Vancomycin Use in Patients Requiring Hemodialysis: A Literature Review

Population Pharmacokinetics of Vancomycin in Patients Receiving Hemodialysis in a Malian and a French Center and Simulation of the Optimal Loading Dose

PURPOSE

Vancomycin dosing remains challenging in patients receiving intermittent hemodialysis, especially in developing countries, where access to therapeutic drug monitoring and model-based dose adjustment services is limited. The objectives of this study were to describe vancomycin population PK in patients receiving hemodialysis in a Malian and French center and examine the optimal loading dose of vancomycin in this setting.

METHODS

Population pharmacokinetic analysis was conducted using Pmetrics in 31 Malian and 27 French hemodialysis patients, having a total of 309 vancomycin plasma concentrations. Structural and covariate analyses were based on goodness-of-fit criteria. The final model was used to perform simulations of the vancomycin loading dose, targeting a daily area under the concentration-time curve (AUC) of 400-600 mg.h/L or trough concentration of 15-20 mg/L at 48 hours.

RESULTS

After 48 hours of therapy, 68% of Malian and 63% of French patients exhibited a daily AUC of <400. The final model was a 2-compartment model, with hemodialysis influencing vancomycin elimination and age influencing the vancomycin volume distribution. Younger Malian patients exhibited a lower distribution volume than French patients. Dosing simulation suggested that loading doses of 1500, 2000, and 2500 mg would be required to minimize underexposure in patients aged 30, 50, and 70 years, respectively.

CONCLUSIONS

In this study, a low AUC was frequently observed in hemodialysis patients in Mali and France after a standard vancomycin loading dose. A larger dose is necessary to achieve the currently recommended AUC target. However, the proposed dosing algorithm requires further clinical evaluation.

Practices, Knowledge, and Attitudes of Nephrologists Towards Prescribing and Monitoring Vancomycin at Dialysis Centers

BACKGROUND

Vancomycin dosing protocols are varied in the literature for hemodialysis patients. This study sought to determine nephrologists' practices, knowledge, attitudes, and barriers toward prescribing and monitoring vancomycin at dialysis centers.

METHODS

A cross-sectional and multi-center study was conducted in Kuwait using a validated self-administered questionnaire among 168 nephrologists. Descriptive and comparative analyses were performed using SPSS (version 28).

RESULTS

The response rate was 75% (n = 126). Over half of nephrologists frequently prescribed a vancomycin loading dose of 1000 mg (53.2%) and a maintenance dose of 500 mg (51.6%) to all patients. Their overall median (IQR) percentage knowledge about the therapeutic monitoring of vancomycin was 66.7% (33.3) and was found to be higher in nephrologists aged ≤ 40 years and in registrars/senior registrars (p < 0.05). Their overall median (IQR) attitude score was 4.0 (1.0) [positive attitude]. Nephrologists with > 15 years of practice experience expressed higher attitudes (p < 0.05). The top two perceived barriers were a lack of clear local hospital/national guidelines (60.3%) for vancomycin dosing in dialysis and inconsistencies among different dosing references and guidelines (51.6%).

CONCLUSION

Findings showed that nephrologists have varying practices, moderate knowledge, and positive attitudes toward prescribing and monitoring vancomycin and highlight the need for interventions to overcome the perceived barriers.

Vancomycin dosing in an obese patient with acute renal failure: A case report and review of literature

BACKGROUND

Vancomycin is the most commonly used drug for methicillin-resistant Staphylococcus aureus. The empirical clinical doses of vancomycin based on non-obese patients may not be optimal for obese ones.

CASE SUMMARY

This study reports a case of vancomycin dosing adjustment in an obese patient (body mass index 78.4 kg/m²) with necrotizing fasciitis of the scrotum and left lower extremity accompanied with acute renal failure. Dosing adjustment was performed based on literature review and factors that influence pharmacokinetic parameters are analyzed. The results of the blood drug concentration monitoring confirmed the successful application of our dosing adjustment strategy in this obese patient. Total body weight is an important consideration for vancomycin administration in obese patients, which affects the volume of distribution and clearance of vancomycin. The alterations of pharmacokinetic parameters dictate that vancomycin should be dose-adjusted when applied to obese patients. At the same time, the pathophysiological status of patients, such as renal function, which also affects the dose adjustment of the patient, should be considered.

