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Zhan R, Lin J, Dai M, Ji B, He X, Jiang Z. Combined nephrotoxicity of Polymyxins and Vancomycin: a study on adverse event reporting for monotherapy versus combinations using the FDA adverse event reporting system (FAERS). Expert Opin Drug Saf 2024:1-6. [PMID: 39391997 DOI: 10.1080/14740338.2024.2416256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 08/27/2024] [Accepted: 09/10/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND Multidrug-resistant (MDR) infections pose a global public health crisis with significant mortality and economic burdens. Combination of polymyxins and vancomycin has shown effectiveness against MDR infections. However, their combined nephrotoxicity complicates clinical use. Given these concerns, we conducted a pharmacovigilance analysis using the FDA Adverse Event Reporting System (FAERS) to assess the nephrotoxicity of combinations of polymyxins and vancomycin compared to monotherapy. RESEARCH DESIGN AND METHODS In this retrospective study, data from FAERS reports (2012 Q4 to 2023 Q2) were deduplicated and analyzed for adverse events (AEs) related to vancomycin, polymyxin B, and colistin. Disproportionality analyses were performed to evaluate the association between drugs and nephrotoxicity. RESULTS A total of 9,796,784 adverse event reports, including 73,009 reports associated with nephrotoxicity, were included. All three drugs showed significant associations with nephrotoxicity. In combination therapy, polymyxin B-vancomycin exhibited a stronger association with nephrotoxicity compared to monotherapy, whereas colistin-vancomycin demonstrated a lower association with nephrotoxicity than colistin monotherapy. CONCLUSIONS This study found that combining vancomycin with colistin alleviated colistin-induced nephrotoxicity, while combining vancomycin with polymyxin B worsened polymyxin B-induced nephrotoxicity.
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Affiliation(s)
- Ruijia Zhan
- Department of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Jiageng Lin
- Department of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Miao Dai
- Department of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Bo Ji
- Department of Pharmacy, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Xianxia He
- Department of Certification, Guangzhou Center for Food and Drug evaluation, Guangzhou, China
| | - Zhihui Jiang
- Department of Pharmacy, General Hospital of Southern Theatre Command, Guangzhou, China
- School of pharmaceutical sciences, Southern Medical University, Guangzhou, China
- Graduate School, Guangzhou University of Chinese Medicine, Guangzhou, China
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Weng SE, Hsu WT, Hsiao FY, Lee CM. Non-steroidal anti-inflammatory drugs, renin-angiotensin system blockade or diuretics and risk of acute kidney injury: A case-crossover study. Arch Gerontol Geriatr 2024; 123:105394. [PMID: 38537386 DOI: 10.1016/j.archger.2024.105394] [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: 12/28/2023] [Revised: 02/21/2024] [Accepted: 03/02/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Aging-related physiological changes, such as decline in renal function, not only exacerbates pre-existing comorbidities but also escalate the susceptibility to adverse events. Previous studies have shown that non-steroidal anti-inflammatory drugs (NSAIDs) are associated with an increased risk of acute kidney injury (AKI), and the concomitant use of renin-angiotensin system blockade or diuretics may further potentiate the risk. However, studies evaluating the risk of AKI associated with NSAIDs (including routes, concomitant use of different NSAIDs, categories (traditional NSAIDs or COX-2 inhibitors), and cumulative doses of NSAIDs) are limited, particularly the risk of AKI associated with the dual or triple combination of NSAIDs with renin-angiotensin system blockade (RAS blockades) and/or diuretics. METHODS A case-crossover study utilized two sets of longitudinal data from Taiwan's National Health Insurance Research Database (NHIRD). Newly admitted patients with a primary AKI diagnosis were included, with the index date defined as the first admission date. The 1-7 days and 181-187 days prior to the index date served as the case and control periods. Exposure to NSAIDs and co-exposures of RAS blockade and/or diuretics were assessed in both periods. Multivariable conditional logistic regression models, adjusting for potential confounders, estimated adjusted odds ratios (aORs) and 95 % confidence intervals (CIs) for AKI associated with NSAIDs, dual, or triple combinations. Sensitivity analyses explored result robustness by varying case and control period lengths. RESULTS The study included 1,284 newly diagnosed AKI patients. NSAIDs showed a 3.55-fold increased risk of AKI (aOR: 3.55; 95 % CI 2.70-4.65), with similar risks for traditional NSAIDs and COX-2 inhibitors. Use of multiple NSAIDs, parenteral dosage forms, and higher cumulative doses increased AKI risk. Dual combination with either RAS blockade or diuretics resulted in a 2.90-fold (aOR: 2.90; 95 %CI 1.47-5.70) and 12.68-fold (aOR: 12.68; 95 %CI 6.15-26.12) risk, respectively. The highest risk occurred with triple combination (aOR: 29.22; 95 %CI 12.82-66.64). CONCLUSIONS NSAIDs, including both non-selective NSAIDs and COX2 inhibitors, elevate the risk of AKI. Increased AKI risk is linked to using multiple NSAIDs, the parenteral dosage form, and higher cumulative doses. Dual combination of RAS blockade with NSAIDs or diuretics with NSAIDs, as well as triple therapy, heightens the risk, with the latter associated with the highest risk of AKI.
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Affiliation(s)
- Shao-En Weng
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, Taipei City Hospital, Zhongxing Branch, Taipei, Taiwan
| | - Wan-Tseng Hsu
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.
| | - Chii-Ming Lee
- Department of Cardiology, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan.
