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Nachiappa Ganesh R, Edwards A, El Zaatari Z, Gaber L, Barrios R, Truong LD. Vancomycin nephrotoxicity: A comprehensive clinico-pathological study. PLoS One 2024; 19:e0295136. [PMID: 38452051 PMCID: PMC10919848 DOI: 10.1371/journal.pone.0295136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 11/15/2023] [Indexed: 03/09/2024] Open
Abstract
INTRODUCTION Vancomycin, a commonly prescribed antibiotic particularly in the setting of multi-drug resistant infections, is limited by its nephrotoxicity. Despite its common occurrence, much remains unknown on the clinicopathologic profile as well as the pathogenesis of vancomycin nephrotoxicity. Clinical studies included patients often with severe comorbidities and concomitant polypharmacy confounding the causal pathogenesis. Animal models cannot recapitulate this complex clinical situation. Kidney biopsy was not commonly performed. METHODS To address this limitation, we studied 36 patients who had renal biopsies for acute kidney injury (AKI) for suspicion of vancomycin nephrotoxicity. Detailed renal biopsy evaluation, meticulous evaluation of clinical profiles, and up-to-date follow-up allowed for a diagnostic categorization of vancomycin nephrotoxicity (VNT) in 25 patients and absence of vancomycin nephrotoxicity (NO-VNT) in 11 patients. For careful comparison of these two groups, we proceeded to compile a clinicopathologic and morphologic profiles characteristic for each group. RESULTS Patients with VNT had a characteristic clinical profile including a common clinical background, a high serum trough level of vancomycin, a rapidly developed and severe acute kidney injury, and a recovery of renal function often shortly after discontinuation of vancomycin. This clinical course was correlated with characteristic renal biopsy findings including acute tubulointerstitial nephritis of allergic type, frequent granulomatous inflammation, concomitant and pronounced acute tubular necrosis of nephrotoxic type, and vancomycin casts, in the absence of significant tubular atrophy and interstitial fibrosis. This clinico-pathologic profile was different from that of patients with NO-VNT, highlighting its role in the diagnosis, management and pathogenetic exploration of vancomycin nephrotoxicity. CONCLUSION Vancomycin nephrotoxicity has a distinctive morphologic and clinical profile, which should facilitate diagnosis, guide treatment and prognostication, and confer pathogenetic insights.
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Affiliation(s)
- Rajesh Nachiappa Ganesh
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
| | - Angelina Edwards
- Division of Nephrology, Department of Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
| | - Ziad El Zaatari
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
| | - Lillian Gaber
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
| | - Roberto Barrios
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
| | - Luan D. Truong
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
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Kim JY, Yee J, Yoon HY, Han JM, Gwak HS. Risk factors for vancomycin‐associated acute kidney injury: a systematic review and meta‐analysis. Br J Clin Pharmacol 2022; 88:3977-3989. [DOI: 10.1111/bcp.15429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/18/2022] [Accepted: 05/29/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jee Yun Kim
- College of Pharmacy and Graduate School of Pharmaceutical Sciences Ewha Womans University Seoul Republic of Korea
- Department of Pharmacy Catholic Kwandong University International St. Mary’s Hospital Incheon Republic of Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences Ewha Womans University Seoul Republic of Korea
| | - Ha Young Yoon
- College of Pharmacy and Graduate School of Pharmaceutical Sciences Ewha Womans University Seoul Republic of Korea
| | - Ji Min Han
- College of Pharmacy Chungbuk National University Cheongju‐si Chungcheongbuk‐do Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences Ewha Womans University Seoul Republic of Korea
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3
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Surgical Site Infection After Transversus Abdominis Release: a Review. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03413-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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4
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Vancomycin-Associated Acute Kidney Injury: A Narrative Review from Pathophysiology to Clinical Application. Int J Mol Sci 2022; 23:ijms23042052. [PMID: 35216167 PMCID: PMC8877514 DOI: 10.3390/ijms23042052] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 12/12/2022] Open
Abstract
Vancomycin is the most frequently used antibiotic, accounting for up to 35% of hospitalized patients with infection, because of its optimal bactericidal effectiveness and relatively low price. Vancomycin-associated AKI (VA-AKI) is a clinically relevant but not yet clearly understood entity in critically ill patients. The current review comprehensively summarizes the pathophysiological mechanisms of, biomarkers for, preventive strategies for, and some crucial issues with VA-AKI. The pathological manifestations of VA-AKI include acute tubular necrosis, acute tubulointerstitial nephritis (ATIN), and intratubular crystal obstruction. The proposed pathological mechanisms of VA-AKI include oxidative stress and allergic reactions induced by vancomycin and vancomycin-associated tubular casts. Concomitant administration with other nephrotoxic antibiotics, such as piperacillin–tazobactam, high vancomycin doses, and intermittent infusion strategies compared to the continuous infusion are associated with a higher risk of VA-AKI. Several biomarkers could be applied to predict and diagnose VA-AKI. To date, no promising therapy is available. Oral steroids could be considered for patients with ATIN, whereas hemodialysis might be applied to remove vancomycin from the patient. In the future, disclosing more promising biomarkers that could precisely identify populations susceptible to VA-AKI and detect VA-AKI occurrence early on, and developing pharmacological agents that could prevent or treat VA-AKI, are the keys to improve the prognoses of patients with severe infection who probably need vancomycin therapy.
