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Joerger T, Hayes M, Stinson C, Mikhail I, Downes KJ. Incidence of Antimicrobial-Associated Acute Kidney Injury in Children: A Structured Review. Paediatr Drugs 2024; 26:59-70. [PMID: 38093147 PMCID: PMC10983053 DOI: 10.1007/s40272-023-00607-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 01/06/2024]
Abstract
Acute kidney injury (AKI) is a commonly reported adverse effect of administration of antimicrobials. While AKI can be associated with poorer outcomes, there is little information available to understand rates of AKI in children exposed to various antimicrobials. We performed a structured review using the PubMed and Embase databases. Articles were included if they provided an AKI definition in patients who were < 19 years of age receiving an antimicrobial and reported the frequency of AKI. Author-defined AKI rates were calculated for each study and mean pooled estimates for each antimicrobial were derived from among all study participants. Pooled estimates were also derived for those studies that reported AKI according to pRIFLE (pediatric risk, injury, failure, loss, end stage criteria), AKIN (acute kidney injury network), or KDIGO (kidney disease improving global outcomes) creatinine criteria. A total of 122 studies evaluating 28 antimicrobials met the inclusion criteria. Vancomycin was the most commonly studied drug: 11,514 courses across 44 included studies. Among the 27,285 antimicrobial exposures, the overall AKI rate was 13.2% (range 0-42.1% by drug), but the rate of AKI varied widely across studies (range 0-68.8%). Cidofovir (42.1%) and conventional amphotericin B (37.0%) had the highest pooled rates of author-defined AKI. Eighty-one studies used pRIFLE, AKIN, or KDIGO AKI criteria and the pooled rates of AKI were similar to author-defined AKI rates. In conclusion, antimicrobial-associated AKI is reported to occur frequently in children, but the rates of AKI varies widely across studies and drugs. Most published studies examined hospitalized patients and heterogeneity in study populations and in author definitions of AKI are barriers to a comparison of nephrotoxicity risk among antimicrobials in children.
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Affiliation(s)
- Torsten Joerger
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Molly Hayes
- Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Connor Stinson
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Ibram Mikhail
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Kevin J Downes
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
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Zhang M, Lang B, Li H, Huang L, Zeng L, Jia ZJ, Cheng G, Zhu Y, Zhang L. Incidence and risk factors of drug-induced kidney injury in children: a systematic review and meta-analysis. Eur J Clin Pharmacol 2023; 79:1595-1606. [PMID: 37787852 DOI: 10.1007/s00228-023-03573-6] [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: 06/08/2023] [Accepted: 09/17/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE To comprehensively summarize the incidence and risk factors of drug-induced kidney injury (DIKI) in children. METHODS We systematically searched seven databases from inception to November 2022. Two independent reviewers selected studies, extracted data, and assessed the risk of bias. Meta-analyses were conducted to quantify the incidence and risk factors of DIKI in children. RESULTS A total of 69 studies comprising 195,894 pediatric patients were included. Overall, the incidence of DIKI in children was 18.2% (95%CI: 16.4%-20.1%). The incidence of DIKI in critically ill children (19.6%, 95%CI: 15.9%-23.3%) was higher than that in non-critically ill children (16.1%, 95%CI: 12.9%-19.4%). Moreover, the risk factors for DIKI in children were intensive care unit (ICU) admission (OR = 1.59, 95% CI: 1.42-1.78, P = 0.000), treatment days (OR = 1.04, 95% CI: 1.03-1.05, P = 0.000), surgical intervention (OR = 1.43, 95% CI: 1.00-2.02, P = 0.048), infection (OR = 2.30, 95% CI: 1.44-3.66, P = 0.000), patent ductus arteriosus (OR = 4.78, 95% CI: 1.82-12.57, P = 0.002), chronic kidney disease (OR = 2.78, 95% CI: 1.92-4.02, P = 0.000), combination with antibacterial agents (OR = 1.98, 95% CI: 1.54-2.55, P = 0.000), diuretics (OR = 1.97, 95% CI: 1.51-2.56, P = 0.000), combination with antiviral agents (OR = 1.50, 95% CI: 1.11-2.04, P = 0.008), combination with non-steroidal anti-inflammatory drugs (OR = 1.79, 95% CI: 1.40-2.28, P = 0.000), and combination with immunosuppressive agents (OR = 2.84, 95% CI: 1.47-5.47, P = 0.002). CONCLUSION The incidence of DIKI in children is high, especially in critically ill children. Identifying high-risk groups and determining safer treatments is critical to reducing the incidence of DIKI in children. In clinical practice, clinicians should adjust medication regimens for high-risk pediatric groups, such as ICU admission, some underlying diseases, combination with nephrotoxic drugs, etc., and regularly evaluate kidney function throughout treatment.
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Affiliation(s)
- Miao Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Bingchen Lang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Hailong Li
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Liang Huang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Zhi-Jun Jia
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Guo Cheng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Laboratory of Molecular Translational Medicine, Center for Translational Medicine, Sichuan University, Chengdu, China
| | - Yu Zhu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China.
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Chen J, Huang X, Yu L, Li J, Yang R, Li L, Zhou J, Yao H, Bu S. Vancomycin population pharmacokinetics analysis in Chinese paediatric patients with varying degrees of renal function and ages: development of new practical dosing recommendations. J Antimicrob Chemother 2023:dkad202. [PMID: 37379498 PMCID: PMC10393882 DOI: 10.1093/jac/dkad202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023] Open
Abstract
OBJECTIVES To describe the pharmacokinetics of vancomycin in a large Chinese paediatric cohort with varying degrees of renal function and ages and to develop practical dosing guidelines. PATIENTS AND METHODS We conducted a retrospective population pharmacokinetic study using data from paediatric patients who received vancomycin between June 2013 and June 2022. A non-linear mixed-effect modelling approach with a one-compartment model structure was applied. Monte Carlo simulations were used to stimulate an optimal dosage regimen to achieve the target of AUC24/MIC between 400 and 650. RESULTS We analysed a total of 673 paediatric patients and 1547 vancomycin serum concentrations. Covariate analysis revealed that physiological maturation, renal function, albumin and cardiothoracic surgery (CTS) significantly affected vancomycin pharmacokinetics. The typical clearance and volume of distribution, standardized to 70 kg, were 7.75 L/h (2.3% relative standard error, RSE) and 36.2 L (1.7% RSE), respectively. Based on the model, we proposed an optimal dosing regimen that considers the patient's age and estimate glomerular filtration rate (eGFR) to achieve a target AUC24/MIC for CTS and non-CTS patients. We also found that a loading dose of 20 mg/kg can help patients with an eGFR of <60 mL/min/1.73 m2 achieve the target AUC on the first day of treatment. CONCLUSIONS We established vancomycin pharmacokinetic parameters in Chinese paediatric patients and proposed a dosing guideline integrating eGFR, age and CTS status, potentially improving clinical outcomes and reducing nephrotoxicity risk.