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Figueroa SC, Pincheira DS, Navarrete CB, Panés JH, Montecinos SM, Cabrera LF. Usefulness of vancomycin treatment individualization via Bayesian algorithms: a 5-year study in critical patients. Per Med 2024; 21:243-255. [PMID: 38940364 DOI: 10.1080/17410541.2024.2365616] [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: 01/16/2024] [Accepted: 06/05/2024] [Indexed: 06/29/2024]
Abstract
Aim: Compare two vancomycin dosing strategies in critical patients with methicillin-resistant Staphylococcus aureus (MRSA) infections, considering the heterogeneity of the dosing regimens administered and their implications for toxicity and efficacy. Materials & methods: Longitudinal retrospective observational study in two patient cohorts (standard dosing vs dosing via Bayesian algorithms). Results: The group of Bayesian algorithms received substantially higher and significantly heterogeneous doses, with an absence of nephrotoxicity. The speed of decrease observed in CRP and PCT was greater for the Bayesian strategy (p = 0.045 and 0.0009, respectively). Conclusion: Applying Bayesian algorithms to vancomycin dosage individualization allows for administering much higher doses than with standard regimens, facilitating a quicker clinical response in the absence of nephrotoxicity.
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Affiliation(s)
- Salvador Cabrera Figueroa
- Personalized Therapy Unit, Regional Clinical Dr. Guillermo Grant Benavente Hospital, San Martín 1436, Concepción, Chile
- Pharmacy Department, Pharmacy Faculty, University of Concepcion, Víctor Lamas 1290, Concepción, Chile
| | - Diego Salazar Pincheira
- Personalized Therapy Unit, Regional Clinical Dr. Guillermo Grant Benavente Hospital, San Martín 1436, Concepción, Chile
- Pharmacy Department, Pharmacy Faculty, University of Concepcion, Víctor Lamas 1290, Concepción, Chile
| | - Claudio Bustos Navarrete
- Psychology Department, Faculty of Social Sciences, University of Concepcion, Víctor Lamas 1290, Concepción, Chile
| | - Juan Hermosilla Panés
- Department of Internal Medicine, Medicine Faculty & Science, San Sebastian University, Lientur 1457, Concepción, Chile
| | - Sergio Mella Montecinos
- Infectious Disease Unit, Regional Clinical Dr. Guillermo Grant Benavente Hospital, San Martín 1436, Concepción, Chile
- Department of Medicine, Medicine Faculty, University of Concepcion, Víctor Lamas 1290, Concepción, Chile
| | - Leonila Ferreira Cabrera
- Critical Patients Unit, Regional Clinical Dr. Guillermo Grant Benavente Hospital, San Martín 1436, Concepción, Chile
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Doan K, Smoke S. Antibiotic de-escalation in pneumonia with pharmacist education and ordering of methicillin-resistant Staphylococcus aureus nasal swabs. Eur J Hosp Pharm 2024; 31:327-331. [PMID: 36754620 PMCID: PMC11265549 DOI: 10.1136/ejhpharm-2022-003504] [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: 08/08/2022] [Accepted: 01/25/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION When methicillin-resistant Staphylococcus aureus (MRSA) is the causative pathogen in pneumonia, in-hospital mortality rate is approximately 31.2%. However, the occurrence of MRSA pneumonia is uncommon, with a reported incidence of approximately 4.2%. Vancomycin is often empirically used for MRSA pneumonia coverage, but can lead to serious harm. The purpose of this study was to measure the impact of a pharmacy-driven MRSA nares testing protocol on vancomycin and linezolid prescribing patterns and clinical outcomes in patients diagnosed with pneumonia after removal of immediate educational intervention. METHODS This single-centre, quasi-experimental study evaluated the use of a MRSA nasal swab on patients diagnosed with community-acquired pneumonia, hospital-acquired pneumonia and ventilator-associated pneumonia. This study consisted of three phases, the preimplementation phase, the active/educational phase and the postimplementation phase. The primary outcome was intravenous anti-MRSA antibiotic duration of therapy. Secondary outcomes included the occurrence of acute kidney injury, duration of hospital stay, number of vancomycin levels obtained, the number of MRSA nares swabs ordered and time points in the MRSA nares collection process. RESULTS The preimplementation phase (n=39), the active phase (n=45) and the postimplementation phase (n=26) demonstrated similar baseline characteristics. The primary outcome for duration of anti-MRSA therapy 0-72 hours was 61.5% vs 77.8% vs 76.9% (p=0.19). Acute kidney injury was decreased throughout the study at 25.6%, 24.4% and 16.7% (p=0.32). The number of MRSA nares swabs ordered were 23.1%, 60% and 30.8% in each of the phases, respectively (p=0.49). DISCUSSION Our novel approach to measuring the impact of pharmacist education and ordering of MRSA nasal swabs has demonstrated benefits that were sustained for a short period after the intervention was removed. Additional study is required to determine the long-term impact. CONCLUSION The implementation of a hospital-wide anti-MRSA protocol in patients with confirmed or suspected pneumonia indicated sustained changes for at least 3 months after direct intervention.
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Affiliation(s)
- Kevin Doan
- Pharmacy, Stanford Medicine, Stanford, California, USA
| | - Steven Smoke
- Pharmacy, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
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Martin T, Wilber E, Advani S, Torrisi J, Patel M, Rebolledo PA, Wang YF, Kandiah S. The impact of implementation of rapid blood culture identification panels on antimicrobial optimization: a retrospective cohort study. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e44. [PMID: 38628375 PMCID: PMC11019579 DOI: 10.1017/ash.2024.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/07/2024] [Accepted: 03/13/2024] [Indexed: 04/19/2024]
Abstract
Objective Determine the impact of limited implementation of a rapid blood culture identification (BCID) panel. Design Retrospective cohort study. Methods From February to April 2022, positive blood cultures identified via e-Plex BCID (Roche, Carlsbad, CA) were compared to those identified using standard microbial identification techniques. The primary outcomes assessed were time to optimal therapy, time to de-escalation of anti-MRSA (methicillin-resistant Staphylococcus aureus) agents, and time to de-escalation of anti-pseudomonal agents. Additional analysis investigated the impact of the availability of antimicrobial stewardship program support. This study was conducted at Grady Health System, a large metropolitan safety-net hospital in the southeastern United States. Results A total of 253 blood cultures were included in this study (153 BCID and 100 standard). Blood culture identification use was associated with a reduction in median time to optimal antimicrobial therapy (43.4 vs 72.1 h, P < .001) and median time to de-escalation of anti-MRSA agents (27.7 vs 46.7 h, P = .006), and a trend towards reduction of median time to de-escalation of anti-pseudomonal agents (38.8 vs 54.8 h, P = .07). These reductions persisted when controlling for patient age, sex, intensive care unit status, Charlson Comorbidity Index, and antimicrobial stewardship program availability. Conclusions Despite restricted use and lack of 24/7 antimicrobial stewardship program availability, BCID panel utilization was associated with earlier initiation of optimal therapy and pathogen identification with subsequent de-escalation of broad-spectrum antimicrobials, as compared to standard antimicrobial techniques. This suggests the potential for benefit from adopting novel diagnostic technologies outside of idealized fully-resourced settings.