CONCLUSION

Monitoring vancomycin blood levels in obese patients is critical to help adjust the dosing regimen to ensure that vancomycin concentrations are within the effective therapeutic range and to reduce the incidence of renal injury.

Optimal Sampling Strategy and Threshold of Serum Vancomycin Concentration in Elderly Japanese Patients Undergoing High-Flux Hemodialysis

BACKGROUND

The optimal sampling points and thresholds for initial serum vancomycin (VCM) concentrations have not been determined in hemodialysis (HD) patients. To clarify this, multiple blood tests were performed, and the correlations between VCM concentrations at several sampling points and the area under the concentration-time curve for 24 hours (AUC24h) were analyzed.

METHODS

A single-center, prospective observational study was conducted. Patients with end-stage renal failure who received VCM treatment while undergoing chronic maintenance HD were enrolled in this study. HD was performed using a high-flux membrane as the dialyzer. After VCM administration, 7 points were sampled between the first and second HD. The AUC24h after the end of the first HD (AUC0-24) and that before the end of the second HD (AUC24-48) were calculated using the linear trapezoidal method. Correlation analysis and simple regression analysis between AUC24h and serum concentrations were performed at each sampling point.

RESULTS

Nine patients were evaluated. Strong correlations were found between AUC24-48 and serum concentrations at 24 hours after the initiation of VCM treatment following the first HD (C24h, R = 0.983 and P < 0.001), between AUC0-24 and C24h (R = 0.967 and P < 0.001), and between AUC24-48 and serum concentration just before the second HD (Cpre(HD2), R = 0.965 and P < 0.001). Regression equations with high coefficients of determination (R2 > 0.9) were obtained, and a C24h of ≥18.0 mg/L and a Cpre(HD2) of ≥16.5 mg/L were required to achieve an AUC24-48 value of ≥400 mg·h/L. In addition, a C24h of ≤23.3 mg/L was estimated to satisfy the AUC0-24 range of ≤600 mg·h/L.

CONCLUSIONS

C24h and Cpre(HD2) are optimal sampling points for predicting VCM-AUC24h in HD patients.

Treatment of recurrent urinary tract infections in anuric hemodialysis patient, do we really need antimicrobial urinary concentration?

Providing care for patients with chronic kidney disease requires considerations that are unique to this population. Several references recommend the treating urinary tract infections with antibiotics that achieve considerable concentrations in urine however this is not applicable in anuric patients undergoing hemodialysis who are unable to excrete antibiotics significantly in urine. We report successful treatment of several episodes of urinary tract infections in hemodialysis patient highlighting the questionable need for antimicrobial urine concentration.

Vancomycin dosing in chronic high-flux haemodialysis: a systematic review

The aim of this study was to systematically evaluate whether non-weight-based dosing (non-WBD) or weight-based dosing (WBD) of vancomycin leads to a higher proportion of patients achieving the pharmacokinetic/pharmacodynamic target. Studies from January 1985 to February 2017 were identified through Cochrane, MEDLINE and Embase databases. Those conducted in adults with end-stage renal disease receiving high-flux haemodialysis (HD) and intravenous vancomycin were included. The primary outcome was the proportion of patients with a pre-HD vancomycin concentration of 15-20 mg/L and/or an area under the concentration-time curve/minimum inhibitory concentration (AUC/MIC) ratio ≥400. Of the 3948 studies screened, 5 met the inclusion criteria. The proportion of patients with pre-HD concentrations between 15-20 mg/L were 35% (non-WBD) and 13% (WBD) post-loading dose. During maintenance dosing, the proportion of patients with pre-HD concentrations between 15-20 mg/L were 37% (non-WBD) and 50-67% (WBD). The proportion of pre-HD concentrations <15 mg/L was greater in the non-WBD group post-loading dose but was similar between the non-WBD and WBD group during maintenance dosing. One study reported that all patients had an AUC/MIC ≥ 400 for micro-organisms with an MIC ≤ 1 mg/L for weight-based maintenance dosing. The limited data suggest that WBD may be preferential as there was a smaller proportion of pre-HD concentrations falling below 15 mg/L. However, larger well-designed studies of higher quality are required to provide guidance for vancomycin dosing in the high-flux HD setting. Future research should focus on reporting AUC/MIC ratios and exploring clinical outcomes in this patient population.