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Liu K, Zhang Y, Xu X, Wu B, Ni J, Li T, Xing C, Mao H. Comparative Prevalence of Acute Kidney Injury in Chinese Patients Receiving Vancomycin with Concurrent β-Lactam Antibiotics: A Retrospective Cohort Study. Clin Ther 2021; 43:e319-e351. [PMID: 34579971 DOI: 10.1016/j.clinthera.2021.08.008] [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] [Received: 04/02/2021] [Revised: 08/07/2021] [Accepted: 08/16/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE The combination of vancomycin and piperacillin/tazobactam (VAN + PTZ) provides a broad spectrum of activity against multiple pathogens. However, a major issue in previous research concerned significant nephrotoxicity associated with this drug combination, and most studies have been conducted in American and European countries, with no similar data available from China. Therefore, this study evaluated the nephrotoxic effects of VAN + PTZ in a large-scale Chinese cohort to determine the prevalence of acute kidney injury (AKI) in this population by comparing PTZ and vancomycin monotherapies and the combined use of vancomycin and β-lactam antibiotics. METHODS This retrospective cohort study identified adult patients who received vancomycin either as monotherapy or in combination with PTZ or carbapenem (VAN + CAR) for at least 48 hours at Jiangsu Province Hospital from January 1, 2017, to December 31, 2018. Patients were also evaluated for the development of AKI, defined according to the Kidney Disease Improving Global Outcome criteria. Duration of vancomycin exposure, steady-state trough vancomycin concentrations, and other risk factors for AKI were assessed. A Bayesian network meta-analysis was conducted to validate our results and comparatively evaluate the nephrotoxicity of β-lactam antibiotics in combination with vancomycin. FINDINGS In all, 752 patients were included in the present study. The prevalence of AKI was higher in the VAN + PTZ group than in the VAN and VAN + CAR groups (15.2% vs 4.0% and 6.0%, respectively). After adjustment for confounding factors, VAN + PTZ was still related to AKI (odds ratio [OR] = 4.37; 95% CI, 1.65-11.59; P = 0.003). The network meta-analysis indicated that VAN + PTZ was associated with a significantly higher risk for AKI than was VAN (OR = 3.23; 95% CI, 2.50-4.35), PTZ (OR = 2.86; 95% CI, 1.92-4.12), VAN + cefepime (FEP) (OR = 2.37; 95% CI, 1.80-3.19), or VAN + CAR (OR = 2.28; 95% CI, 1.64-3.21). However, there was no significant difference with respect to AKI prevalence among the VAN, PTZ, VAN + FEP, and VAN + CAR groups. IMPLICATIONS The prevalence of AKI was higher with VAN + PTZ therapy than with VAN or PTZ monotherapy or with the concurrent use of VAN and FEP or CAR in our study. Clinicians should adequately assess renal function and consider this differential risk for nephrotoxicity when choosing empiric antibiotics in hospitalized patients to minimize the rates of AKI.
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Affiliation(s)
- Kang Liu
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Ying Zhang
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Xueqiang Xu
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Buyun Wu
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Juan Ni
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Ting Li
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Changying Xing
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Huijuan Mao
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China.
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6
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Triffault-Fillit C, Mabrut E, Corbin K, Braun E, Becker A, Goutelle S, Chaudier P, Fessy MH, Dupieux C, Laurent F, Gunst S, Lustig S, Chidiac C, Ferry T, Valour F. Tolerance and microbiological efficacy of cefepime or piperacillin/tazobactam in combination with vancomycin as empirical antimicrobial therapy of prosthetic joint infection: a propensity-matched cohort study. J Antimicrob Chemother 2021; 75:2299-2306. [PMID: 32407512 DOI: 10.1093/jac/dkaa166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The use of piperacillin/tazobactam with vancomycin as empirical antimicrobial therapy (EAT) for prosthetic joint infection (PJI) has been associated with an increased risk of acute kidney injury (AKI), leading us to propose cefepime as an alternative since 2017 in our reference centre. OBJECTIVES To compare microbiological efficacy and tolerance of these two EAT strategies. METHODS All adult patients with PJI empirically treated with vancomycin+cefepime (n = 89) were enrolled in a prospective observational study and matched with vancomycin+piperacillin/tazobactam-treated historical controls (n = 89) according to a propensity score including age, baseline renal function and concomitant use of other nephrotoxic agents. The two groups were compared using Kaplan-Meier curve analysis, and non-parametric tests regarding the proportion of efficacious empirical regimen and the incidence of empirical therapy-related adverse events (AE). RESULTS Among 146 (82.0%) documented infections, the EAT was considered efficacious in 77 (98.7%) and 65 (98.5%) of the piperacillin/tazobactam- and cefepime-treated patients, respectively (P = 1.000). The rate of AE, particularly AKI, was significantly higher in the vancomycin+piperacillin/tazobactam group [n = 27 (30.3%) for all AE and 23 (25.8%) for AKI] compared with the vancomycin+cefepime [n = 13 (14.6%) and 6 (6.7%)] group (P = 0.019 and <0.001, respectively), leading to premature EAT discontinuation in 20 (22.5%) and 5 (5.6%) patients (P = 0.002). The two groups were not significantly different regarding their comorbidities, and AKI incidence was not related to vancomycin plasma overexposure. CONCLUSIONS Based on the susceptibility profile of bacterial isolates from included patients, microbiological efficacy of both strategies was expected to be similar, but vancomycin + cefepime was associated with a significantly lower incidence of AKI.
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Affiliation(s)
- C Triffault-Fillit
- Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - E Mabrut
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - K Corbin
- Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - E Braun
- Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - A Becker
- Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - S Goutelle
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service pharmaceutique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, ISPB Faculté de Pharmacie de Lyon, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Lyon, France
| | - P Chaudier
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service de chirurgie orthopédique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - M H Fessy
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service de chirurgie orthopédique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France
| | - C Dupieux
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm, U1111, Université´ Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007, Lyon, France.,Institut des agents infectieux, Laboratoire de bactériologie, Centre National de référence des staphylocoques, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - F Laurent
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm, U1111, Université´ Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007, Lyon, France.,Institut des agents infectieux, Laboratoire de bactériologie, Centre National de référence des staphylocoques, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - S Gunst
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service de chirurgie orthopédique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - S Lustig
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Service de chirurgie orthopédique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - C Chidiac
- Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - T Ferry
- Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm, U1111, Université´ Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007, Lyon, France
| | - F Valour
- Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm, U1111, Université´ Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007, Lyon, France
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7
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Pais GM, Liu J, Avedissian SN, Hiner D, Xanthos T, Chalkias A, d'Aloja E, Locci E, Gilchrist A, Prozialeck WC, Rhodes NJ, Lodise TP, Fitzgerald JC, Downes KJ, Zuppa AF, Scheetz MH. Lack of synergistic nephrotoxicity between vancomycin and piperacillin/tazobactam in a rat model and a confirmatory cellular model. J Antimicrob Chemother 2021; 75:1228-1236. [PMID: 32011685 DOI: 10.1093/jac/dkz563] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Vancomycin and piperacillin/tazobactam are reported in clinical studies to increase acute kidney injury (AKI). However, no clinical study has demonstrated synergistic toxicity, only that serum creatinine increases. OBJECTIVES To clarify the potential for synergistic toxicity between vancomycin, piperacillin/tazobactam and vancomycin + piperacillin/tazobactam treatments by quantifying kidney injury in a translational rat model of AKI and using cell studies. METHODS (i) Male Sprague-Dawley rats (n = 32) received saline, vancomycin 150 mg/kg/day intravenously, piperacillin/tazobactam 1400 mg/kg/day intraperitoneally or vancomycin + piperacillin/tazobactam for 3 days. Urinary biomarkers and histopathology were analysed. (ii) Cellular injury was assessed in NRK-52E cells using alamarBlue®. RESULTS Urinary output increased from Day -1 to Day 1 with vancomycin but only after Day 2 for vancomycin + piperacillin/tazobactam-treated rats. Plasma creatinine was elevated from baseline with vancomycin by Day 2 and only by Day 4 for vancomycin + piperacillin/tazobactam. Urinary KIM-1 and clusterin were increased with vancomycin from Day 1 versus controls (P < 0.001) and only on Day 3 with vancomycin + piperacillin/tazobactam (P < 0.001, KIM-1; P < 0.05, clusterin). The histopathology injury score was elevated only in the vancomycin group when compared with piperacillin/tazobactam as a control (P = 0.04) and generally not so with vancomycin + piperacillin/tazobactam. In NRK-52E cells, vancomycin induced cell death with high doses (IC50 48.76 mg/mL) but piperacillin/tazobactam did not, and vancomycin + piperacillin/tazobactam was similar to vancomycin. CONCLUSIONS All groups treated with vancomycin demonstrated AKI; however, vancomycin + piperacillin/tazobactam was not worse than vancomycin. Histopathology suggested that piperacillin/tazobactam did not worsen vancomycin-induced AKI and may even be protective.