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Affiliation(s)
- Tyler Martin
- Department of Pharmacy, Grady Health System, Atlanta, GA, USA
| | - Eli Wilber
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Shreena Advani
- Department of Pharmacy, Grady Health System, Atlanta, GA, USA
| | - Joseph Torrisi
- Department of Pharmacy, Grady Health System, Atlanta, GA, USA
| | - Manish Patel
- Department of Pharmacy, Grady Health System, Atlanta, GA, USA
| | - Paulina A. Rebolledo
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Grady Healthcare System, Atlanta, GA, USA
| | - Yun F. Wang
- Clinical Microbiology Laboratory, Grady Health System, Atlanta, GA, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sheetal Kandiah
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Grady Healthcare System, Atlanta, GA, USA
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Kanazawa N, Shigemi A, Amadatsu N, Arimura K, Shimono S, Oda K, Chuang VTG, Matsumoto K, Kawamura H, Terazono H. A cohort study of the risk factors and the target AUC to avoid vancomycin-associated acute kidney injury in pediatric patients. J Infect Chemother 2024; 30:323-328. [PMID: 37940038 DOI: 10.1016/j.jiac.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/20/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES In recent years, Vancomycin (VCM) dosing design using area under the concentration-time curve (AUC) has been recommended as a measure of efficacy and safety, but there are fewer reports on pediatric patients than on adults. In this study, we evaluated the threshold of AUC for AKI occurrence in pediatric patients and investigated the factors that contribute to the occurrence of AKI. METHODS Pediatric patients aged 1-15 years on VCM treatment who underwent TDM at Kagoshima University Hospital from April 2016 to March 2022 were included in the computation of AUC using pediatric population pharmacokinetic parameters. RESULTS The ROC curve showed that the AUC threshold for the risk of developing AKI was 583.0 μg・h/mL, and the AUC-ROC curve was 0.873 (sensitivity 0.930, specificity 0.750). Univariate analysis showed that factors associated with AKI incidence were the duration of VCM administration, ICU admission, and AUCSS. Concomitant medications identified as risk factors for AKI incidence were tazobactam/piperacillin, liposomal amphotericin B, calcineurin inhibitors, contrast agents, and H2-receptor blockers. The multivariate analysis showed that AUC ≧ 583.0 μg・h/mL (odds ratio 20.14, 95% CI 3.52-115.22, p < 0.001) and H2-receptor blockers (odds ratio 8.70, 95% confidence interval = 1.38-54.87, p = 0.02) were independent factors for AKI incidence. CONCLUSIONS We showed that in pediatric patients receiving VCM, the risk of AKI increases as AUC increases. The findings imply that concurrent use of VCM and H2-receptor blockers may increase the risk of AKI.
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Affiliation(s)
- Naoko Kanazawa
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Akari Shigemi
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan; Department of Infection Control and Prevention, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Nao Amadatsu
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Kotaro Arimura
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Shohei Shimono
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1, Honjo, Chuo-ku, Kumamoto-shi, Kumamoto, 860-8556, Japan
| | - Victor Tuan Giam Chuang
- Discipline of Pharmacy, Curtin Medical School, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Hideki Kawamura
- Department of Infection Control and Prevention, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Hideyuki Terazono
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan.
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Chen J, Lin J, Weng J, Ju Y, Li Y. Association between trough serum vancomycin concentration and vancomycin-associated acute kidney injury and 30-day mortality in critically ill elderly adults. BMC Infect Dis 2024; 24:330. [PMID: 38509460 PMCID: PMC10953182 DOI: 10.1186/s12879-024-09227-x] [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: 11/27/2023] [Accepted: 03/14/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Vancomycin-associated acute kidney injury (VA-AKI) is the most clinically relevant side effect of vancomycin. The objective of this study was to investigate the association between VTC and VA-AKI as well as 30-day mortality in critically ill elderly adults. METHOD Elderly patients with trough serum vancomycin concentration records(VTC) in the Medical Information Mart-IV (MIMIC-IV) and eICU databases were retrospectively studied. RESULTS A total of 3,146 critically ill elderly adults were finally enrolled. The incidence of VA-AKI in the elderly population was 76.5%. Logistic regression analysis revealed significant relationships between VA-AKI and various factors, including VTC, comorbidities, and laboratory indicators, and SOFA, and GCS score. For each mg/L increase, the OR for VA-AKI increased by 2.5%. The association between VTC and 30-day mortality was found to be statistically significant (odds ratio (OR): 1.021, 95% CI: 1.010-1.031), P < 0.001). The Restricted cubic splines (RCS) curves revealed that VTC ranged of 19.67 to 35.72 mg/l for AKI and 19.17 to 42.86 mg/l for 30-day mortality exhibit OR with 95% CI above 1, indicating statistically significant associations with an increased risk of AKI and 30-day mortality, respectively. In the subgroup analysis, VTC was identified as a risk factor for VA-AKI in specific patient groups, including white individuals, female patients, those with shock, patients with SOFA > 6, patients with baseline creatinine > 1.2 mg/dl and patients with or without exposed to other nephrotoxic medications. CONCLUSION This study found the significant association between VTC and the incidence of VA-AKI and 30-day mortality in critically ill elderly adults. The RCS curves indicated concentration ranges for AKI (19.67-35.72 mg/L) and 30-day mortality (19.17-42.86 mg/L), signifying increased risk.