The Nephrotoxicity of Vancomycin

Vancomycin use is often associated with nephrotoxicity. It remains uncertain, however, to what extent vancomycin is directly responsible, as numerous potential risk factors for acute kidney injury frequently coexist. Herein, we critically examine available data in adult patients pertinent to this question. We review the pharmacokinetics/pharmacodynamics of vancomycin metabolism. Efficacy and safety data are discussed. The pathophysiology of vancomycin nephrotoxicity is considered. Risk factors for nephrotoxicity are enumerated, including the potential synergistic nephrotoxicity of vancomycin and piperacillin‐tazobactam. Suggestions for clinical practice and future research are given.

Predicting Maintenance Doses of Vancomycin for Hospitalized Patients Undergoing Hemodialysis

BACKGROUND

Methicillin-resistant Staphylococcus aureus is a leading cause of death in patients undergoing hemodialysis. However, controversy exists about the optimal dose of vancomycin that will yield the recommended pre-hemodialysis serum concentration of 15-20 mg/L.

OBJECTIVE

To develop a data-driven model to optimize the accuracy of maintenance dosing of vancomycin for patients undergoing hemodialysis.

METHODS

A prospective observational cohort study was performed with 164 observations obtained from a convenience sample of 63 patients undergoing hemodialysis. All vancomycin doses were given on the floor after completion of a hemodialysis session. Multivariate linear generalized estimating equation analysis was used to examine independent predictors of pre-hemodialysis serum vancomycin concentration.

RESULTS

Pre-hemodialysis serum vancomycin concentration was independently associated with maintenance dose (B = 0.658, p < 0.001), baseline pre-hemodialysis serum concentration of the drug (B = 0.492, p < 0.001), and interdialytic interval (B = -2.133, p < 0.001). According to the best of 4 models that were developed, the maintenance dose of vancomycin required to achieve a pre-hemodialysis serum concentration of 15-20 mg/L, if the baseline serum concentration of the drug was also 15-20 mg/L, was 5.9 mg/kg with interdialytic interval of 48 h and 7.1 mg/kg with interdialytic interval of 72 h. However, if the baseline pre-hemodialysis serum concentration was 10-14.99 mg/L, the required dose increased to 9.2 mg/kg with an interdialytic interval of 48 h and 10.0 mg/kg with an interdialytic interval of 72 h.

CONCLUSIONS

The maintenance dose of vancomycin varied according to baseline pre-hemodialysis serum concentration of the drug and interdialytic interval. The current practice of targeting a pre-hemodialysis concentration of 15-20 mg/L may be difficult to achieve for the majority of patients undergoing hemodialysis.

Vancomycin dosing and monitoring for patients with end-stage renal disease receiving intermittent hemodialysis

PURPOSE

Vancomycin dosing and monitoring algorithms for patients with end-stage renal disease (ESRD) receiving intermittent hemodialysis are reviewed.