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Affiliation(s)
- Jihui Chen
- Department of Clinical Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaohui Huang
- Department of Clinical Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Liting Yu
- Department of Pharmacy, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jiru Li
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Rui Yang
- Department of Clinical Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lixia Li
- Department of Clinical Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jia Zhou
- Department of Clinical Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Huijuan Yao
- Department of Clinical Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shuhong Bu
- Department of Clinical Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Celegen K, Celegen M. A Retrospective Analysis of Risk Factors and Impact of Acute Kidney Injury in Critically Ill Children. KLINISCHE PADIATRIE 2023. [PMID: 36848938 DOI: 10.1055/a-1996-1761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a serious clinical condition in critically ill children and is associated with worse outcomes. A few pediatric studies focused on the risk factors of AKI. We aimed to identify the incidence, risk factors, and outcomes of AKI in the pediatric intensive care unit (PICU). PATIENTS AND METHODS All the patients admitted to PICU over a period of 20 months were included. We compared both groups the risk factors between AKI and non-AKI. RESULTS A total of 63 patients (17.5%) of the 360 patients developed AKI during PICU stay. The presence of comorbidity, diagnosis of sepsis, increased PRISM III score, and positive renal angina index were found to be risk factors for AKI on admission. Thrombocytopenia, multiple organ failure syndrome, the requirement of mechanical ventilation, use of inotropic drugs, intravenous iodinated contrast media, and exposure to an increased number of nephrotoxic drugs were independent risk factors during the hospital stay. The patients with AKI had a lower renal function on discharge and had worse overall survival. CONCLUSIONS AKI is prevalent and multifactorial in critically sick children. The risk factors of AKI may be present on admission and during the hospital stay. AKI is related to prolonged mechanical ventilation days, longer PICU stays, and a higher mortality rate. Based on the presented results early prediction of AKI and consequent modification of nephrotoxic medication may generate positive effects on the outcome of critically ill children.
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Affiliation(s)
- Kubra Celegen
- Division of Pediatric Nephrology, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
- Pediatric Nephrology, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Mehmet Celegen
- Pediatric Intensive Care, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
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Williams C, Hankinson C, McWilliam SJ, Oni L. Vancomycin-associated acute kidney injury epidemiology in children: a systematic review. Arch Dis Child 2022; 107:947-954. [PMID: 35210220 DOI: 10.1136/archdischild-2021-323429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/03/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Vancomycin is a recognised cause of drug-induced acute kidney injury (AKI). OBJECTIVE The aim of this systematic review was to summarise the incidence of, and the risk factors for, vancomycin-associated AKI (v-AKI) in children. DESIGN A systematic search was performed in November 2020 on the search engines PubMed, Web of Science and Medline, using predefined search terms. The inclusion criteria were primary paediatric studies, intervention with vancomycin and studies that included AKI as an outcome. Study quality was assessed using the relevant Critical Appraisal Skills Programme checklist. The data are reported using descriptive statistics. RESULTS 890 studies were identified and screened with 25 studies suitable for inclusion. A cohort of 12 730 patients with v-AKI were included and the incidence of v-AKI in children was found to be 11.8% (1.6%-27.2%). The median age of the cohort was 2.5 years (range 0-23) and 57% were male patients. Risk factors that increased the likelihood of v-AKI were concomitant use of nephrotoxic medications, increased trough concentrations and, to a lesser extent, increased dose, longer duration of treatment, impaired renal function and if the patient required paediatric intensive care. CONCLUSIONS The incidence of v-AKI in children is significant and methods to reduce this risk should be considered. Further prospective interventional studies to understand the mechanisms of nephrotoxicity from vancomycin are needed and targeting risk factors may make vancomycin administration safer.
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Affiliation(s)
- Chloe Williams
- School of Medicine, University of Liverpool, Liverpool, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Charlotte Hankinson
- School of Medicine, University of Liverpool, Liverpool, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Stephen J McWilliam
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Louise Oni
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Resztak M, Sobiak J, Czyrski A. Recent Advances in Therapeutic Drug Monitoring of Voriconazole, Mycophenolic Acid, and Vancomycin: A Literature Review of Pediatric Studies. Pharmaceutics 2021; 13:1991. [PMID: 34959272 PMCID: PMC8707246 DOI: 10.3390/pharmaceutics13121991] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 01/05/2023] Open
Abstract
The review includes studies dated 2011-2021 presenting the newest information on voriconazole (VCZ), mycophenolic acid (MPA), and vancomycin (VAN) therapeutic drug monitoring (TDM) in children. The need of TDM in pediatric patients has been emphasized by providing the information on the differences in the drugs pharmacokinetics. TDM of VCZ should be mandatory for all pediatric patients with invasive fungal infections (IFIs). Wide inter- and intrapatient variability in VCZ pharmacokinetics cause achieving and maintaining therapeutic concentration during therapy challenging in this population. Demonstrated studies showed, in most cases, VCZ plasma concentrations to be subtherapeutic, despite the updated dosages recommendations. Only repeated TDM can predict drug exposure and individualizing dosing in antifungal therapy in children. In children treated with mycophenolate mofetil (MMF), similarly as in adult patients, the role of TDM for MMF active form, MPA, has not been well established and is undergoing continued debate. Studies on the MPA TDM have been carried out in children after renal transplantation, other organ transplantation such as heart, liver, or intestine, in children after hematopoietic stem cell transplantation or cord blood transplantation, and in children with lupus, nephrotic syndrome, Henoch-Schönlein purpura, and other autoimmune diseases. MPA TDM is based on the area under the concentration-time curve; however, the proposed values differ according to the treatment indication, and other approaches such as pharmacodynamic and pharmacogenetic biomarkers have been proposed. VAN is a bactericidal agent that requires TDM to prevent an acute kidney disease. The particular group of patients is the pediatric one. For this group, the general recommendations of the dosing may not be valid due to the change of the elimination rate and volume of distribution between the subjects. The other factor is the variability among patients that concerns the free fraction of the drug. It may be caused by both the patients' population and sample preconditioning. Although VCZ, MMF, and VAN have been applied in pediatric patients for many years, there are still few issues to be solve regarding TDM of these drugs to ensure safe and effective treatment. Except for pharmacokinetic approach, pharmacodynamics and pharmacogenetics have been more often proposed for TDM.
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Affiliation(s)
- Matylda Resztak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (J.S.); (A.C.)
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Lanata MM, Diaz A, Hecht SM, Katragkou A, Gallup N, Buckingham DA, Tansmore JL, Sargel C, Watson JR, Karsies T. Empiric Vancomycin Reduction in a Pediatric Intensive Care Unit. Pediatrics 2021; 148:peds.2020-009142. [PMID: 34452978 DOI: 10.1542/peds.2020-009142] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND At our institution, empirical vancomycin is overused in children with suspected bacterial community-acquired infections (CAIs) admitted to the PICU because of high community rates of methicillin-resistant Staphylococcus aureus (MRSA). Our goal was to reduce unnecessary vancomycin use for CAIs in the PICU. METHODS Empirical PICU vancomycin indications for suspected CAIs were developed by using epidemiological risk factors for MRSA. We aimed to reduce empirical PICU vancomycin use in CAIs by 30%. After retrospectively testing, the indications were implemented and monthly PICU empirical vancomycin use during baseline (May 2017-April 2018) and postintervention (May 2018-July 2019) periods. Education was provided to PICU providers, vancomycin indications were posted, and the antibiotic order set was revised. Statistical process control methods tracked improvement over time. Proven S aureus infections for which vancomycin was not empirically prescribed and linezolid or clindamycin use were balancing measures. RESULTS We identified 1620 PICU patients with suspected bacterial CAIs. Empirical vancomycin decreased from a baseline of 73% to 45%, a 38% relative reduction. No patient not prescribed empirical vancomycin later required the addition of vancomycin or other MRSA-targeted antibiotics. There was no change in nephrotoxicity or in the balancing measures. CONCLUSIONS Development of clear and concise recommendations, combined with clinician education and decision support via an order set, was an effective and safe strategy to reduce PICU vancomycin use. Retrospective validation of the recommendations with local data were key to obtaining PICU clinician buy in.