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Affiliation(s)
- Jialong Chen
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, the Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Lin
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jianzhen Weng
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, the Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yang Ju
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, the Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yanming Li
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, the Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China.
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Nachiappa Ganesh R, Edwards A, El Zaatari Z, Gaber L, Barrios R, Truong LD. Vancomycin nephrotoxicity: A comprehensive clinico-pathological study. PLoS One 2024; 19:e0295136. [PMID: 38452051 PMCID: PMC10919848 DOI: 10.1371/journal.pone.0295136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 11/15/2023] [Indexed: 03/09/2024] Open
Abstract
INTRODUCTION Vancomycin, a commonly prescribed antibiotic particularly in the setting of multi-drug resistant infections, is limited by its nephrotoxicity. Despite its common occurrence, much remains unknown on the clinicopathologic profile as well as the pathogenesis of vancomycin nephrotoxicity. Clinical studies included patients often with severe comorbidities and concomitant polypharmacy confounding the causal pathogenesis. Animal models cannot recapitulate this complex clinical situation. Kidney biopsy was not commonly performed. METHODS To address this limitation, we studied 36 patients who had renal biopsies for acute kidney injury (AKI) for suspicion of vancomycin nephrotoxicity. Detailed renal biopsy evaluation, meticulous evaluation of clinical profiles, and up-to-date follow-up allowed for a diagnostic categorization of vancomycin nephrotoxicity (VNT) in 25 patients and absence of vancomycin nephrotoxicity (NO-VNT) in 11 patients. For careful comparison of these two groups, we proceeded to compile a clinicopathologic and morphologic profiles characteristic for each group. RESULTS Patients with VNT had a characteristic clinical profile including a common clinical background, a high serum trough level of vancomycin, a rapidly developed and severe acute kidney injury, and a recovery of renal function often shortly after discontinuation of vancomycin. This clinical course was correlated with characteristic renal biopsy findings including acute tubulointerstitial nephritis of allergic type, frequent granulomatous inflammation, concomitant and pronounced acute tubular necrosis of nephrotoxic type, and vancomycin casts, in the absence of significant tubular atrophy and interstitial fibrosis. This clinico-pathologic profile was different from that of patients with NO-VNT, highlighting its role in the diagnosis, management and pathogenetic exploration of vancomycin nephrotoxicity. CONCLUSION Vancomycin nephrotoxicity has a distinctive morphologic and clinical profile, which should facilitate diagnosis, guide treatment and prognostication, and confer pathogenetic insights.
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Affiliation(s)
- Rajesh Nachiappa Ganesh
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
| | - Angelina Edwards
- Division of Nephrology, Department of Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
| | - Ziad El Zaatari
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
| | - Lillian Gaber
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
| | - Roberto Barrios
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
| | - Luan D. Truong
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, United States of America
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9
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Chen D, Ren H, Zhao Y. Cefepime vs Piperacillin-Tazobactam for Acute Infection in Hospitalized Adults. JAMA 2024; 331:708-709. [PMID: 38411651 DOI: 10.1001/jama.2023.27894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Affiliation(s)
- Dayu Chen
- Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing, China
| | - Haozhen Ren
- Division of Hepatobiliary and Transplant Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Yuanjin Zhao
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital, Nanjing, China
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10
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Raley AR, Brown ML, Frawley M, Oster RA, Edwards WS. Impact of Limiting Vancomycin Loading Doses in Patients With Methicillin-resistant Staphylococcus aureus Infections After Hospital Protocol Revision. Hosp Pharm 2024; 59:118-125. [PMID: 38223860 PMCID: PMC10786050 DOI: 10.1177/00185787231196435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Background: Vancomycin loading doses are commonly used to quickly attain target serum concentrations; however, data supporting their effect on clinical patient outcomes is limited. In April 2020, our institution revised our pharmacist-driven vancomycin dosing protocol to reserve loading doses for hemodynamically unstable patients with suspected serious methicillin-resistant Staphylococcus aureus (MRSA) infections. Prior to the protocol update, all patients treated with vancomycin at our institution received a weight-based loading dose. The purpose of this study is to assess clinical efficacy and safety outcomes related to the use of vancomycin loading doses. Methods: A retrospective, quasi-experimental study was performed to compare clinical outcomes in adult patients treated with vancomycin for laboratory-confirmed MRSA infections. Patients who received vancomycin therapy prior to our institution's vancomycin dosing protocol revisions (pre-intervention) were compared to patients who received vancomycin after the revisions (post-intervention). The primary outcome was all-cause, inpatient mortality. Secondary outcomes included persistent signs and symptoms of infection ≥5 days after vancomycin initiation, switch to alternative anti-MRSA therapy, and nephrotoxicity. Results: A total of 122 patients (63 pre-intervention patients and 59 post-intervention patients) were included. Receipt of a vancomycin loading dose did not impact the rate of inpatient mortality (4.76%vs 6.78%; OR 1.46, 95% CI [0.31, 6.79]). All secondary outcomes were similar between the two groups, including persistent signs and symptoms of infection, switch to alternative anti-MRSA therapy, and nephrotoxicity. Conclusions: Routine use of vancomycin loading doses is not associated with improved outcomes in hemodynamically stable patients with MRSA infections.
