin and piperacillin‐tazobactam. Suggestions for clinical practice and future research are given.
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Affiliation(s)
- E J Filippone
- Department of Medicine, Sydney Kimmel College of Medicine at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Division of Nephrology, Sydney Kimmel College of Medicine at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - W K Kraft
- Department of Pharmacology and Experimental Therapeutics, Sydney Kimmel College of Medicine at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - J L Farber
- Department of Pathology, Sydney Kimmel College of Medicine at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Pan K, Ma L, Xiang Q, Li X, Li H, Zhou Y, Yang L, Cui Y. Vancomycin-associated acute kidney injury: A cross-sectional study from a single center in China. PLoS One 2017; 12:e0175688. [PMID: 28426688 PMCID: PMC5398886 DOI: 10.1371/journal.pone.0175688] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 03/29/2017] [Indexed: 12/31/2022] Open
Abstract
Objective The objective of this study was to investigate the current situation of vancomycin (VAN)-associated acute kidney injury (VA-AKI) in China and identify the risk factors for VA-AKI, as well as to comprehensively examine the risk related to concurrent drug use. Further, we assessed the outcomes of patients who developed VA-AKI and the risk factors for these outcomes. Finally, we aimed to provide suggestions for improving the prevention and treatment of VA-AKI in China. Methods We conducted a retrospective observational study of inpatients who had been treated with VAN between January 2013 and December 2013 at Peking University First Hospital. AKI was defined as an increase in SCr of ≥0.3 mg/dl (≥26.5 μmol/l) within 48 hours or an increase to ≥1.5 times the baseline certainly or presumably within the past 7 days. VA-AKI was defined as the development of AKI during VAN therapy or within 7 days following the termination of VAN therapy. In addition, we compared patients with NO-AKI, who did not develop AKI during their hospitalization, with those with VA-AKI. Results Of the 934 patients treated with VAN during their hospital stay, 740 were included in this study. Among those excluded, 38.1% (74/194) were excluded because of a lack of data on serum creatinine (SCr). Among the included patients, 120 had confirmed VA-AKI, with an incidence of 16.2% (120/740). Multiple logistic regression analysis revealed that an elevated baseline estimated glomerular filtration rate (eGFR) (odds ratio [OR] = 1.009; p = 0.017) and concomitant vasopressor therapy (OR = 2.942; p = 0.009), nitrate use (OR = 2.869; p = 0.007), imipenem-cilastatin treatment (OR = 4.708; p = 0.000), and contrast medium administration (OR = 6.609 p = 0.005) were independent risk factors for VA-AKI; in addition, the receipt of orthopedic/trauma/burn surgery (OR = 0.3575; p = 0.011) and concomitant compound glycyrrhizin use (OR = 0.290; p = 0.017) were independent protective factors for VA-AKI. Multiple logistic regression analysis also demonstrated that among the patients who developed VA-AKI, coronary heart disease (CHD) (OR = 12.6; p = 0.006) and concomitant vasopressor therapy (OR = 15.4; p = 0.001) were independent risk factors for death. We also evaluated the factors influencing improvement of renal function. Multiple logistic regression analysis demonstrated that CHD (OR = 8.858, p = 0.019) and concomitant contrast medium administration (OR = 9.779, p = 0.005) were independent risk factors and that simultaneous β-blocker treatment (OR = 0.124, p = 0.001) was an independent protective factor for improvement of renal function. Conclusion Patients treated with VAN received insufficient monitoring of SCr and inadequate therapeutic drug monitoring. We recommend that hospitals increase their investment in clinical pharmacists. An elevated baseline eGFR and concomitant vasopressor therapy, nitrate use, imipenem-cilastatin treatment, and contrast medium administration were independent risk factors for VA-AKI; in addition, orthopedic/trauma/burn surgery and concomitant compound glycyrrhizin use were independent protective factors for VA-AKI.
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Affiliation(s)
- Kunming Pan
- Department of Pharmacy, Peking University First Hospital & College of Pharmacy, Peking University Health Science Center, Beijing, China
| | - Lingyun Ma
- Department of Pharmacy, Peking University First Hospital & College of Pharmacy, Peking University Health Science Center, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Xueying Li
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Haixia Li
- Department of Clinical Laboratory, Peking University First Hospital, Xicheng District, Beijing, China
| | - Ying Zhou
- Department of Pharmacy, Peking University First Hospital & College of Pharmacy, Peking University Health Science Center, Beijing, China
- * E-mail: (ZY); (YL)
| | - Li Yang
- Department of Nephrology, Peking University First Hospital, Xicheng District, Beijing, China
- * E-mail: (ZY); (YL)
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital & College of Pharmacy, Peking University Health Science Center, Beijing, China
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Acute Kidney Injury Associated With Vancomycin When Laxity Leads to Injury and Findings on Kidney Biopsy. Am J Ther 2017; 23:e1064-7. [PMID: 26035034 DOI: 10.1097/mjt.0000000000000287] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The issue of vancomycin-induced acute kidney injury (AKI) has resurged with the use of intravenous vancomycin as a first-line antibiotic, often for prolonged periods of time for the management of serious methicillin-resistant Staphylococcus aureus infections, and with a higher recommended trough level (15-20 μg/mL). We have observed 3 patients on intravenous vancomycin who developed very high trough levels (>40 μg/mL) and severe (stage 3) AKI. Those 3 patients underwent kidney biopsy for unresolving AKI, which revealed findings compatible with acute tubular necrosis. The first patient initially developed asymptomatic acute interstitial nephritis because of a concomitant antibiotic that caused worsening of kidney function, and the dose of vancomycin was not properly adjusted while staying at the nursing home. The second was an emaciated patient (BMI, 14) whose serum creatinine level was a deceptive marker of kidney function for the proper dosing of vancomycin, resulting in a toxic level. The third patient developed vancomycin-related AKI on an initially high therapeutic level, which then contributed to further rising in vancomycin level and subsequently causing severe AKI. One patient required hemodialysis, but all 3 patients ultimately recovered their kidney function significantly. A regular monitoring (preferably twice weekly) of serum creatinine and vancomycin trough level is advisable to minimize vancomycin-associated AKI, primarily acute tubular necrosis, for patients requiring prolonged administration of vancomycin (>2 weeks) on the currently recommended higher therapeutic trough levels (>15 μg/mL).
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