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Affiliation(s)
- Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA
| | - Jiajun Liu
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA
| | - Sean N Avedissian
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA
| | - Danielle Hiner
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | | | | | - Ernesto d'Aloja
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Emanuela Locci
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Annette Gilchrist
- Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA.,Department of Pharmaceutical Sciences, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Walter C Prozialeck
- Department of Pharmacology, College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Nathaniel J Rhodes
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA
| | - Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Julie C Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kevin J Downes
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Athena F Zuppa
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Midwestern University, Chicago College of Pharmacy Pharmacometrics Center of Excellence, Downers Grove, IL, USA.,Department of Pharmacology, College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
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8
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Blair M, Côté JM, Cotter A, Lynch B, Redahan L, Murray PT. Nephrotoxicity from Vancomycin Combined with Piperacillin-Tazobactam: A Comprehensive Review. Am J Nephrol 2021; 52:85-97. [PMID: 33735856 DOI: 10.1159/000513742] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/11/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recent studies have identified the combination of vancomycin with piperacillin-tazobactam (VPT) to be associated with increased nephrotoxicity. Multiple, large cohort studies have found this widely used combination to have a higher risk of nephrotoxicity than other regimens in a variety of populations. SUMMARY This review summarizes the epidemiology and clinical features of VPT-associated acute kidney injury (AKI). Potential mechanisms involved in the pathogenesis of this phenomenon are also discussed. Key Message: VPT-associated nephrotoxicity is a recently recognized clinical entity. Clinical strategies to minimize the risk of toxicity in this setting include antimicrobial stewardship, monitoring of kidney function, and emerging data supporting the potential role for novel biomarkers in predicting and managing AKI.
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Affiliation(s)
- Matthew Blair
- Division of Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jean-Maxime Côté
- Service of Nephrology, Department of Medicine, Centre Hospitalier Universitaire de Montréal, Montréal, Québec, Canada
- Clinical Research Centre, University College Dublin, Dublin, Ireland
| | - Aoife Cotter
- Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Breda Lynch
- Department of Clinical Microbiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Lynn Redahan
- Division of Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Renal Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Patrick T Murray
- Division of Medicine, Mater Misericordiae University Hospital, Dublin, Ireland,
- Clinical Research Centre, University College Dublin, Dublin, Ireland,
- Department of Renal Medicine, Mater Misericordiae University Hospital, Dublin, Ireland,
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9
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Yabes JM, Stewart L, Shaikh F, Robben PM, Petfield JL, Ganesan A, Campbell WR, Tribble DR, Blyth DM. Risk of Acute Kidney Injury in Combat-Injured Patients Associated With Concomitant Vancomycin and Extended-Spectrum β-Lactam Antibiotic Use. J Intensive Care Med 2020; 36:818-827. [PMID: 32508215 DOI: 10.1177/0885066620930994] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Multidrug-resistant infections complicating combat-related trauma necessitate the use of broad-spectrum antimicrobials. Recent literature posits an association between vancomycin (VANC) and piperacillin-tazobactam (VPT) combination therapy and acute kidney injury (AKI). We examined whether therapy with VPT was associated with an increased risk of AKI compared to VANC and other broad-spectrum β-lactam antibiotics (VBL) following combat-related injuries. METHODS Patients within the Trauma Infectious Disease Outcomes Study (TIDOS) who received ≥48 hours concomitant VPT or VBL started within 24 hours of each other were assessed. Exclusion criteria were receipt of renal replacement therapy and baseline creatinine >1.5 mg/dL. Acute kidney injury was defined by meeting any of the Risk, Injury, Failure, Loss, End Stage Renal Disease (RIFLE), AKIN, or VANC consensus guidelines criteria 3 to 7 days after therapy initiation. Variables significantly associated with AKI were used in inverse probability treatment weighting to perform univariate and subsequent logistic regression multivariate modeling to determine significant risk factors for AKI. RESULTS Sixty-one patients who received VPT and 207 who received VBL were included. Both groups had a median age of 24 years and initial median creatinine of 0.7 mg/dL. The VBL patients were more likely to have sustained blast injuries (P = .001) and received nephrotoxic agents (amphotericin [P = .002] and aminoglycosides [P < .001]). In the VBL group, AKI incidence was 9.7% compared to 13.1% in the VPT group (P = .438). Multivariate analysis identified a relative risk of 1.727 (95% CI: 1.027-2.765) for AKI associated with VPT exposure. Acute kidney injury severity generally met RIFLE Risk criteria and was 1 day in duration. Only 1 patient had persistent renal dysfunction 30 days after therapy completion. CONCLUSION In this young and previously healthy, severely ill combat-injured population, VPT was associated with nearly twice the risk of AKI compared to VBL. Nevertheless, AKI was of low severity, short duration, and had high rates of renal recovery.