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Affiliation(s)
- Alec R. Raley
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Morgan Frawley
- University of Alabama at Birmingham, Birmingham, AL, USA
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Crawford L, Pertsovskaya V, Shanklin A, Zhang A, Hamdy RF. Predictive Value of Methicillin-Resistant Staphylococcus aureus Nasal Swab PCR Assay for MRSA Infection in Critically Ill Pediatric Patients. J Pediatric Infect Dis Soc 2024; 13:84-90. [PMID: 38070165 DOI: 10.1093/jpids/piad111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/07/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Critically ill pediatric patients are frequently initiated methicillin-resistant Staphylococcus aureus (MRSA) active antibiotics during infection evaluation even though MRSA infections are rare in many patient populations. The MRSA nasal swab polymerase chain reaction assay (MRSA-NS-PCR) is a test that has been shown to have a high negative predictive value (NPV) for MRSA infection in adults. This study evaluated the diagnostic test characteristics of the MRSA-NS-PCR in predicting the presence of MRSA infection in critically ill pediatric patients. STUDY DESIGN A retrospective cohort study was performed in a 44-bed pediatric intensive care unit (PICU) between 2013 and 2017. 3860 pediatric patients (54% male, median age 4 years [IQR 1-11 years]) admitted to the PICU who met pediatric systemic inflammatory response syndrome (pSIRS) criteria, were screened with a MRSA-NS-PCR, and had cultures obtained within seven days of MRSA-NS-PCR collection were included. Predictive values and post-test probabilities of the MRSA-NS-PCR for MRSA infection were calculated. RESULTS MRSA-NS-PCR was positive in 8.6% of patients. MRSA infection was identified in 40 patients, equaling an incidence rate of 2 per 1000 patient days. The MRSA-NS-PCR demonstrated a positive predictive value (PPV) of 9.7%, a NPV of 99.8%, and a post-test probability for a negative test of 0.2% for MRSA infection. CONCLUSIONS The MRSA-NS-PCR has a poor PPV but a high NPV for MRSA infection in PICU patients when the incidence of MRSA infection is low. Creation of protocols to guide antimicrobial selection based on MRSA-NS-PCR results may lead to improved antimicrobial stewardship and significant risk reduction.
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Affiliation(s)
- Lexi Crawford
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Vera Pertsovskaya
- The George Washington University School of Medicine and Health Sciences, Department of Pediatrics, The George Washington University, Washington, District of Columbia, USA
| | - Alice Shanklin
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Anqing Zhang
- The George Washington University School of Medicine and Health Sciences, Department of Pediatrics, The George Washington University, Washington, District of Columbia, USA
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, District of Columbia, USA
| | - Rana F Hamdy
- The George Washington University School of Medicine and Health Sciences, Department of Pediatrics, The George Washington University, Washington, District of Columbia, USA
- Division of Infectious Diseases, Children's National Hospital, Washington, District of Columbia, USA
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12
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Džidić-Krivić A, Sher EK, Kusturica J, Farhat EK, Nawaz A, Sher F. Unveiling drug induced nephrotoxicity using novel biomarkers and cutting-edge preventive strategies. Chem Biol Interact 2024; 388:110838. [PMID: 38104745 DOI: 10.1016/j.cbi.2023.110838] [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: 09/18/2023] [Revised: 12/03/2023] [Accepted: 12/15/2023] [Indexed: 12/19/2023]
Abstract
Drug-induced nephrotoxicity is still a significant obstacle in pharmacotherapy of various diseases and it accounts for around 25 % of serious side-effects reported after drug administration. Furthermore, some groups of drugs such as nonsteroidal anti-inflammatory drugs, antibiotics, antiviral drugs, antifungal drugs, immunosuppressants, and chemotherapeutic drugs have the "preference" for damaging the kidney and are often referred to as the kidney's "silent killer". Clinically, the onset of acute kidney injury associated with drug administration is registered in approximately 20 % of patients and many of them develop chronic kidney disease vulnerability. However, current knowledge about the mechanisms underlying this dangerous phenomenon is still insufficient with many unknowns. Hence, the valuable use of these drugs in clinical practice is significantly limited. The main aim of this study is to draw attention to commonly prescribed nephrotoxic drugs by clinicians or drugs bought over the counter. In addition, the complex relationship between immunological, vascular and inflammatory events that promote kidney damage is discussed. The practical use of this knowledge could be implemented in the engineering of novel biomarkers for early detection of drug-associated kidney damage such as Kidney Injury Molecule (KIM-1), lipocalin associated with neutrophil gelatinase (NGAL) and various microRNAs. In addition, the utilization of artificial intelligence (AI) for the development of computer algorithms that could detect kidney damage at an early stage should be further explored. Therefore, this comprehensive review provides a new outlook on drug nephrotoxicity that opens the door for further clinical research of novel potential drugs or natural products for the prevention of drug-induced nephrotoxicity and accessible education.
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Affiliation(s)
- Amina Džidić-Krivić
- Department of Neurology, Cantonal Hospital Zenica, Zenica, 72000, Bosnia and Herzegovina; International Society of Engineering Science and Technology, Nottingham, United Kingdom
| | - Emina K Sher
- Department of Biosciences, School of Science and Technology, Nottingham Trent University, Nottingham, NG11 8NS, United Kingdom.
| | - Jasna Kusturica
- Faculty of Medicine,Univerisity of Sarajevo, Sarajevo, 71000, Bosnia and Herzegovina
| | - Esma K Farhat
- International Society of Engineering Science and Technology, Nottingham, United Kingdom; Department of Food and Nutrition Research, Faculty of Food Technology, Juraj Strossmayer University of Osijek, Osijek, 31000, Croatia
| | - Asma Nawaz
- International Society of Engineering Science and Technology, Nottingham, United Kingdom; Department of Biochemistry, University of Agriculture, Faisalabad, 38040, Pakistan
| | - Farooq Sher
- Department of Engineering, School of Science and Technology, Nottingham Trent University, Nottingham, NG11 8NS, United Kingdom.