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Ahmed R, Shahzad M, Umer A, Azim A, Jamil MT, Haque A. Frequency of Exposure of Nephrotoxic Drugs and Drug-Induced Acute Kidney Injury in Pediatric Intensive Care Unit: A Retrospective Review From a Tertiary Care Centre in Pakistan. Cureus 2020; 12:e12183. [PMID: 33489594 PMCID: PMC7815304 DOI: 10.7759/cureus.12183] [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: 11/13/2022] Open
Abstract
Introduction Acute kidney injury (AKI) is one of the most common problems seen in the pediatric intensive care unit (PICU), with an overall 27% incidence. Besides many other factors, nephrotoxic medications (Nephrotoxins; Ntx) are also responsible for a large proportion of potentially avoidable pediatric AKI, directly accounting for 16% of AKI events. Objective To assess potential associations between nephrotoxic drugs and the risk of developing AKI in children admitted in PICU. Material and methods This is a retrospective cross-sectional study. Children (aged 1 month - 18 years) admitted to the PICU, with a length of stay >24 hours, were included. AKI was defined as according to KDIGO (Kidney Disease Improving Global Outcomes) criteria. Mild AKI was defined as a rise in creatinine value of 0.3 mg/dl from presenting value at a 24-hour interval. Patients were grouped according to the presence or absence of AKI. All medications administered in the ICU were assessed for nephrotoxicity through a review of adverse reactions mentioned in the Pediatric Dosage Handbook, along with consultation with a clinical pharmacist. Results Among 752 patients, the mean age was 4.8 years ± 4.37. There were 57.3% male and 42.7% female children. Among the exposed children, 37.4% received one drug, 32.4% received two drugs and 12.1% had high nephrotoxin exposure. The most commonly used drug was vancomycin (16.8%), as a single Ntx; vancomycin/colistin (12.9%), in dual nephrotoxic combination; and vancomycin/colistin/amphotericin (2.9%) in highly exposed children (i.e., with equal or more than three). Overall, the incidence of AKI was 14.9%. Conclusion Nephrotoxins are potentially avoidable risk factors in critically ill children. Whenever a combination of medications is required, it’s advisable to review all medications for better protection of kidneys and preventing of acute kidney injury.
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Affiliation(s)
- Rahim Ahmed
- Pediatric Intensive Care Unit, The Indus Hospital, Karachi, PAK
| | | | - Anum Umer
- Pediatrics, The Indus Hospital, Karachi, PAK
| | - Asim Azim
- Pediatric Intensive Care Unit, The Indus Hospital, Karachi, PAK
| | | | - Anwar Haque
- Pediatrics, The Indus Hospital, Karachi, PAK
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Uber AM, Sutherland SM. Nephrotoxins and nephrotoxic acute kidney injury. Pediatr Nephrol 2020; 35:1825-1833. [PMID: 31646405 DOI: 10.1007/s00467-019-04397-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/30/2019] [Accepted: 10/08/2019] [Indexed: 12/18/2022]
Abstract
Although the concept of nephrotoxicity has been recognized for more than 80 years, interest in nephrotoxins has intensified dramatically over the past two decades. Much of this attention has rightfully been focused on pharmaceutical agents and iatrogenic harm; however, it is important for providers to recognize that nephrotoxins can be found in naturally occurring substances as well. Although nephrotoxins exist in a myriad of forms, the means by which they induce injury can be organized into a few categories. For most of these agents, regardless of the mechanism, the final common pathway is acute kidney injury (AKI). Unfortunately, therapeutic options are limited and no treatments currently exist to reverse nephrotoxic AKI once it occurs. As a result, current strategies focus on increased awareness, nephrotoxin avoidance, early injury detection, and mitigation of disease severity. The goal of this review is to summarize our current understanding of nephrotoxic mechanisms and the epidemiology of nephrotoxic AKI. Additionally, avoidance and preventative strategies are discussed, screening approaches are suggested, and chronic monitoring recommendations are made.
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Affiliation(s)
- Amanda M Uber
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, 300 Pasteur Drive, Room G-306, Stanford, CA, 94304, USA.
| | - Scott M Sutherland
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, 300 Pasteur Drive, Room G-306, Stanford, CA, 94304, USA
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Moffett BS, Resendiz K, Morris J, Akcan-Arikan A, Checchia PA. Population Pharmacokinetics of Vancomycin in the Pediatric Cardiac Surgical Population. J Pediatr Pharmacol Ther 2019; 24:107-116. [PMID: 31019403 DOI: 10.5863/1551-6776-24.2.107] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Vancomycin is often used in the pediatric cardiac surgical population, but few pharmacokinetic data are available to guide dosing. METHODS A retrospective, population pharmacokinetic study was performed for patients <19 years of age initiated on vancomycin after cardiac surgery in the cardiac intensive care unit from 2011-2016 in our institution. Patient data were summarized by using descriptive statistical methods, and population pharmacokinetic analysis was performed by using NONMEM. Simulation was performed to determine a dosing strategy that most frequently obtained an AUC0-24:MIC (minimum inhibitory concentration) ratio of >400. RESULTS A total of 261 patients (281 cardiac surgical procedures, cardiopulmonary bypass 82.3%) met inclusion criteria (60.1% male, median age 0.31 [IQR, 0.07-0.77] years). Vancomycin (14.5 ± 1.7 mg/kg/dose) was administered at median postoperative day 9 (IQR, 4-14), with a mean serum concentration of 11.5 ± 5.5 mg/L at 8.9 ± 3.8 hours after a dose. Population pharmacokinetic analysis demonstrated that a 1-compartment proportional error model with allometrically scaled weight best fit the data, with creatinine clearance and postmenstrual age as significant covariates. Simulation identified that a dosing regimen of 20 mg/kg/dose every 8 hours was most likely to achieve an AUC0-24:MIC ratio > 400 at a mean trough serum concentration of 12.9 ± 3.2 mg/L. CONCLUSIONS Vancomycin dosing in the postoperative pediatric cardiac surgical population should incorporate postmenstrual age and creatinine clearance. A vancomycin dose of 20 mg/kg every 8 hours is a reasonable empiric strategy.