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Affiliation(s)
- Joseph M Yabes
- Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, USA
| | - Laveta Stewart
- 231653Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Faraz Shaikh
- 231653Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Paul M Robben
- 8395Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Anuradha Ganesan
- 231653Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA.,8395Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - David R Tribble
- 231653Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Dana M Blyth
- Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, USA
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10
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Bellos I, Karageorgiou V, Pergialiotis V, Perrea DN. Acute kidney injury following the concurrent administration of antipseudomonal β-lactams and vancomycin: a network meta-analysis. Clin Microbiol Infect 2020; 26:696-705. [PMID: 32222460 DOI: 10.1016/j.cmi.2020.03.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/28/2020] [Accepted: 03/17/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute kidney injury is a major complication of vancomycin treatment, especially when it is co-administered with other nephrotoxins. OBJECTIVES This meta-analysis aims to comparatively assess the nephrotoxicity of antipseudomonal β-lactams when combined with vancomycin. DATA SOURCES Medline, Scopus, CENTRAL and Clinicaltrials.gov databases were systematically searched from inception through 20 August 2019. STUDY ELIGIBILITY CRITERIA Studies evaluating acute kidney injury risk following the concurrent use of antipseudomonal β-lactams and vancomycin were selected. PARTICIPANTS Adult and paediatric patients treated in hospital or intensive care unit. INTERVENTIONS Administration of vancomycin combined with any antipseudomonal β-lactam. METHODS Acute kidney injury incidence was defined as the primary outcome. Secondary outcomes included severity, onset, duration, need of renal replacement therapy, length of hospitalization and mortality. Quality of evidence was assessed using the ROBINS-I tool and the Confidence In Network Meta-Analysis approach. RESULTS Forty-seven cohort studies were included, with a total of 56 984 patients. In the adult population, the combination of piperacillin-tazobactam and vancomycin resulted in significantly higher nephrotoxicity rates than vancomycin monotherapy (odds ratio (OR) 2.05, 95% confidence intervals (CI) 1.17-3.46) and its concurrent use with meropenem (OR 1.84, 95% CI 1.02-3.10) or cefepime (OR 1.80, 95% CI 1.13-2.77). In paediatric patients, acute kidney injury was significantly higher with vancomycin plus piperacillin-tazobactam than vancomycin alone (OR 4.18, 95% CI 1.01-17.29) or vancomycin plus cefepime OR 3.71, 95% CI 1.08-11.24). No significant differences were estimated for the secondary outcomes. Credibility of outcomes was judged as moderate, mainly due to imprecision and inter-study heterogeneity. CONCLUSIONS The combination of vancomycin and piperacillin-tazobactam is associated with higher acute kidney injury rates than its parallel use with meropenem or cefepime. Current evidence is exclusively observational and is limited by inter-study heterogeneity. Randomized controlled trials are needed to verify these results and define preventive strategies to minimize nephrotoxicity risk.
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Affiliation(s)
- I Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Greece.
| | - V Karageorgiou
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Greece
| | - V Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Greece
| | - D N Perrea
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Greece
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11
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Alqurashi R, Batwa M, Alghamdi B, Aljohani S, Zaher N, Alzahrani A, Aldigs E, Safdar O. Acute Kidney Injury in Pediatric Patients Treated with Vancomycin and Piperacillin-Tazobactam Versus Vancomycin and Cefotaxime: A Single-center Study. Cureus 2020; 12:e6805. [PMID: 32140363 PMCID: PMC7047341 DOI: 10.7759/cureus.6805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background Previous literature showed a higher incidence of acute kidney injury (AKI) in pediatric patients using vancomycin + piperacillin-tazobactam compared to cefepime + vancomycin. Our aim was to compare the incidence of developing AKI during the use of vancomycin + cefotaxime with that during the use of vancomycin + piperacillin-tazobactam in pediatric patients. Methods This was a retrospective, matched cohort study that used electronic records from May 1, 2015 through April 30, 2018 for all patients aged less than 16 years who received intravenous (IV) vancomycin + piperacillin-tazobactam or cefotaxime + vancomycin for at least 72 hours. AKI was defined by Kidney Disease Improving Global Outcomes (KDIGO) guidelines. Each patient from the vancomycin + piperacillin-tazobactam group was matched 1:1 with those in the vancomycin + cefotaxime group according to their age, chronic disease, gender, and the number of concomitant nephrotoxic agents. A total of 64 cases were included. Statistical analysis was performed using descriptive statistics and binary logistic regression. Results AKI developed in 10 of 32 patients (31.25%) who were using vancomycin + piperacillin-tazobactam. On the other hand, 13 of 32 patients (40.62%) were using cefotaxime + vancomycin (p = 0.047). Of the 10 patients who were on vancomycin + piperacillin-tazobactam regimen, 80% developed AKI Stage I. Of the 13 patients who were using cefotaxime + vancomycin, 46% developed AKI Stage II, although no statistical significance was noted in all stages. Conclusion Our study showed that patients treated with cefotaxime and vancomycin showed a higher incidence of AKI than patients treated with vancomycin and piperacillin-tazobactam, although the study showed no statistical significance.
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Affiliation(s)
| | - Mawaddah Batwa
- Internal Medicine, King Abdulaziz University, Jeddah, SAU
| | | | - Saja Aljohani
- Internal Medicine, King Abdulaziz University, Jeddah, SAU
| | - Nada Zaher
- Internal Medicine, King Abdulaziz University, Jeddah, SAU
| | - Amal Alzahrani
- Internal Medicine, King Abdulaziz University, Jeddah, SAU
| | - Eman Aldigs
- Medical Microbiology and Parasitology, King Abdulaziz University, Jeddah, SAU
| | - Osama Safdar
- Pediatrics, King Abdulaziz University, Jeddah, SAU
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12
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Inage S, Nakamura S, Isoe Y, Okamoto S, Uetake S, Murakami M, Yamaguchi A, Morishima M, Nei T, Ise Y, Katayama S. Acute Kidney Injury in Non-Intensive Care and Intensive Care Patients Treated with Vancomycin and Piperacillin-Tazobactam. J NIPPON MED SCH 2019; 87:66-72. [PMID: 31611508 DOI: 10.1272/jnms.jnms.2020_87-203] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We investigated the incidence of acute kidney injury (AKI) and risk factors associated with vancomycin (VAN) and piperacillin-tazobactam (TZP) combination therapy in non-intensive care unit (ICU) and ICU settings. METHODS In this single-center retrospective cohort study, adults who received VAN for ≥48 h during the period from 1 January 2016 through 31 December 2017 were included. The primary endpoint was incidence of AKI. RESULTS Data from 593 adults were analyzed. The incidence of AKI was 10.6% overall, 8.0% in the non-TZP group, and 19.8% in the TZP group. In univariate analysis, the odds ratio (OR) for AKI was higher in the TZP group than in the non-TZP group (2.84, 95% CI = 1.64-4.90). In both the non-ICU and ICU settings, the OR for AKI was higher in the TZP group than in the non-TZP group (non-ICU: OR = 3.04, 95% CI = 1.52-6.09; ICU: OR = 2.51, 95% CI = 1.03-6.08). Furthermore, in propensity score analysis, the OR for AKI was higher in the TZP group than in the non-TZP group (OR = 2.81, 95% CI = 1.52-5.17). In both the non-ICU and ICU settings, the OR for AKI was higher in the TZP group than in the non-TZP group (non-ICU: OR = 2.57, 95% CI = 1.17-5.64; ICU: OR = 3.51, 95% CI = 1.05-11.6). CONCLUSIONS Combined use of TZP in patients receiving VAN increased AKI incidence in non-ICU and ICU settings.