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13
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Gilliam D, Acosta D, Carvour ML, Walraven C. Retrospective review of intermittent and continuous infusion vancomycin for methicillin-resistant Staphylococcus aureus bacteremia. Eur J Clin Pharmacol 2024; 80:75-81. [PMID: 37897529 DOI: 10.1007/s00228-023-03585-2] [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: 05/19/2023] [Accepted: 10/16/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE Vancomycin is commonly administered as an intermittent infusion (IIV), although vancomycin's stability at room temperature permits administration continuously over 24 h (CIV). At our institution, CIV has been the preferred infusion method for over 20 years due to ease of administration and simplicity of therapeutic drug monitoring. The purpose of this study was to examine the outcomes associated with IIV compared to CIV. METHODS This was a retrospective study of patients who received vancomycin for MRSA bacteremia. The primary outcomes were the time to therapeutic goal and frequency of adverse drug reactions on IIV compared to CIV. Secondary outcomes evaluated all-cause readmission, relapse, and mortality 30 days after completion of therapy. RESULTS Sixty-three patients were included. Significantly fewer patients were able to achieve a therapeutic goal on IIV compared to CIV (52.4% vs. 82.5%, p < 0.01). Patients on IIV took 3.6 days, on average, to reach the target goal, compared to 1.9 days when patients were switched to CIV (95% confidence interval, 0.48-3.04, p < 0.01). Six patients experienced adverse events on IIV, and 15 patients experienced adverse events on CIV (IIV 9.5%, CIV 23.8%, p = 0.035). One patient experienced relapse of infection, and six patients (9.5%) were readmitted 30 days after completion of therapy. There were no deaths in the cohort. CONCLUSION For MRSA bacteremia, CIV enabled patients to achieve the AUC/MIC goal significantly faster than when patients received IIV. Furthermore, patients who were unable to achieve a therapeutic trough on IIV became therapeutic once switched to CIV.
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Affiliation(s)
- Diari Gilliam
- Department of Pharmacy, University of New Mexico Hospitals, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA.
| | - Dominic Acosta
- Department of Pharmacy, Presbyterian Healthcare Services, Albuquerque, NM, 87106, USA
| | - Martha L Carvour
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Carla Walraven
- Department of Pharmacy, University of New Mexico Hospitals, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
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14
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Lu R, Ren J, Zhou X, Zheng B, Peng F. Risk factors for acute kidney injury associated with intravenous vancomycin in neurosurgical inpatients: a retrospective study. Eur J Clin Pharmacol 2024; 80:65-73. [PMID: 37889297 PMCID: PMC10781849 DOI: 10.1007/s00228-023-03581-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/15/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE Vancomycin (VAN) is widely used in neurosurgical patients for intracranial infections. We aimed to assess the incidence and risk factors for VAN-associated acute kidney injury (VA-AKI) in this population. METHODS A case-control study of patients who treated with vancomycin in neurosurgery from January 2020 to December 2022 was conducted. Demographics and potential risk factors were collected. Multivariate logistic regression analyses were performed to identify risk factors for VA-AKI. AKI was defined according to the Kidney Disease Improving Global Outcomes Guidelines (KDIGO). RESULTS A total of 345 patients participated with a VA-AKI incidence of 17.1% (59 cases). Among them, 15 patients had renal impairment (Stage 2 or higher), and 2 required dialysis. With univariate analysis and binary logistic regression analysis, we found that the use of mannitol (OR: 4.164; 95% CI: 1.606-10.792; P = 0.003), loop diuretics (OR: 3.371; 95% CI: 1.633-6.958; P = 0.001), three or more antimicrobial applications (OR: 3.623; 95% CI: 1.600-8.206; P = 0.002), diastolic blood pressure 80-89 mm Hg (OR: 5.532; 95% CI: 1.677-18.250; P = 0.005) and diastolic blood pressure ≥ 90 mm Hg (OR: 6.845; 95% CI: 1.518-30.866; P = 0.012) were independent risk factors for VA-AKI. In addition, according to the Youden Index, the trough concentration of vancomycin should not exceed 15.845 mg/L. CONCLUSION The incidence of VA-AKI in neurosurgical patients was 17.1%. The concomitant use of mannitol and loop diuretics, along with higher diastolic blood pressure and the combined use of more than three antimicrobial agents, were associated with an increased risk of neurosurgical VA-AKI.
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Affiliation(s)
- Ruqi Lu
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, 030001, China
| | - Junli Ren
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, 030001, China
| | - Xuanping Zhou
- School of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, 030001, China
| | - Bin Zheng
- Department of Pharmacy, Shanxi Provincial People's Hospital, Shuangtasi Street 29#, Taiyuan, Shanxi, 030012, China
| | - Fangchen Peng
- Department of Pharmacy, Shanxi Provincial People's Hospital, Shuangtasi Street 29#, Taiyuan, Shanxi, 030012, China.
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15
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Al-Obaydi S, Ssentongo P, Cherneskie JJ, Craig TJ, Al-Shaikhly T. Outcomes of acute pyelonephritis in patients with a penicillin allergy label in the United States. Ann Allergy Asthma Immunol 2024; 132:97-99. [PMID: 37778455 PMCID: PMC10842634 DOI: 10.1016/j.anai.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/10/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Sarah Al-Obaydi
- Division of Hospitalist Medicine, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Paddy Ssentongo
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania; Division of Infectious Diseases, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - John J Cherneskie
- Section of Allergy, Asthma & Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Timothy J Craig
- Section of Allergy, Asthma & Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Taha Al-Shaikhly
- Section of Allergy, Asthma & Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania.
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16
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Taylor ZL, Poweleit EA, Paice K, Somers KM, Pavia K, Vinks AA, Punt N, Mizuno T, Girdwood ST. Tutorial on model selection and validation of model input into precision dosing software for model-informed precision dosing. CPT Pharmacometrics Syst Pharmacol 2023; 12:1827-1845. [PMID: 37771190 PMCID: PMC10725261 DOI: 10.1002/psp4.13056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023] Open
Abstract
There has been rising interest in using model-informed precision dosing to provide personalized medicine to patients at the bedside. This methodology utilizes population pharmacokinetic models, measured drug concentrations from individual patients, pharmacodynamic biomarkers, and Bayesian estimation to estimate pharmacokinetic parameters and predict concentration-time profiles in individual patients. Using these individualized parameter estimates and simulated drug exposure, dosing recommendations can be generated to maximize target attainment to improve beneficial effect and minimize toxicity. However, the accuracy of the output from this evaluation is highly dependent on the population pharmacokinetic model selected. This tutorial provides a comprehensive approach to evaluating, selecting, and validating a model for input and implementation into a model-informed precision dosing program. A step-by-step outline to validate successful implementation into a precision dosing tool is described using the clinical software platforms Edsim++ and MwPharm++ as examples.