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Hays WB, Tillman E. Vancomycin-Associated Acute Kidney Injury in Critically Ill Adolescent and Young Adult Patients. J Pharm Pract 2019; 33:749-753. [PMID: 30808269 DOI: 10.1177/0897190019829652] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Risk factors for the development of vancomycin-associated acute kidney injury (AKI) have been evaluated in both pediatric and adult populations; however, no previous studies exist evaluating this in the critically ill adolescent and young adult patients. OBJECTIVE Identify the incidence of AKI and examine risk factors for the development of AKI in critically ill adolescents and young adults on vancomycin. METHODS This retrospective review evaluated the incidence of AKI in patients 15 to 25 years of age who received vancomycin, while admitted to an intensive care unit. Acute kidney injury in this population was defined as an increase in serum creatinine by 0.5 mg/dL or 50% from baseline. Patients who developed AKI were evaluated for specific risk factors compared to those who did not develop AKI. RESULTS A total of 50 patients (20 developed AKI) were included in the study. There was no difference in vancomycin daily dose or duration of vancomycin therapy. Maximum vancomycin trough (31.15 mg/dL vs 12.5 mg/dL, P = .006), percentage of patients with concurrent nephrotoxic medication (95% vs 60%, P = .012) and concurrent vasopressor (55% vs 23%, P = .029) were higher in those who developed AKI. Percentage of patients who underwent a procedure while on vancomycin (35% vs 6.7%, P = .021) was also higher within the AKI group. CONCLUSIONS Vancomycin-associated AKI occurred in 40% of critically ill adolescent and young adult patients. These patients may be more likely to develop vancomycin-associated AKI if they had undergone a procedure, as well as in the presence of high vancomycin trough levels, concurrent nephrotoxic agents, and concurrent vasopressor therapy.
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Affiliation(s)
- William B Hays
- Department of Pharmacy, 22535Indiana University Health Methodist Hospital, Indianapolis, IN, USA
| | - Emma Tillman
- Department of Pharmacy, 22536Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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12
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Uber AM, Montez-Rath ME, Kwiatkowski DM, Krawczeski CD, Sutherland SM. Nephrotoxin exposure and acute kidney injury in critically ill children undergoing congenital cardiac surgery. Pediatr Nephrol 2018; 33:2193-2199. [PMID: 29987455 DOI: 10.1007/s00467-018-4010-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/16/2018] [Accepted: 06/22/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Though acute kidney injury (AKI) is often multifactorial, investigators are now emphasizing the specific contribution of nephrotoxins. This study examines the epidemiology of nephrotoxin exposure and nephrotoxin-associated AKI among children undergoing congenital heart surgery (CHS). METHODS This is a retrospective cohort study of children admitted following CHS between June 1, 2014, and September 30, 2014. Nephrotoxins were defined according to the Nephrotoxic Injury Negated by Just-in-time-Action (NINJA) collaborative; high nephrotoxin exposure was defined as receipt of ≥ 3 nephrotoxins concurrently. AKI was diagnosed according to KDIGO creatinine criteria. Severe AKI was defined as KDIGO stage ≥ 2. Poisson models were used to compute adjusted relative risk (aRR) of high nephrotoxin exposure for AKI. RESULTS One hundred fifty-four children (median age 20.4 months, IQR 2.3-59.5) were included. One hundred thirty-one (85.1%) received at least one nephrotoxin; 32 (20.8%) received ≥ 3 nephrotoxins. The most commonly administered medications were ketorolac (n = 74, 48.1%), aspirin (n = 62, 40.3%), ibuprofen (n = 51, 33.1%), vancomycin (n = 39, 25.3%), piperacillin/tazobactam (n = 35, 22.7%), and enalapril (n = 14, 9.1%). AKI occurred more commonly in those exposed to ≥ 3 nephrotoxins (62.5 vs. 50.8%); this was not statistically significant after adjusting for confounders (aRR = 1.2, 95% CI 0.9-1.7). Severe AKI was similar between those with and without high nephrotoxin exposure (21.9 vs. 19.7%, p = 0.78). CONCLUSIONS Nephrotoxin use is common following pediatric CHS. While we found no association between high nephrotoxin exposure and AKI, this may be related to the multifactorial nature of AKI in this population. For many common nephrotoxins, less injurious agents exist and nephrotoxin exposure may represent a modifiable risk factor for AKI.
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Affiliation(s)
- Amanda M Uber
- Department of Pediatrics (General Pediatrics), Stanford University School of Medicine, Stanford, CA, USA. .,Stanford Children's Health/Lucile Packard Children's Hospital, Stanford, 725 Welch Road, MC 5906, Palo Alto, CA, 94304, USA.
| | - Maria E Montez-Rath
- Department of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - David M Kwiatkowski
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - Catherine D Krawczeski
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - Scott M Sutherland
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, Stanford, CA, USA
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13
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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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14
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Fiorito TM, Luther MK, Dennehy PH, LaPlante KL, Matson KL. Nephrotoxicity With Vancomycin in the Pediatric Population: A Systematic Review and Meta-Analysis. Pediatr Infect Dis J 2018; 37:654-661. [PMID: 29280786 DOI: 10.1097/inf.0000000000001882] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Vancomycin is frequently used to treat methicillin-resistant Staphylococcus aureus infections in pediatric patients. Vancomycin exposure may lead to an increase in frequency of nephrotoxicity. Our aim was to conduct a systematic review to describe predictors of nephrotoxicity associated with vancomycin, including documented trough concentrations ≥15 mg/L. We also aimed to use a meta-analysis to assess the impact of a vancomycin trough ≥15 mg/L on nephrotoxicity. METHODS A literature search was performed using PubMed, Cochrane Library, Embase and Web of Sciences database. We included randomized clinical trials and observational studies evaluating the relationship between vancomycin troughs and nephrotoxicity in pediatric-age patients. Studies not measuring troughs or defining a different cut-off point than 15 mg/L were excluded. Data on age, exclusion criteria, nephrotoxicity definition, risk factors for nephrotoxicity and vancomycin trough levels were extracted from selected papers. RESULTS Ten studies were identified for meta-analysis. All subjects had comparatively normal baseline serum creatinine values. Common risk factors identified included elevated (≥15 mg/L) trough levels, renal impairment, hypovolemia and concurrent use of nephrotoxic medications. Troughs ≥15 mg/L increased nephrotoxicity by 2.7-fold (odds ratio (OR), 2.71; 95% confidence interval: 1.82-4.05; I(2) = 40%; Q = 0.09). These odds were further increased among patients in the pediatric intensive care unit (OR, 3.61; 95% confidence interval: 1.21-10.74; I(2) = 45%; Q = 0.18). CONCLUSIONS Though the rate of vancomycin-induced nephrotoxicity is increased in pediatric patients with higher vancomycin troughs, other factors such as intensive care unit admission, hypovolemia and concurrent nephrotoxic drug use appear to contribute to the development of nephrotoxicity.