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Affiliation(s)
- Shunsuke Inage
- Section of Pharmaceutical Services, Nippon Medical School Hospital
| | - Shotaro Nakamura
- Section of Pharmaceutical Services, Nippon Medical School Hospital
| | - Yuto Isoe
- Section of Pharmaceutical Services, Nippon Medical School Hospital
| | - Saori Okamoto
- Section of Pharmaceutical Services, Nippon Medical School Hospital
| | - Sho Uetake
- Section of Pharmaceutical Services, Nippon Medical School Hospital
| | - Misato Murakami
- Section of Pharmaceutical Services, Nippon Medical School Hospital
| | - Ayaka Yamaguchi
- Section of Pharmaceutical Services, Nippon Medical School Hospital
| | - Masayo Morishima
- Department of Infection Control and Prevention, Nippon Medical School Hospital
| | - Takahito Nei
- Department of Infection Control and Prevention, Nippon Medical School Hospital
| | - Yuya Ise
- Section of Pharmaceutical Services, Nippon Medical School Hospital
| | - Shiro Katayama
- Section of Pharmaceutical Services, Nippon Medical School Hospital
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13
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Incidence of Acute Kidney Injury in Critically Ill Patients Receiving Vancomycin with Concomitant Piperacillin-Tazobactam, Cefepime, or Meropenem. Antimicrob Agents Chemother 2019; 63:AAC.02658-18. [PMID: 30782987 DOI: 10.1128/aac.02658-18] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/13/2019] [Indexed: 12/13/2022] Open
Abstract
Critically ill patients are frequently treated with empirical antibiotic therapy, including vancomycin and β-lactams. Recent evidence suggests an increased risk of acute kidney injury (AKI) in patients who received a combination of vancomycin and piperacillin-tazobactam (VPT) compared with patients who received vancomycin alone or vancomycin in combination with cefepime (VC) or meropenem (VM), but most studies were conducted predominately in the non-critically ill population. A retrospective cohort study that included 2,492 patients was conducted in the intensive care units of a large university hospital with the primary outcome being the development of any AKI. The rates of any AKI, as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, were 39.3% for VPT patients, 24.2% for VC patients, and 23.5% for VM patients (P < 0.0001 for both comparisons). Similarly, the incidences of stage 2 and stage 3 AKI were also significantly higher for VPT patients than for the patients in the other groups. The rates of stage 2 and stage 3 AKI, respectively, were 15% and 6.6% for VPT patients, 5.8% and 1.8% for VC patients, and 6.6% and 1.3% for VM patients (P < 0.0001 for both comparisons). In multivariate analysis, the use of vancomycin in combination with piperacillin-tazobactam was found to be an independent predictor of AKI (odds ratio [OR], 2.161; 95% confidence interval [CI], 1.620 to 2.883). In conclusion, critically ill patients receiving the combination of VPT had the highest incidence of AKI compared to critically ill patients receiving either VC or VM.
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14
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Comparison of acute kidney injury risk associated with vancomycin and concomitant piperacillin/tazobactam or cefepime in the intensive care unit. J Crit Care 2018; 48:32-38. [DOI: 10.1016/j.jcrc.2018.08.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/07/2018] [Accepted: 08/10/2018] [Indexed: 11/23/2022]
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15
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Hammond DA, James TB, Atkinson LN, Painter JT, Lusardi K. Changing the Time of Blood Collection to Determine Vancomycin Concentrations in Intensive Care Unit Patients. Crit Care Nurse 2018; 38:24-28. [PMID: 29437075 DOI: 10.4037/ccn2018594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Clinical practice guidelines for initiation and therapeutic drug monitoring, but not timing, of vancomycin dosing exist at many institutions. Scheduling vancomycin trough measurements and doses around the morning blood sample collection could yield more interpretable troughs and increase patient safety. OBJECTIVE To evaluate the appropriateness of blood sample collection times for vancomycin trough measurements before and after an initiative to change the timing of blood sampling to determine vancomycin doses and trough levels in a medical intensive care unit. METHODS A retrospective cohort study was conducted of patients in a medical intensive care unit who received intravenous vancomycin at a scheduled interval. Differences in continuous and categorical data were compared between pre- and postintervention groups. The primary outcome was proportion of blood samples collected for vancomycin trough measurements within 30 minutes of the next scheduled vancomycin dose. RESULTS Baseline characteristics were similar between the preintervention (n = 68) and postintervention (n = 176) groups except for the percentage of blood samples drawn for trough measurements and morning laboratory tests (6% vs 81%; P < .001). Frequency of loading doses was similar between patients in the pre- and postintervention groups, as was weight-based maintenance dosing. There was no significant difference in the percentage of blood samples collected to measure vancomycin trough levels appropriately at 30, 60, or 75 minutes from the next scheduled dose. CONCLUSION Measuring vancomycin trough levels in morning blood samples did not affect the percentage of inappropriately collected blood samples used to measure vancomycin trough levels.