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Affiliation(s)
- Zachary L. Taylor
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Ethan A. Poweleit
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of Biomedical InformaticsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Biomedical InformaticsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Research in Patient ServicesCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Kelli Paice
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Critical Care Medicine, Department of PediatricsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Katherine M. Somers
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Critical Care Medicine, Department of PediatricsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Hematology and Oncology, Department of PediatricsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Kathryn Pavia
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Critical Care Medicine, Department of PediatricsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Alexander A. Vinks
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Research in Patient ServicesCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Nieko Punt
- Department of Clinical Pharmacy and Pharmacology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
- MedimaticsMaastrichtThe Netherlands
| | - Tomoyuki Mizuno
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Sonya Tang Girdwood
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Hospital Medicine, Department of PediatricsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
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17
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Joseph WS, Kosinski MA, Rogers LC. Parenteral Vancomycin in the Treatment of MRSA-Associated Diabetic Foot Infections: An Unnecessary Risk. INT J LOW EXTR WOUND 2023:15347346231207553. [PMID: 37886812 DOI: 10.1177/15347346231207553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Diabetic foot infections (DFIs) are a common and costly complication of diabetes. Soft tissue and bone infections in DFIs frequently lead to amputation and/or sepsis which can be costly for both the patient and the healthcare system. Staphylococcus aureus is the most commonly identified causative agent in DFIs, and people with diabetes may have an increased risk of infection with methicillin-resistant Staphylococcus aureus (MRSA). In addition to increased susceptibility to severe infection, MRSA in DFIs is associated with high rates of treatment failure, morbidity, and hospitalization costs meaning appropriate treatment is a high priority. While hospitalized patients are usually treated with intravenous (IV) vancomycin, this can be costly in terms of inpatient stays, staffing costs, and adverse events. For example, vancomycin-associated acute kidney injury not only delays hospital discharge and increases costs but is also a particular concern for patients with diabetes who already have an increased risk of kidney problems. Vancomycin-resistant strains of S. aureus have also been identified, which means that alternative treatment options may need to be explored. Treatment alternatives to IV vancomycin, including oral antibiotics, have been shown to provide similar efficacy, with reduced costs, outpatient or home-based administration, and with fewer serious adverse effects. Although infectious disease specialists often use IV vancomycin alone, or in combination, as a first-line therapeutic option, they are increasingly seeing the value of outpatient or at-home oral antibiotics as an alternative. This manuscript reviews the evidence for true costs of vancomycin therapy for MRSA-associated DFIs and examines the alternatives.
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Affiliation(s)
- Warren S Joseph
- Arizona College of Podiatric Medicine, Midwestern University, Glendale, AZ, USA
| | - Mark A Kosinski
- Department of Medicine, New York College of Podiatric Medicine, New York, NY, USA
| | - Lee C Rogers
- Department of Orthopaedics, University of Texas Health Science Center, San Antonio, TX, USA
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18
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Chen Z, Taubert M, Chen C, Dokos C, Fuhr U, Weig T, Zoller M, Heck S, Dimitriadis K, Terpolilli N, Kinast C, Scharf C, Lier C, Dorn C, Liebchen U. Plasma and Cerebrospinal Fluid Population Pharmacokinetics of Vancomycin in Patients with External Ventricular Drain. Antimicrob Agents Chemother 2023; 67:e0024123. [PMID: 37162349 PMCID: PMC10269048 DOI: 10.1128/aac.00241-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/15/2023] [Indexed: 05/11/2023] Open
Abstract
Vancomycin is a commonly used antibacterial agent in patients with primary central nervous system (CNS) infection. This study aims to examine predictors of vancomycin penetration into cerebrospinal fluid (CSF) in patients with external ventricular drainage and the feasibility of CSF sampling from the distal drainage port for therapeutic drug monitoring. Fourteen adult patients (9 with primary CNS infection) were treated with vancomycin intravenously. The vancomycin concentrations in blood and CSF (from proximal [CSF_P] and distal [CSF_D] drainage ports) were evaluated by population pharmacokinetics. Model-based simulations were conducted to compare various infusion modes. A three-compartment model with first-order elimination best described the vancomycin data. Estimated parameters included clearance (CL, 4.53 L/h), central compartment volume (Vc, 24.0 L), apparent CSF compartment volume (VCSF, 0.445 L), and clearance between central and CSF compartments (QCSF, 0.00322 L/h and 0.00135 L/h for patients with and without primary CNS infection, respectively). Creatinine clearance was a significant covariate on vancomycin CL. CSF protein was the primary covariate to explain the variability of QCSF. There was no detectable difference between the data for sampling from the proximal and the distal port. Intermittent infusion and continuous infusion with a loading dose reached the CSF target concentration faster than continuous infusion only. All infusion schedules reached similar CSF trough concentrations. Beyond adjusting doses according to renal function, starting treatment with a loading dose in patients with primary CSF infection is recommended. Occasionally, very high and possibly toxic doses would be required to achieve adequate CSF concentrations, which calls for more investigation of direct intraventricular administration of vancomycin. (This study has been registered at ClinicalTrials.gov under registration no. NCT04426383).