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Affiliation(s)
- Theresa M Fiorito
- From the Department of Pediatrics, Hasbro Children's Hospital.,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Megan K Luther
- Department of Pharmacy Practice, University of Rhode Island, College of Pharmacy, Kingston, Rhode Island.,Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, Rhode Island
| | - Penelope H Dennehy
- From the Department of Pediatrics, Hasbro Children's Hospital.,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kerry L LaPlante
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Department of Pharmacy Practice, University of Rhode Island, College of Pharmacy, Kingston, Rhode Island.,Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, Rhode Island
| | - Kelly L Matson
- Department of Pharmacy Practice, University of Rhode Island, College of Pharmacy, Kingston, Rhode Island
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Cies JJ, Moore WS, Enache A, Chopra A. Ceftaroline for Suspected or Confirmed Invasive Methicillin-Resistant Staphylococcus aureus: A Pharmacokinetic Case Series. Pediatr Crit Care Med 2018; 19:e292-e299. [PMID: 29419605 DOI: 10.1097/pcc.0000000000001497] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To describe the ceftaroline pharmacokinetics in critically ill children treated for suspected or confirmed methicillin-resistant Staphylococcus aureus infections, including blood stream infection and describe the microbiological and clinical outcomes. DESIGN Retrospective electronic medical record review. SETTINGS Free-standing tertiary/quaternary pediatric children's hospital. PATIENTS Critically ill children receiving ceftaroline monotherapy or combination therapy for suspected or confirmed methicillin-resistant S. aureus infections in the PICU. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Seven patients, three females (43%), and four males (57%), accounted for 33 ceftaroline samples for therapeutic drug management. A median of four samples for therapeutic drug management was collected per patient (range, 2-9 samples). The median age was 7 years (range, 1-13 yr) with a median weight of 25.5 kg (range, 12.6-40.1 kg). Six of seven patients (86%) demonstrated an increase in volume of distribution, five of seven patients (71%) demonstrated an increase in clearance, and 100% of patients demonstrated a shorter half-life estimate as compared with the package insert estimate. Six of seven patients (85.7%) had documented methicillin-resistant S. aureus growth from a normally sterile site with five of six (83.3%) having documented BSI, allowing six total patients to be evaluated for the secondary objective of microbiological and clinical response. All six patients achieved a positive microbiological and clinical response for a response rate of 100%. CONCLUSIONS These data suggest the pharmacokinetics of ceftaroline in PICU patients is different than healthy pediatric and adult patients, most notably a faster clearance and larger volume of distribution. A higher mg/kg dose and a more frequent dosing interval for ceftaroline may be needed in PICU patients to provide appropriate pharmacodynamic exposures. Larger pharmacokinetic, pharmacodynamic, and interventional treatment trials in the PICU population are warranted.
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Affiliation(s)
| | - Wayne S Moore
- The Center for Pediatric Pharmacotherapy LLC, Pottstown, PA
| | | | - Arun Chopra
- The Center for Pediatric Pharmacotherapy LLC, Pottstown, PA
- NYU Langone Medical Center, New York, NY
- NYU School of Medicine, New York, NY
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16
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Pan KM, Wu Y, Chen C, Chen ZZ, Xu JA, Cao L, Xu Q, Wu W, Dai PF, Li XY, Lv QZ. Vancomycin-induced acute kidney injury in elderly Chinese patients: a single-centre cross-sectional study. Br J Clin Pharmacol 2018; 84:1706-1718. [PMID: 29607531 DOI: 10.1111/bcp.13594] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/06/2018] [Accepted: 03/17/2018] [Indexed: 01/20/2023] Open
Abstract
AIMS The objective of the present study was to investigate the current situation concerning, and risk factors for, vancomycin (VAN)-induced acute kidney injury (VI-AKI) in elderly Chinese patients, to assess outcomes and risk factors in patients who have developed VI-AKI, in order to provide suggestions for improving the prevention and treatment of this condition in these patients. METHOD We retrospectively identified elderly older inpatients who had received four or more doses of VAN treatment. We compared patients with VI-AKI with those who received VAN treatment and had not developed AKI (NO-AKI). We defined VI-AKI as developing AKI during VAN therapy or within 3 days after withdrawal of VAN. RESULTS A total of 647 out of 862 elderly inpatients were included in the study. Among those excluded, in 89.3% of cases (192/215) this was because of lack of data on serum creatinine (SCr). Among included patients, 32.5% (210/647) of patients received therapeutic drug monitoring (TDM) during VAN therapy. In 66.9% of cases (424/634), there was insufficient TDM, and in 3.9% (25/634) this was appropriate. A total of 102 patients had confirmed VI-AKI, with an incidence of 15.8% (102/647). Multiple logistic regression analysis revealed that hyperuricaemia [odds ratio (OR) = 3.045; P = 0.000)], mechanical ventilation (OR = 1.906; P = 0.022) and concomitant vasopressor therapy (OR = 1.919; P = 0.027) were independent risk factors for VI-AKI; higher serum albumin (OR = 0.885; P = 0.000) was determined to be an independent protective factor for VI-AKI. CONCLUSIONS For the elderly Chinese patients treated with VAN, there was insufficient monitoring of SCr, too little use of VAN TDM, and lower rate of patients whose VAN though serum concentrations were not obtained at the correct time. We recommend that hospital managers increase investment in clinical pharmacists, to strengthen professional management. Patients with concomitant hyperuricaemia and on mechanical ventilation and vasopressor therapy should be paid more attention, and a higher serum albumin was determined to be an independent protective factor for VI-AKI.
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Affiliation(s)
- Kun-Ming Pan
- Department of Pharmacy, Zhongshan Hospital FuDan University, Shanghai, China
| | - Yi Wu
- Department of Pharmacy, Zhongshan Hospital FuDan University, Shanghai, China
| | - Can Chen
- Department of Pharmacy, Zhongshan Hospital FuDan University, Shanghai, China
| | - Zhang-Zhang Chen
- Department of Pharmacy, Zhongshan Hospital FuDan University, Shanghai, China
| | - Jian-An Xu
- Department of Pharmacy, Zhongshan Hospital FuDan University, Shanghai, China
| | - Lei Cao
- Department of Pharmacy, Zhongshan Hospital FuDan University, Shanghai, China
| | - Qing Xu
- Department of Pharmacy, Zhongshan Hospital FuDan University, Shanghai, China
| | - Wei Wu
- Department of Pharmacy, Zhongshan Hospital FuDan University, Shanghai, China
| | - Pei-Fang Dai
- Department of Pharmacy, Zhongshan Hospital FuDan University, Shanghai, China
| | - Xiao-Yu Li
- Department of Pharmacy, Zhongshan Hospital FuDan University, Shanghai, China
| | - Qian-Zhou Lv
- Department of Pharmacy, Zhongshan Hospital FuDan University, Shanghai, China
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17
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Thomas CA, Picone A, Menon S, Willis BC. Empirical Vancomycin Dosing in Pediatric Patients with Congenital Heart Disease and the Impact of Cardiopulmonary Bypass on Trough Concentrations. Pharmacotherapy 2017; 37:1341-1346. [PMID: 28833385 DOI: 10.1002/phar.2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To determine the optimal vancomycin dosing regimen to achieve empirical goal trough concentrations in pediatric patients with congenital heart disease and to examine the impact of cardiopulmonary bypass on vancomycin dosing requirements. METHODS Patients younger than 18 years admitted to the pediatric cardiovascular intensive care unit (CVICU) at our institution from October 1, 2012-December 31, 2014, who received at least one dose of vancomycin, were reviewed retrospectively. Included patients had a steady-state vancomycin trough concentration drawn during the study period. The first steady-state vancomycin trough drawn after being initiated on empirical vancomycin therapy was analyzed for each patient. Excluded patients were those who received mechanical circulatory support, any form of renal replacement therapy, or had a serum creatinine result greater than 1.0 mg/dl on the day of vancomycin initiation. RESULTS Overall, 77 patients met inclusion criteria, of which 57.1% had undergone cardiopulmonary bypass (CPB) before CVICU admission. Median age was 62 days (interquartile range [IQR] 8.3-176 days). Median daily vancomycin dose was 36.25 mg/kg/day (IQR 29-40 mg/kg/day), resulting in a median steady-state trough of 10.0 μg/ml (IQR 6.3-12.9 μg/ml). Therapeutic troughs occurred in 50.6% of patients; supratherapeutic and subtherapeutic concentrations were attained in 18.2% and 31.2% of patients, respectively. A subgroup analysis of patients who were post-CPB revealed that the only additional variable to affect vancomycin trough concentrations was aortic cross-clamp time (median 56 min, IQR 0-123.3 min, p=0.02). CONCLUSIONS Empirical vancomycin dosing to achieve troughs of 8-15 μg/dl in patients with congenital heart disease without evidence of significant acute kidney injury should be 30 mg/kg/day for neonates, 35-40 mg/kg/day for infants, and 45 mg/kg/day in children, with adjustments required for patients with elevated creatinine or significant aortic cross-clamp time. The receipt and duration of CPB did not affect total daily vancomycin dose requirements.