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Affiliation(s)
- Drayton A Hammond
- Drayton A. Hammond is a clinical pharmacy specialist at the Rush University Medical Center, Chicago, Illinois. .,Taylor B. James is a first-year pharmacy resident at the University of Arkansas for Medical Sciences Medical Center, Little Rock, Arkansas. .,Lexis N. Atkinson is a first-year pharmacy resident at the University of Arkansas for Medical Sciences Medical Center. .,Jacob T. Painter is an assistant professor of pharmacy practice within the Division of Pharmaceutical Evaluation and Policy at the University of Arkansas for Medical Sciences College of Pharmacy. .,Katherine Lusardi is an antimicrobial stewardship pharmacist at the University of Arkansas for Medical Sciences College of Pharmacy.
| | - Taylor B James
- Drayton A. Hammond is a clinical pharmacy specialist at the Rush University Medical Center, Chicago, Illinois.,Taylor B. James is a first-year pharmacy resident at the University of Arkansas for Medical Sciences Medical Center, Little Rock, Arkansas.,Lexis N. Atkinson is a first-year pharmacy resident at the University of Arkansas for Medical Sciences Medical Center.,Jacob T. Painter is an assistant professor of pharmacy practice within the Division of Pharmaceutical Evaluation and Policy at the University of Arkansas for Medical Sciences College of Pharmacy.,Katherine Lusardi is an antimicrobial stewardship pharmacist at the University of Arkansas for Medical Sciences College of Pharmacy
| | - Lexis N Atkinson
- Drayton A. Hammond is a clinical pharmacy specialist at the Rush University Medical Center, Chicago, Illinois.,Taylor B. James is a first-year pharmacy resident at the University of Arkansas for Medical Sciences Medical Center, Little Rock, Arkansas.,Lexis N. Atkinson is a first-year pharmacy resident at the University of Arkansas for Medical Sciences Medical Center.,Jacob T. Painter is an assistant professor of pharmacy practice within the Division of Pharmaceutical Evaluation and Policy at the University of Arkansas for Medical Sciences College of Pharmacy.,Katherine Lusardi is an antimicrobial stewardship pharmacist at the University of Arkansas for Medical Sciences College of Pharmacy
| | - Jacob T Painter
- Drayton A. Hammond is a clinical pharmacy specialist at the Rush University Medical Center, Chicago, Illinois.,Taylor B. James is a first-year pharmacy resident at the University of Arkansas for Medical Sciences Medical Center, Little Rock, Arkansas.,Lexis N. Atkinson is a first-year pharmacy resident at the University of Arkansas for Medical Sciences Medical Center.,Jacob T. Painter is an assistant professor of pharmacy practice within the Division of Pharmaceutical Evaluation and Policy at the University of Arkansas for Medical Sciences College of Pharmacy.,Katherine Lusardi is an antimicrobial stewardship pharmacist at the University of Arkansas for Medical Sciences College of Pharmacy
| | - Katherine Lusardi
- Drayton A. Hammond is a clinical pharmacy specialist at the Rush University Medical Center, Chicago, Illinois.,Taylor B. James is a first-year pharmacy resident at the University of Arkansas for Medical Sciences Medical Center, Little Rock, Arkansas.,Lexis N. Atkinson is a first-year pharmacy resident at the University of Arkansas for Medical Sciences Medical Center.,Jacob T. Painter is an assistant professor of pharmacy practice within the Division of Pharmaceutical Evaluation and Policy at the University of Arkansas for Medical Sciences College of Pharmacy.,Katherine Lusardi is an antimicrobial stewardship pharmacist at the University of Arkansas for Medical Sciences College of Pharmacy
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16
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Comparative incidence and excess risk of acute kidney injury in hospitalised patients receiving vancomycin and piperacillin/tazobactam in combination or as monotherapy. Int J Antimicrob Agents 2018; 52:643-650. [PMID: 30103003 DOI: 10.1016/j.ijantimicag.2018.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/20/2018] [Accepted: 08/04/2018] [Indexed: 12/13/2022]
Abstract
Combination therapy with vancomycin and piperacillin/tazobactam (TZP) has been associated with increased risk of acute kidney injury (AKI) compared with monotherapy with either agent. This retrospective, matched cohort study was conducted to assess the comparative incidence of AKI due to combination therapy in patients receiving vancomycin and TZP in combination or as monotherapy. Patients aged ≥18 years admitted to Albany Medical Center (Albany, NY) between September 2013 and August 2014 who had received therapy for at least two consecutive days were included. Patients who were pregnant, neutropenic, had AKI on admission or with cystic fibrosis were excluded. Patients were matched on baseline risk of AKI. The main outcome of interest was AKI, defined as an increase in serum creatinine of ≥0.3 mg/L or ≥50% within 48 h. Secondary outcomes evaluated were length of hospital and ICU stay and inpatient mortality associated with AKI. The risk of AKI was 7.0%, 8.5% and 26.8% in the vancomycin monotherapy, TZP monotherapy and combination groups, respectively (P < 0.001). In the multivariate analysis, combination therapy was independently associated with an increased odds of AKI (adjusted odds ratio = 4.406, 95% confidence interval 1.472-13.188) compared with vancomycin monotherapy. The excess risk of combination therapy was 11.3%. In this matched cohort study, there was an increased incidence of AKI in patients receiving vancomycin and TZP combination therapy. Further research is needed to determine the individual strategies to best prevent inpatient AKI in patients receiving this combination therapy.
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17
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Luther MK, Timbrook TT, Caffrey AR, Dosa D, Lodise TP, LaPlante KL. Vancomycin Plus Piperacillin-Tazobactam and Acute Kidney Injury in Adults: A Systematic Review and Meta-Analysis. Crit Care Med 2017; 46:12-20. [PMID: 29088001 DOI: 10.1097/ccm.0000000000002769] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The objective of this systematic review and meta-analysis was to assess acute kidney injury with combination therapy of vancomycin plus piperacillin-tazobactam, in general, adult patients and in critically ill adults. Rates of acute kidney injury, time to acute kidney injury, and odds of acute kidney injury were compared with vancomycin monotherapy, vancomycin plus cefepime or carbapenem, or piperacillin-tazobactam monotherapy. DATA SOURCES Studies were identified by searching Pubmed, Embase, Web of Science, and Cochrane from inception to April 2017. Abstracts from selected conference proceedings were manually searched. STUDY SELECTION Articles not in English, pediatric studies, and case reports were excluded. DATA EXTRACTION Two authors independently extracted data on study methods, rates of acute kidney injury, and time to acute kidney injury. Effect estimates and 95% CIs were calculated using the random effects model in RevMan 5.3. DATA SYNTHESIS Literature search identified 15 published studies and 17 conference abstracts with at least 24,799 patients. The overall occurrence rate of acute kidney injury was 16.7%, with 22.2% for vancomycin plus piperacillin-tazobactam and 12.9% for comparators. This yielded an overall number needed to harm of 11. Time to acute kidney injury was faster for vancomycin plus piperacillin-tazobactam than vancomycin plus cefepime or carbapenem, but not significantly (mean difference, -1.30; 95% CI, -3.00 to 0.41 d). The odds of acute kidney injury with vancomycin plus piperacillin-tazobactam were increased versus vancomycin monotherapy (odds ratio, 3.40; 95% CI, 2.57-4.50), versus vancomycin plus cefepime or carbapenem (odds ratio, 2.68; 95% CI, 1.83-3.91), and versus piperacillin-tazobactam monotherapy (odds ratio, 2.70; 95% CI, 1.97-3.69). In a small subanalysis of 968 critically ill patients, the odds of acute kidney injury were increased versus vancomycin monotherapy (odds ratio, 9.62; 95% CI, 4.48-20.68), but not significantly different for vancomycin plus cefepime or carbapenem (odds ratio, 1.43; 95% CI, 0.83-2.47) or piperacillin-tazobactam monotherapy (odds ratio, 1.35; 95% CI, 0.86-2.11). CONCLUSIONS The combination of vancomycin plus piperacillin-tazobactam increased the odds of acute kidney injury over vancomycin monotherapy, vancomycin plus cefepime or carbapenem, and piperacillin-tazobactam monotherapy. Limited data in critically ill patients suggest the odds of acute kidney injury are increased versus vancomycin monotherapy, and mitigated versus the other comparators. Further research in the critically ill population is needed.