SUMMARY

Vancomycin is one of the most commonly administered antimicrobial agents in adult patients with ESRD receiving intermittent hemodialysis. However, despite the availability of many published studies, the single best method of vancomycin administration in this population remains unclear. Many studies evaluating vancomycin dosing in adult patients with ESRD receiving intermittent hemodialysis were limited by a small sample size, inappropriate therapeutic targets, older hemodialysis modalities (e.g., low-flux intermittent hemodialysis), and inconsistencies in the timing of dosing or therapeutic drug monitoring. Pharmacokinetic variables that must be accounted for include a prolonged distribution phase, a redistribution phase and rebound effect after completion of hemodialysis, patient weight, residual renal function, and nonrenal clearance. Optimal vancomycin dosing recommendations are needed, but clinicians should always consider patient-specific variables, the timing of vancomycin administration, the timing of serum vancomycin concentrations, and technical aspects of the dialysis procedure when creating a dosing regimen.

CONCLUSION

Individualized vancomycin dosing regimens and therapeutic drug monitoring are necessary for patients with ESRD receiving intermittent hemodialysis to ensure that goal serum vancomycin levels are reached to adequately treat an infection.

Vancomycin: the tale of the vanquisher and the pyrrhic victory

Vancomycin has been the antibiotic of choice in the treatment of methicillin-resistant Staphylococcus aureus infections for decades. But relatively recently, vancomycin-intermediate-susceptible S. aureus (VISA) have been reported. Phenotypically, VISA are characterized by thicker cell walls, requiring higher concentrations of vancomycin for inhibition of bacterial cell growth. Vancomycin-intermediate-susceptible S. aureus represent just the tip of the iceberg of an insidious loss of vancomycin susceptibility in staphylococci. Increasing proportions of S. aureus isolates have higher minimum inhibitory concentrations that are still within the officially susceptible range, a characteristic that is associated with treatment failure. The most important risk factor for decreased vancomycin susceptibility is in vivo selection pressure. To prevent the development of VISA, prolonged or inappropriate use of vancomycin and suboptimal vancomycin levels should be avoided. Trough serum vancomycin concentrations of 15 - 20 mg/L for intermittent dosing and plateau serum vancomycin concentrations of 20 - 25 mg/L for continuous infusions are therefore currently recommended. The widespread clinical application of these intensive dosing regimens has resulted in an increasing awareness of vancomycin-induced nephrotoxicity, which is especially relevant in patients whose renal function is already compromised. This narrow therapeutic-toxic window reinforces the use of rigorous dosing protocols. In hemodialysis, the use of a vancomycin dose calculator permits achievement of target concentrations in most patients. In peritoneal dialysis (PD), intermittent vancomycin dosing regimens often lead to low end-of-dwell concentrations. On the other hand, a continuous vancomycin dosing regimen after a loading dose offers the desired combination of high local levels without toxic systemic levels.

Pharmacokinetic considerations in chronic kidney disease and patients requiring dialysis

INTRODUCTION

Chronic kidney disease (CKD) is the progressive decline in renal function over time. Patients with end-stage renal disease require renal replacement therapy such as hemodialysis to support life. Hemodialysis patients require several medications to treat a variety of comorbid conditions. Polypharmacy accompanied by alterations in the pharmacokinetics of medications places hemodialysis patients at increased risk of drug accumulation and adverse events.

AREAS COVERED

We review alterations in the pharmacokinetics of drugs in hemodialysis patients. The major areas of pharmacokinetics, absorption, distribution, metabolism and excretion, are covered and, where appropriate, differences between dialysis patients and non-dialysis CKD patients are compared. In addition, we review the importance of drug dialyzability and its potential impact on drug efficacy. Finally, we describe important clinical examples demonstrating nonrenal drug clearance is significantly altered in CKD.

EXPERT OPINION

Decreases in renal drug excretion experienced by hemodialysis patients have been known for years. Recent animal and human clinical pharmacokinetic studies have highlighted that nonrenal clearance of drugs is also substantially decreased in CKD. Clinical pharmacokinetic studies are required to determine the optimal dosage of drugs in CKD and hemodialysis patients in order to decrease the incidence of adverse medication events in these patient populations.