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Affiliation(s)
- Christopher A Thomas
- Department of Pharmacy, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Amy Picone
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | | | - Brigham C Willis
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona.,Phoenix Children's Hospital, Phoenix, Arizona
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18
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Lameire N, Van Biesen W, Vanholder R. Epidemiology of acute kidney injury in children worldwide, including developing countries. Pediatr Nephrol 2017; 32:1301-1314. [PMID: 27307245 DOI: 10.1007/s00467-016-3433-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/12/2016] [Accepted: 05/12/2016] [Indexed: 01/06/2023]
Abstract
In this review we summarize the world-wide epidemiology of acute kidney injury (AKI) in children with special emphasis on low-income countries, notably those of the sub-Saharan continent. We discuss definitions and classification systems used in pediatric AKI literature. At present, despite some shortcomings, traditional Pediatric Risk Injury Failure Loss and End Stage Kidney Disease (pRIFLE) and Kidney Disease Improving Global Outcomes (KDIGO) systems are the most clinically useful. Alternative definitions, such as monitoring serum cystatin or novel urinary biomarkers, including cell cycle inhibitors, require more long-term studies in heterogenous pediatric AKI populations before they can be recommended in routine clinical practice. A potentially interesting future application of some novel biomarkers could be incorporation into the "renal angina index", a concept recently introduced in pediatric nephrology. The most reliable epidemiological data on AKI in children come from high-outcome countries and are frequently focused on critically ill pediatric intensive care unit populations. In these patients AKI is often secondary to other systemic illnesses or their treatment. Based on a recent literature search performed within the framework of the "AKI 0by25" project of the International Society of Nephrology, we discuss the scarce and often inaccurate data on AKI epidemiology in low-income countries, notably those on the African continent. The last section reflects on some of the many barriers to improvement of overall health care in low-income populations. Although preventive strategies for AKI in low-income countries should essentially be the same as those in high-income countries, we believe any intervention for earlier detection and better treatment of AKI must address all health determinants, including educational, cultural, socio-economic and environmental factors, specific for these deprived areas.
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Affiliation(s)
- Norbert Lameire
- Renal Division, Department of Medicine, University Hospital, De Pintelaan 285, 9000, Gent, Belgium.
| | - Wim Van Biesen
- Renal Division, Department of Medicine, University Hospital, De Pintelaan 285, 9000, Gent, Belgium
| | - Raymond Vanholder
- Renal Division, Department of Medicine, University Hospital, De Pintelaan 285, 9000, Gent, Belgium
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19
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LeCleir LK, Pettit RS. Piperacillin-tazobactam versus cefepime incidence of acute kidney injury in combination with vancomycin and tobramycin in pediatric cystic fibrosis patients. Pediatr Pulmonol 2017; 52:1000-1005. [PMID: 28440913 DOI: 10.1002/ppul.23718] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 04/03/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) patients often receive prolonged courses of broad spectrum antibiotics, such as piperacillin-tazobactam or cefepime in combination with vancomycin and tobramycin. The objective of this study was to determine the difference in AKI for pediatric CF patients receiving piperacillin-tazobactam or cefepime in combination with vancomycin and tobramycin. METHODS IRB approval from a single CF center was obtained for this retrospective cohort study. Charts were evaluated from December 1, 2008 to June 30,2015. Patients were included if they had a diagnosis of CF, age 30 days to 18 years, and received intravenous vancomycin, tobramycin, and piperacillin-tazobactam or cefepime. The primary outcome was difference of AKI incidence in patients receiving piperacillin-tazobactam or cefepime, as defined by modified pediatric risk, injury, failure, loss, end stage renal disease (pRIFLE) criteria. RESULTS Seventy-one patients were included with a median (interquartile range) age 11 years (7-16) and weight 36.2 kg (22.7-50). AKI was identified in 54.5% (18/33) of patients receiving piperacillin-tazobactam and 13.2% (5/38) of patients receiving cefepime (P ≤ 0.0001). One patient receiving piperacillin-tazobactam experienced acute renal failure. There was a slight difference in length of admission (13 vs 10 days, P = 0.042), but no difference in days to maximum SCr (6 vs 3, P = 0.127) nor FEV1 percent predicted on admission (69% vs 65%, P = 1.00). CONCLUSIONS AKI occurred in nearly 55% of patients with piperacillin-tazobactam therapy versus 13% of patients with cefepime therapy, which suggests cefepime may be preferred in combination with vancomycin and tobramycin for pediatric CF patients.
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Affiliation(s)
- Lisa K LeCleir
- Riley Hospital for Children at IU Health, Indianapolis, Indiana
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20
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McNeil JC, Kaplan SL, Vallejo JG. The Influence of the Route of Antibiotic Administration, Methicillin Susceptibility, Vancomycin Duration and Serum Trough Concentration on Outcomes of Pediatric Staphylococcus aureus Bacteremic Osteoarticular Infection. Pediatr Infect Dis J 2017; 36:572-577. [PMID: 28027279 PMCID: PMC5534171 DOI: 10.1097/inf.0000000000001503] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bacteremia is often one factor used in deciding the need for prolonged intravenous antimicrobial therapy in osteoarticular infections (OAIs). We examined treatment practices and outcomes of Staphylococcus aureus bacteremic osteoarticular infections (BOAIs) evaluated at Texas Children's Hospital. METHODS Cases of acute hematogenous OAI in children with positive blood cultures for S. aureus at Texas Children's Hospital between 2011 and 2014 were reviewed. Orthopedic complications included chronic osteomyelitis, growth arrest, pathologic fracture, avascular necrosis and chronic dislocation. Acute kidney injury was defined as a doubling of the baseline creatinine. RESULTS One hundred and ninety-two cases of S. aureus OAI were identified with 102 cases of BOAI included [35 methicillin-resistant S. aureus (MRSA)]. Twenty-five patients were discharged home on oral antibiotics. Patients discharged on oral antibiotics had a shorter duration of fever, had a more rapid decline in C-reactive protein and were less likely to have MRSA. The frequency of orthopedic complications did not increase in patients who received early transition to oral antibiotics. For patients with MRSA bacteremia, the rates of complications between those who received ≥7 days versus <7 days of vancomycin did not differ. Vancomycin serum troughs >15 µg/mL were not associated with a decreased duration of fever, bacteremia or hospitalization, need for repeat operation or orthopedic complications but were associated with acute kidney injury. CONCLUSIONS S. aureus BOAIs are associated with substantial morbidity. Early transition to oral therapy may be a safe option for select patients with S. aureus BOAI, including those due to MRSA. Prolonged courses of vancomycin and vancomycin troughs >15 μg/mL were not associated with improved outcomes for MRSA OAI.