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Affiliation(s)
| | - Tristan T Timbrook
- Rhode Island Infectious Diseases (RIID) Research Program, Veterans Affairs Medical Center, Providence, RI.,University of Rhode Island, College of Pharmacy, Kingston, RI
| | | | - David Dosa
- Center of Innovation in Long-Term Services and Supports, Veterans Affairs Medical Center, Providence, RI.,Brown University, Providence, RI
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18
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Watkins RR, Deresinski S. Increasing Evidence of the Nephrotoxicity of Piperacillin/Tazobactam and Vancomycin Combination Therapy—What Is the Clinician to Do? Clin Infect Dis 2017; 65:2137-2143. [DOI: 10.1093/cid/cix675] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/27/2017] [Indexed: 12/12/2022] Open
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19
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Jeon N, Staley B, Klinker KP, Hincapie Castillo J, Winterstein AG. Acute kidney injury risk associated with piperacillin/tazobactam compared with cefepime during vancomycin therapy in hospitalised patients: a cohort study stratified by baseline kidney function. Int J Antimicrob Agents 2017; 50:63-67. [DOI: 10.1016/j.ijantimicag.2017.02.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/20/2017] [Accepted: 02/22/2017] [Indexed: 12/31/2022]
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20
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Hammond DA, Atkinson LN, James TB, Painter JT, Lusardi K. Effects of staff education and standardizing dosing and collection times on vancomycin trough appropriateness in ward patients. Pharm Pract (Granada) 2017; 15:949. [PMID: 28690700 PMCID: PMC5499355 DOI: 10.18549/pharmpract.2017.02.949] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/30/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Many institutions have guidelines for initiation and monitoring, but not timing, of vancomycin. OBJECTIVE Our objective was to evaluate vancomycin trough collection appropriateness before and after an initiative to change the dosing and trough collection times in ward patients. METHODS A retrospective cohort study of ward patients from May 2014-16 who received scheduled intravenous vancomycin was performed. Nurse managers and pharmacists provided staff education. Differences between pre- and post-intervention groups were compared using student's t-test for continuous data and chi-square test for categorical data. RESULTS Baseline characteristics were similar between the pre-intervention (n=124) and post-intervention (n=122) groups except for weight-based maintenance dose (15.3 mg/kg vs. 16.5 mg/kg, p=0.03) and percentage of troughs collected with morning labs (14% vs. 87%, p<0.001). Patients in the pre- and post-intervention groups received a similar frequency of loading doses (14.5% vs. 16%, p=0.68). There was no significant difference in percentage of vancomycin troughs collected appropriately at 30 (40% vs. 42%, p=0.72), 60 (57% vs. 63%, p=0.35), or 75 (60% vs. 68%, p=0.22) minutes from the scheduled time of the next dose. CONCLUSION Staff education and standardizing collection of vancomycin troughs with morning blood collections did not affect the percentage of appropriately collected vancomycin troughs.
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Affiliation(s)
- Drayton A Hammond
- PharmD, MBA, BCPS, BCCCP. Assistant Professor. Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciences; & Department of Pharmacy, University of Arkansas for Medical Sciences Medical Center. Little Rock, AR (United States).
| | - Lexis N Atkinson
- Pharmacy Resident. Department of Pharmacy, Central Arkansas Veterans Healthcare System. Little Rock, AR (United States).
| | - Taylor B James
- Pharmacy Resident. Department of Pharmacy, University of Arkansas for Medical Sciences Medical Center. Little Rock, AR (United States).
| | - Jacob T Painter
- PharmD, PhD, MBA. Assistant Professor. Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciences. Little Rock, AR (United States).
| | - Katherine Lusardi
- PharmD, BCPS (AQ-Infectious Diseases). Antimicrobial Stewardship Pharmacist. Department of Pharmacy, University of Arkansas for Medical Sciences Medical Center. Little Rock, AR (United States).
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21
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Rutter WC, Burgess DS. Acute Kidney Injury in Patients Treated with IV Beta-Lactam/Beta-Lactamase Inhibitor Combinations. Pharmacotherapy 2017; 37:593-598. [PMID: 28247443 DOI: 10.1002/phar.1918] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE Increased acute kidney injury (AKI) incidence has been reported in patients receiving piperacillin-tazobactam (PTZ) therapy compared with other β-lactams. The authors sought to determine if the addition of β-lactamase inhibitors impacts AKI incidence by comparing patients treated with PTZ or ampicillin-sulbactam (SAM). DESIGN Retrospective cohort study. SETTING Large academic tertiary care hospital. PATIENTS Overall, 2448 patients received PTZ (n=1836) or SAM (n=612) for at least 48 hours between September 1, 2007, and September 30, 2015. Patients were excluded for pregnancy, cystic fibrosis, chronic kidney disease, and initial creatinine clearance < 30 ml/min. Patients were matched on Charlson Comorbidity Index, initial creatinine clearance, hypotension exposure, various nephrotoxic drug exposures, history of diabetes, heart failure, and hypertension. MEASUREMENTS AND MAIN RESULTS AKI occurred in 265 patients at similar rates for both groups (PTZ 11.4% vs SAM 9.2%; p=0.14). After stratifying by vancomycin exposure and controlling for confounders, there was no difference in the risk of AKI for SAM or PTZ (adjusted odds ratio [aOR] 0.87, 95% confidence interval [CI] 0.59-1.25). The addition of vancomycin (VAN) to PTZ increased the likelihood of AKI compared with PTZ alone (aOR 1.77, 95% CI 1.26-2.46). Concomitant SAM and VAN therapy was not associated with a significant increase in AKI compared with SAM monotherapy (aOR 1.01, 95% CI 0.48-1.97). CONCLUSION Rates of AKI were similar for PTZ and SAM in a matched cohort. The addition of a β-lactamase inhibitor is not likely the mechanism in the observed increased rates of AKI in patients treated with vancomycin and PTZ.