The challenge of methicillin-resistant Staphylococcus aureus prevention in hemodialysis therapy

Methicillin-resistant Staphylococcus aureus (MRSA) infections have challenged care process and resource utilization in the acute hospital care setting for nearly 30 years. These infections have become important causes of morbidity, mortality, and a source of concern in the primary and emergency care context over the past decade. As individuals receiving recurrent therapy with features of both ambulatory care and acute care, hemodialysis patients are exposed to numerous opportunities for MRSA acquisition. Surprisingly, high prevalence rates for MRSA colonization have been demonstrated for both hemodialysis patients and their care providers. The necessity of vascular access and the persistent high prevalence of endovascular catheter use among patients repeatedly exposed to healthcare settings provide the perfect milieu for the troubling rates of MRSA infection, particularly bloodstream infections, in outpatient dialysis care. Dialysis industry shifts, including increased requirements for compliance and reporting in other areas of dialysis care, tax resources for infection prevention processes. Multifaceted strategies that include reassessment of vascular access care, attention to the interruption of MRSA transmission dynamics, and emphasis on organizational learning processes are needed to accomplish a meaningful reduction in the morbidity, mortality, and cost associated with MRSA infections in dialysis care.

Clinical Experience with Aminoglycosides in Dialysis-Dependent Patients: Risk Factors for Mortality and Reassessment of Current Dosing Practices

Background::

A resurgence of aminoglycoside use has followed the recent increase of multidrug-resistant gram-negative pathogens and is often needed even in the treatment of dialysis-dependent patients; however, studies evaluating the treatment of gram-negative infections with aminoglycosides, including the optimal dose, in the setting of dialysis are limited.

Objective:

To evaluate the current patterns of aminoglycoside use, including microbiologic and clinical indications, and identify risk factors associated with mortality in dialysis-dependent patients receiving aminoglycosides.

Methods:

Utilization, clinical, and microbiologic data were collected retrospectively over a 2-year period (July 2008-June 2010) for adults with a diagnosis of renal failure requiring dialysis and aminoglycoside therapy. Binary logistic and multivariate regression analyses were performed to identify risk factors for alt-cause 30-day mortality.

Results:

Ninety-five consecutive aminoglycoside courses in 88 patients met inclusion criteria for evaluation. A wide variety of clinical and microbiologic indications were documented. The average duration of aminoglycoside therapy was 5.2 days (range 1-42), the average duration of antimicrobial therapy was 13.5 days (1-60), and the all-cause 30-day mortality rate was 36.5%. Factors associated with all-cause 30-day mortality were gram-negative rod (GNR) bacteremia (OR 28.6; p = 0.035), advanced age (OR 8.5; p = 0.030), recent admission (OR 33.4; p = 0.038). and inadequate empiric therapy (OR 14.9; p = 0.024). Intravenous catheter removal was protective of all-cause 30-day mortality (OR 0.01; p = 0.005). A first pre-dialysis plasma concentration relative to the minimum inhibitory concentration (Cp:MIC) <6 mg/L (gentamicin/tobramycin) was associated with an increased risk of mortality (p = 0.026) upon subgroup analysis of dialysis-dependent patients with GNR bloodstream infections.

Conclusions:

Outcomes among dialysis-dependent patients who received aminoglycosides were below expectations. Various risk factors for mortality were identified, including retention of the catheter, inadequate empiric therapy, and a Cp:MIC <6 mg/L. Improved approaches to dosing of aminoglycosides in dialysis-dependent patients, including more aggressive dosing practices, should be urgently explored in attempts to maximize favorable patient outcomes.