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21
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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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Malhotra R, Kashani KB, Macedo E, Kim J, Bouchard J, Wynn S, Li G, Ohno-Machado L, Mehta R. A risk prediction score for acute kidney injury in the intensive care unit. Nephrol Dial Transplant 2017; 32:814-822. [DOI: 10.1093/ndt/gfx026] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/28/2017] [Indexed: 12/12/2022] Open
Affiliation(s)
- Rakesh Malhotra
- Division of Nephrology and Hypertension, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Kianoush B. Kashani
- Division of Nephrology and Hypertension and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Etienne Macedo
- Division of Nephrology and Hypertension, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Jihoon Kim
- Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Josee Bouchard
- Service de Néphrologie, Département de médecine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Susan Wynn
- Division of Nephrology and Hypertension, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Guangxi Li
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Lucila Ohno-Machado
- Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Ravindra Mehta
- Division of Nephrology and Hypertension, Department of Medicine, University of California, San Diego, San Diego, CA, USA
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Slater MB, Gruneir A, Rochon PA, Howard AW, Koren G, Parshuram CS. Identifying High-Risk Medications Associated with Acute Kidney Injury in Critically Ill Patients: A Pharmacoepidemiologic Evaluation. Paediatr Drugs 2017; 19:59-67. [PMID: 27943125 DOI: 10.1007/s40272-016-0205-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Nephrotoxic medications are a common cause of acute kidney injury (AKI). Critically ill children receive more medication than other inpatients; however, the risk of nephrotoxic medication-induced AKI in these children is not well understood. OBJECTIVE The aim of this study was to determine the association between exposure to nephrotoxic medications in the intensive care unit (ICU) and the development of AKI amongst critically ill children, adjusting for differences in underlying risk. METHODS We conducted a nested case-control study among a cohort of patients admitted to a paediatric intensive care unit between January 2006 and June 2009. Cases were identified according to the RIFLE criteria. Using incidence density sampling, controls were matched 1:1 according to pre-ICU nephrotoxic drug exposure. Administration of nephrotoxic medications and other known risk factors of AKI were evaluated during the ICU stay prior to the diagnosis of AKI. RESULTS A total of 914 patients in the cohort developed AKI and had an identifiable matched control. Eighty-seven percent of cases and 74% of controls were exposed to one or more nephrotoxic medications in the ICU during the study period. Furosemide (administered to 67.8% of patients), vancomycin (28.7%), and gentamicin (21.4%) were the most frequently administered nephrotoxic drugs. Patients who developed AKI were more likely to be exposed to at least one nephrotoxic medication and risk increased with increasing number of nephrotoxic medications. Ganciclovir (adjusted odds ratio [AOR] 4.7; 95% CI 1.7-13.0), furosemide (AOR 1.9; 95% CI 1.4-2.4), and gentamicin (AOR 1.8; 95% CI 1.4-2.4) significantly increased the odds of developing AKI after adjusting for underlying differences in risk factors of AKI. CONCLUSION This is the first study to assess the association between risk-adjusted nephrotoxic medication exposure and the development of AKI in critically ill children. Nephrotoxic medication exposure was common amongst children in the ICU and we found AKI was associated with the administration of specific drugs after adjustment for important risk factors.
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Affiliation(s)
- Morgan B Slater
- Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Andrea Gruneir
- Department of Family Medicine, University of Alberta, Edmonton, AB, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Paula A Rochon
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrew W Howard
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Gideon Koren
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Christopher S Parshuram
- Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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Drug-associated acute kidney injury: who's at risk? Pediatr Nephrol 2017; 32:59-69. [PMID: 27338726 PMCID: PMC5826624 DOI: 10.1007/s00467-016-3446-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/02/2016] [Accepted: 06/08/2016] [Indexed: 02/07/2023]
Abstract
The contribution of nephrotoxic medications to the development of acute kidney injury (AKI) is becoming better understood concomitant with the increased incidence of AKI in children. Treatment of AKI is not yet available, so prevention continues to be the most effective approach. There is an opportunity to mitigate severity and prevent the occurrence of AKI if children at increased risk are identified early and nephrotoxins are used judiciously. Early detection of AKI is limited by the dependence of nephrologists on serum creatinine as an indicator. Promising new biomarkers may offer early detection of AKI prior to the rise in serum creatinine. Early detection of evolving AKI is improving and offers opportunities for better management of nephrotoxins. However, the identification of patients at increased risk will remain an important first step, with a focus on the use of biomarker testing and interpretation of the results.
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Abstract
OBJECTIVES Acute kidney injury may be promoted by critical illness, preexisting medical conditions, and treatments received both before and during ICU admission. We aimed to estimate the frequency of acute kidney injury during ICU treatment and to determine factors, occurring both before and during the ICU stay, associated with the development of acute kidney injury. DESIGN Cohort study of critically ill children. SETTING University-affiliated PICU. PATIENTS Eligible patients were admitted to the ICU between January 2006 and June 2009. We excluded those admitted with known primary renal failure, chronic renal failure or postrenal transplant, conditions with known renal complications, or metabolic conditions treated with dialysis. Patients were also excluded if they had a short ICU stay (< 6 hr) and those who had no creatinine or urine output measurements during their ICU stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 3,865 pediatric patients who met the inclusion criteria, 915 (23.7%) developed acute kidney injury, as classified by the Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease criteria, during their ICU stay. Patients at high risk for development of acute kidney injury included those urgently admitted to the ICU (adjusted odds ratio, 1.88), those who developed respiratory dysfunction during their ICU care (adjusted odds ratio, 2.90), and those who treated with extracorporeal membrane oxygenation (adjusted odds ratio, 2.72). The single greatest risk factor for acute kidney injury was the administration of nephrotoxic medications during ICU admission (adjusted odds ratio, 3.37). CONCLUSIONS This study, the largest evaluating the incidence of RIFLE-defined acute kidney injury in critically ill children, found that one-quarter of patients admitted to the ICU developed acute kidney injury. We identified a number of potentially modifiable risk factors, the largest of which was the administration of nephrotoxic medication. The results of this study may be used to inform targeted interventions to reduce acute kidney injury and improve the outcomes of critically ill children.