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Affiliation(s)
- W Cliff Rutter
- University of Kentucky College of Pharmacy, Lexington, Kentucky.,University of Kentucky HealthCare, Lexington, Kentucky
| | - David S Burgess
- University of Kentucky College of Pharmacy, Lexington, Kentucky
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Rutter WC, Burgess DR, Talbert JC, Burgess DS. Acute kidney injury in patients treated with vancomycin and piperacillin-tazobactam: A retrospective cohort analysis. J Hosp Med 2017; 12:77-82. [PMID: 28182801 PMCID: PMC5573255 DOI: 10.12788/jhm.2684] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Empiric antimicrobial therapy often consists of the combination of gram-positive coverage with vancomycin (VAN) and gram-negative coverage, specifically an antipseudomonal beta-lactam such as piperacillin-tazobactam (PTZ). Nephrotoxicity is commonly associated with VAN therapy; however, recent reports show higher nephrotoxicity rates among patients treated with the combination of VAN and PTZ. OBJECTIVE This study evaluated the effect of the VAN/PTZ combination on acute kidney injury (AKI) compared to VAN and PTZ monotherapies. DESIGN, SETTING, AND PATIENTS This is a retrospective cohort analysis of adult patients without renal disease receiving VAN, PTZ, or the combination from September 1, 2010 through August 31, 2014 at an academic medical center. MEASUREMENTS The primary outcome was AKI incidence as defined by the Risk, Injury, Failure, Loss, End-stage (RIFLE) criteria. METHODS Continuous and categorical variables were assessed with appropriate tests. Univariate and multivariate logistic regressions were performed to assess for associations between variables and AKI incidence. Subanalyses based on severity of illness were performed. RESULTS Overall, 11,650 patients were analyzed, with 1647 (14.1%) developing AKI. AKI was significantly more frequent in the VAN/PTZ group (21%) compared to either monotherapy group (VAN 8.3%, PTZ 7.8%, P ⟨ 0.001 for both). Combination therapy was independently associated with higher AKI odds compared to monotherapy with either agent (adjusted odds ratio [aOR], 2.03; 95% confidence interval [CI], 1.74-2.39; aOR, 2.31; 95% CI, 1.97-2.71, for VAN and PTZ, respectively). Receipt of concomitant nephrotoxic drugs was independently associated with increased AKI rates, as were increased duration of therapy, hospital length of stay, increasing severity of illness, and increasing baseline renal function. CONCLUSIONS In this study of more than 10,000 patients, VAN combined with PTZ was associated with twice the odds of AKI development compared to either agent as monotherapy. This demonstrates the need for judicious use of combination empiric therapy. Journal of Hospital Medicine 2017;12:77-82.
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Affiliation(s)
- W. Cliff Rutter
- University of Kentucky College of Pharmacy, Lexington, Kentucky
- University of Kentucky HealthCare, Lexington, Kentucky
- University of Kentucky Institute for Pharmaceutical Outcomes and Policy, Lexington, Kentucky
| | - Donna R. Burgess
- University of Kentucky College of Pharmacy, Lexington, Kentucky
- University of Kentucky HealthCare, Lexington, Kentucky
| | - Jeffery C. Talbert
- University of Kentucky College of Pharmacy, Lexington, Kentucky
- University of Kentucky Institute for Pharmaceutical Outcomes and Policy, Lexington, Kentucky
- University of Kentucky Center for Clinical and Translational Science, Lexington, Kentucky
| | - David S. Burgess
- University of Kentucky College of Pharmacy, Lexington, Kentucky
- Address for correspondence and reprint requests: David S. Burgess, PharmD, FCCP, University of Kentucky College of Pharmacy, 789 South Limestone Street, TODD 292K, Lexington, KY 40536-0596; Telephone: 859-218-0948; Fax: 859 323-0069;
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Nephrotoxicity during Vancomycin Therapy in Combination with Piperacillin-Tazobactam or Cefepime. Antimicrob Agents Chemother 2017; 61:AAC.02089-16. [PMID: 27895019 DOI: 10.1128/aac.02089-16] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 11/21/2016] [Indexed: 02/02/2023] Open
Abstract
Recent reports have demonstrated that vancomycin (VAN) may lead to an increase in the incidence of acute kidney injury (AKI) when it is combined with antipseudomonal beta-lactams. This study compared the incidence of AKI associated with VAN plus piperacillin-tazobactam (TZP) or cefepime (FEP). This was a retrospective, matched cohort study that was conducted at an academic medical center between September 2010 and September 2014 and that included adult patients without severe chronic or structural kidney disease, dialysis, pregnancy, cystic fibrosis, or a hospital transfer receiving TZP-VAN or FEP-VAN for at least 48 h. The primary outcome was the difference in the AKI incidence between the TZP-VAN and FEP-VAN groups, evaluated using the risk, injury, failure, loss of kidney function, and end-stage kidney disease (RIFLE) criteria. Patients in the two groups were matched on the basis of age, sex, severity of illness, baseline creatinine clearance, hypotension, number of nephrotoxicity risk factors, and intravenous contrast exposure. In total, 4,193 patients met all inclusion criteria (3,605 received TZP-VAN and 588 received FEP-VAN). The unadjusted AKI incidence was 21.4% in patients receiving TZP-VAN, whereas it was 12.6% in patients receiving FEP-VAN (P < 0.001). After the patients were matched, 1,633 patients receiving TZP-VAN and 578 patients receiving FEP-VAN were evaluated. The AKI incidence remained higher in patients receiving TZP-VAN than in those receiving FEP-VAN (21.4% versus 12.5%, P < 0.0001). This trend remained true for all classifications of the RIFLE criteria. After controlling for remaining confounders, TZP-VAN therapy was associated with 2.18 times the odds of AKI than FEP-VAN therapy (95% confidence interval, 1.64 to 2.94 times) in logistic regression. AKI was significantly more common in patients receiving vancomycin in combination with piperacillin-tazobactam than in those receiving vancomycin in combination with cefepime. This finding reinforces the need for the judicious use of combination empirical antimicrobial therapy.
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