Evaluation of the synergistic potential of vancomycin combined with other antimicrobial agents against methicillin-resistant Staphylococcus aureus and coagulase-negative Staphylococcus spp strains

Methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative Staphylococcus spp (CNS) are the most common pathogens that cause serious long term infections in patients. Despite the existence of new antimicrobial agents, such as linezolid, vancomycin (VAN) remains the standard therapy for the treatment of infections caused by these multidrug-resistant strains. However, the use of VAN has been associated with a high frequency of therapeutic failures in some clinical scenarios, mainly with decreasing concentration of VAN. This work aims to evaluate the synergic potential of VAN plus sulfamethoxazole/trimethoprim (SXT), VAN plus rifampin (RIF) and VAN plus imipenem (IPM) in sub-minimum inhibitory concentrations against 22 clinical strains of MRSA and CNS. The checkerboard method showed synergism of VAN/RIF and VAN/SXT against two and three of the 22 strains, respectively. The combination of VAN with IPM showed synergistic effects against 21 out of 22 strains by the E-test method. Four strains were analyzed by the time-kill curve method and synergistic activity was observed with VAN/SXT, VAN/RIF and especially VAN/IPM in sub-inhibitory concentrations. It would be interesting to determine if synergy occurs in vivo. Evidence of in vivo synergy could lead to a reduction of the standard VAN dosage or treatment time.

Antibiotics for gram-positive bacterial infection: vancomycin, teicoplanin, quinupristin/dalfopristin, oxazolidinones, daptomycin, telavancin, and ceftaroline

An overview of the mechanism of action, dosing, clinical indications, and toxicities of the glycopeptide vancomycin is provided. The emerging gram-positive bacterial resistance to antimicrobials and its mechanisms are reviewed. Strategies to control this emergence of resistance are expected to be proposed. Newer antimicrobial agents that have activity against vancomycin-resistant organisms are now available and play a critical role in the treatment of life-threatening infections.

Vancomycin pharmacokinetics and pharmacodynamics during short daily hemodialysis

BACKGROUND AND OBJECTIVES

Short daily hemodialysis (SDHD) is an alternative to thrice-weekly HD because of its putative physiologic benefits. The purpose of this study was to investigate the effect of SDHD on the pharmacokinetics and pharmacodynamics of vancomycin.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Six noninfected adults who had anuria and were treated with SDHD were studied and received four dialysis sessions over 4 days. After completion of the first SDHD, each patient received vancomycin 15 mg/kg by intravenous infusion. Blood samples were collected over the ensuing 3 days during each subsequent inter- and intradialytic period. Pharmacokinetic parameters were determined. Serum concentration-time profiles were simulated for four vancomycin regimens with maintenance doses administered after every other SDHD. Area under the serum-concentration time curve (AUC) from 0 to 48 hours, 48 to 96 hours, and 96 to 144 hours were calculated, and Monte Carlo simulations were performed to determine the probability of target attainment at an AUC/minimum inhibitory concentration (MIC) ratio ≥800 for each 48-hour AUC at MICs ranging from 0.5 to 2.0 μg/ml.

RESULTS

Median (range) systemic clearance was 7.2 ml/min (5.3 to 10.0 ml/min), and dialytic clearance was 104 ml/min (94 to 106 ml/min). The steady-state volume of distribution was 55.4 L (34.8 to 77.2 L). At MICs ≤1 μg/ml, probability of target attainment was >90% for each 48-hour AUC when vancomycin was administered as a 20-mg/kg loading dose followed by 10 mg/kg after every other SDHD.

CONCLUSIONS

Vancomycin pharmacokinetic parameters in SDHD are consistent with data from thrice-weekly HD. A loading dose of 20 mg/kg followed by 10 mg/kg after every other SDHD provides adequate exposure for pathogens with MICs ≤1 μg/ml.

Antibiotics for gram-positive bacterial infections: vancomycin, teicoplanin, quinupristin/dalfopristin, oxazolidinones, daptomycin, dalbavancin, and telavancin

An overview of the mechanism of action, dosing, clinical indications, and toxicities of the glycopeptide vancomycin is provided. The emerging gram-positive bacterial resistance to antimicrobials and its mechanisms are reviewed. Strategies to control this emergence of resistance are expected to be proposed. Newer antimicrobial agents that have activity against vancomycin-resistant organisms are now available and play a critical role in the treatment of life-threatening infections.