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Benefield EC, Hagemann TM, Allen HC, Farmer K, Burton ME, Chavez-Bueno S, Johnson PN. Vancomycin Dosing and Pharmacokinetics in Postoperative Pediatric Cardiothoracic Surgery Patients. J Pediatr Pharmacol Ther 2016; 21:66-74. [PMID: 26997930 DOI: 10.5863/1551-6776-21.1.66] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study compared vancomycin trough concentrations and pharmacokinetic parameters in pediatric cardiothoracic surgery (CTS) patients versus those in controls receiving 20 mg/kg/dose, intravenously, every 8 hours. METHODS A retrospective study was conducted in children <18 years of age, following CTS, versus an age-and sex-matched control group. The primary objective was to determine differences in trough concentrations between groups. Secondary objectives included comparisons of pharmacokinetics between groups and development of vancomycin-associated acute kidney injury (AKI), defined as a doubling in serum creatinine from baseline. Also dosing projections were developed to target an area-under-the-curve-to-minimum inhibitory concentration (AUC:MIC) ratio of ≥400. RESULTS Twenty-seven patients in each group were evaluated. Mean trough concentrations were significantly different between groups (CTS: 18.4 mg/L; control: 8.8 mg/L; p < 0.01). Vancomycin-associated acute kidney injury AKI was significantly higher in the CTS group than in controls (25.9% versus 0%, respectively, p<0.01). There were significant differences in vancomycin elimination rates, with a high degree of variability, but no statistical differences in other parameters. Based on dosing projections, CTS patients would require 21 to 88 mg/kg/day, with a dosage interval determined by the child's glomerular filtration rate to achieve the target AUC:MIC ≥400. CONCLUSIONS Vancomycin dosage of 20 mg/kg/dose intravenously every 8 hours achieved significantly higher trough concentrations in CTS patients than in controls. Pharmacokinetic parameters were highly variable in CTS patients, indicating more individualization of dosage is needed. A future prospective study is needed to determine whether the revised dosage projections achieve the AUC:MIC target and to determine whether these regimens are associated with less vancomycin-associated AKI.
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Affiliation(s)
| | - Tracy M Hagemann
- Department of Clinical Pharmacy, University of Tennessee Health Science Center College of Pharmacy, Nashville, Tennessee
| | | | - Kevin Farmer
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Michael E Burton
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | | | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
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Healthcare-associated Staphylococcus aureus Bacteremia in Children: Evidence for Reverse Vancomycin Creep and Impact of Vancomycin Trough Values on Outcome. Pediatr Infect Dis J 2016; 35:263-8. [PMID: 26646549 PMCID: PMC4752422 DOI: 10.1097/inf.0000000000000991] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Elevated vancomycin minimum inhibitory concentrations (MICs) in Staphylococcus aureus have been associated with worse clinical outcomes in adults. For invasive meticillin-resistant S. aureus (MRSA) infections in adults, the Infectious Diseases Society of America recommends targeting vancomycin serum trough concentrations between 15 and 20 μg/mL. We evaluated trends in vancomycin MICs from healthcare-associated (HCA) S. aureus bacteremia isolates in children in addition to correlating vancomycin serum trough levels with clinical outcomes. METHODS Patients and isolates were identified from a prospective S. aureus surveillance study at Texas Children's Hospital (TCH). HCA S. aureus bacteremia isolates from 2003 to 2013 were selected. Vancomycin MICs by E-test were determined and medical records were reviewed. Acute kidney injury (AKI) was defined as doubling of the baseline serum creatinine. RESULTS Three hundred forty-one isolates met inclusion criteria. We observed a reverse vancomycin creep among MRSA isolates in the study period with a decline in the proportion of isolates with vancomycin MIC ≥ 2 μg/mL (from 32.7% to 5.6%; P < 0.001). However, the proportion of MSSA isolates with MIC ≥ 2 μg/mL increased (from 2.9% to 9%; P = 0.04). Among patients who had vancomycin troughs performed, there was no difference in duration of bacteremia or fever with vancomycin trough >15 versus <15 μg/mL. A vancomycin trough >15 μg/mL was, however, an independent risk factor for AKI. CONCLUSIONS Vancomycin MICs are shifting among HCA S. aureus bacteremia isolates with significant differences between MRSA and MSSA at TCH. Higher vancomycin troughs did not improve outcomes in pediatric HCA S. aureus bacteremia but were associated with increased nephrotoxicity. Further studies are needed to better understand optimal management of children with S. aureus bacteremia.
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Nichols KR, Israel EN, Thomas CA, Knoderer CA. Optimizing Guideline-Recommended Antibiotic Doses for Pediatric Infective Endocarditis. Ann Pharmacother 2016; 50:423-7. [PMID: 26917819 DOI: 10.1177/1060028016635660] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The American Heart Association recently published an updated scientific statement on the management of infective endocarditis in childhood. The recommendations included for vancomycin, aminoglycoside, and β-lactam dosing and monitoring are based primarily on expert opinion and do not consider available evidence for dose optimization based on pharmacokinetic and pharmacodynamic principles in pediatric patients. This is concerning because even when clinically necessary, some practitioners may be hesitant to deviate from guideline-recommended doses. In this perspective, we highlight potential areas for improvement in the statement-recommended doses and summarize evidence supporting antibiotic dosing optimization. The addition of a pediatric clinical pharmacist with expertise in antibiotic dosing to the panel would be beneficial for future updates.
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Affiliation(s)
- Kristen R Nichols
- Butler University, Indianapolis, IN, USA Indiana University Health, Indianapolis, IN, USA Indiana University School of Medicine, Indianapolis, IN, USA
| | - Emily N Israel
- Indiana University Health, Indianapolis, IN, USA Purdue University, Indianapolis and West Lafayette, IN, USA
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30
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Dong MH, Wang JW, Wu Y, Chen BY, Yu M, Wen AD. Evaluation of body weight-based vancomycin therapy and the incidence of nephrotoxicity: a retrospective study in the northwest of China. Int J Infect Dis 2015; 37:125-8. [DOI: 10.1016/j.ijid.2015.06.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/26/2015] [Accepted: 06/30/2015] [Indexed: 10/23/2022] Open
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Patel K, Crumby AS, Maples HD. Balancing vancomycin efficacy and nephrotoxicity: should we be aiming for trough or AUC/MIC? Paediatr Drugs 2015; 17:97-103. [PMID: 25644329 DOI: 10.1007/s40272-015-0117-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Sixty years later, the question that still remains is how to appropriately utilize vancomycin in the pediatric population. The Infectious Diseases Society of America published guidelines in 2011 that provide guidance for dosing and monitoring of vancomycin in adults and pediatrics. However, goal vancomycin trough concentrations of 15-20 μg/mL for invasive infections caused by methicillin-resistant Staphylococcus aureus were based primarily on adult pharmacokinetic and pharmacodynamic data that achieved an area under the curve to minimum inhibitory concentration ratio (AUC/MIC) of ≥400. Recent pediatric literature shows that vancomycin trough concentrations needed to achieve the target AUC/MIC are different than the adult goal troughs cited in the guidelines. This paper addresses several thoughts, including the role of vancomycin AUC/MIC in dosing strategies and safety monitoring, consistency in laboratory reporting, and future directions for calculating AUC/MIC in pediatrics.
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Affiliation(s)
- Karisma Patel
- Infectious Diseases, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO, 64108, USA
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32
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Antimicrobial Renal Injury in a Pediatric Intensive Care Unit: β-Lactams vs. Vancomycin. PHARMACY 2014. [DOI: 10.3390/pharmacy2040276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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