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Affiliation(s)
- Zhendong Chen
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Max Taubert
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Chunli Chen
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Heilongjiang Key Laboratory for Animal Disease Control and Pharmaceutical Development, College of Veterinary Medicine, Northeast Agricultural University, Harbin, People’s Republic of China
| | - Charalambos Dokos
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Uwe Fuhr
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thomas Weig
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Suzette Heck
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Konstantinos Dimitriadis
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Nicole Terpolilli
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig Maximilians University, Munich, Germany
- Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Christina Kinast
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Constantin Lier
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, Regensburg, Germany
| | - Christoph Dorn
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, Regensburg, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
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19
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Kaminsky LW, Al-Obaydi S, Hussein RH, Horwitz AA, Al-Shaikhly T. Impact of Penicillin Allergy Label on Clinical Outcomes of Pneumonia in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1899-1906.e2. [PMID: 36948494 PMCID: PMC10272071 DOI: 10.1016/j.jaip.2023.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Penicillin (PCN) allergy label, reported in approximately 5% of children, influences antibiotic choice and prolongs hospital stay. To our knowledge, the impact of PCN allergy label on clinical outcomes of pneumonia in children is not well characterized. OBJECTIVES To investigate the impact of PCN allergy label on clinical outcomes of pneumonia in children. METHODS In this propensity score-matched cohort study, we used the TriNetX research network, a population-based database, to compare the 30-day risk of hospitalization, need for intensive level of care, and acute respiratory failure from pneumonia between pediatric patients (aged 1-17 years) with and without a PCN allergy label after matching the 2 cohorts for demographic and medical comorbidities. Antibiotic prescription patterns were also contrasted. RESULTS When comparing 3793 pediatric patients with pneumonia labeled with a PCN allergy with matched children without a PCN allergy label, PCN allergy label was associated with a higher risk of hospitalization (relative risk [RR], 1.15; 95% confidence interval [CI], 1.07-1.23), acute respiratory failure (RR, 1.27; 95% CI, 1.17-1.39), and need for intensive level of care (RR, 1.46; 95% CI, 1.15-1.84). PCN allergy label resulted in overutilization of broader-spectrum antibiotics and increased complications including cutaneous drug reactions (RR, 2.43; 95% CI, 1.31-4.52) and Clostridioides difficile infection (RR, 2.25; 95% CI, 1.14-4.44). CONCLUSION Children with a PCN allergy label are more likely to be hospitalized, receive broader-spectrum antibiotics, and develop acute respiratory failure from pneumonia. Delabeling may offer a way to lessen morbidity from pneumonia in children.
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Affiliation(s)
- Lauren W Kaminsky
- Section of Allergy, Asthma and Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pa
| | - Sarah Al-Obaydi
- Division of Hospitalist Medicine, Department of Medicine, Penn State College of Medicine, Hershey, Pa
| | - Rezhan H Hussein
- Division of Infectious Diseases, Department of Medicine, Penn State College of Medicine, Hershey, Pa
| | - Alexandra A Horwitz
- Division of Allergy-Immunology, Department of Pediatrics, Penn State College of Medicine, Hershey, Pa
| | - Taha Al-Shaikhly
- Section of Allergy, Asthma and Immunology, Department of Medicine, Penn State College of Medicine, Hershey, Pa.
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20
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Cherian JP, Jones GF, Bachina P, Helsel T, Virk Z, Lee JH, Fiawoo S, Salinas A, Dzintars K, O'Shaughnessy E, Gopinath R, Tamma PD, Cosgrove SE, Klein EY. An Electronic Algorithm to Identify Vancomycin-Associated Acute Kidney Injury. Open Forum Infect Dis 2023; 10:ofad264. [PMID: 37383251 PMCID: PMC10296058 DOI: 10.1093/ofid/ofad264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/12/2023] [Indexed: 06/30/2023] Open
Abstract
Background The burden of vancomycin-associated acute kidney injury (V-AKI) is unclear because it is not systematically monitored. The objective of this study was to develop and validate an electronic algorithm to identify cases of V-AKI and to determine its incidence. Methods Adults and children admitted to 1 of 5 health system hospitals from January 2018 to December 2019 who received at least 1 dose of intravenous (IV) vancomycin were included. A subset of charts was reviewed using a V-AKI assessment framework to classify cases as unlikely, possible, or probable events. Based on review, an electronic algorithm was developed and then validated using another subset of charts. Percentage agreement and kappa coefficients were calculated. Sensitivity and specificity were determined at various cutoffs, using chart review as the reference standard. For courses ≥48 hours, the incidence of possible or probable V-AKI events was assessed. Results The algorithm was developed using 494 cases and validated using 200 cases. The percentage agreement between the electronic algorithm and chart review was 92.5% and the weighted kappa was 0.95. The electronic algorithm was 89.7% sensitive and 98.2% specific in detecting possible or probable V-AKI events. For the 11 073 courses of ≥48 hours of vancomycin among 8963 patients, the incidence of possible or probable V-AKI events was 14.0%; the V-AKI incidence rate was 22.8 per 1000 days of IV vancomycin therapy. Conclusions An electronic algorithm demonstrated substantial agreement with chart review and had excellent sensitivity and specificity in detecting possible or probable V-AKI events. The electronic algorithm may be useful for informing future interventions to reduce V-AKI.
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Affiliation(s)
- Jerald P Cherian
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - George F Jones
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Preetham Bachina
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Taylor Helsel
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zunaira Virk
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jae Hyoung Lee
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Suiyini Fiawoo
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alejandra Salinas
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kate Dzintars
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth O'Shaughnessy
- Division of Anti-Infectives, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ramya Gopinath
- Division of Anti-Infectives, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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21
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Kim B, Hwang S, Heo E, Kim HS, Jung J, Kim ES, Kim HB, Lee K, Park JS, Song J, Lee JH, Chung JY, Song KH, Yoon S. Evaluation of Vancomycin TDM Strategies: Prediction and Prevention of Kidney Injuries Based on Vancomycin TDM Results. J Korean Med Sci 2023; 38:e101. [PMID: 37038640 PMCID: PMC10086380 DOI: 10.3346/jkms.2023.38.e101] [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: 08/10/2022] [Accepted: 12/22/2022] [Indexed: 04/12/2023] Open
Abstract
The current guidelines for therapeutic drug monitoring (TDM) of vancomycin suggest a target 24-hour area under the curve (AUC0-24) of 400 to 600 mg*h/L for serious methicillin-resistant Staphylococcus aureus infections. In this study, the predictabilities of acute kidney injury (AKI) of various TDM target parameters, target levels, and sampling methods were evaluated in patients who underwent TDM from January 2020 to December 2020. The AUC0-24 and trough values were calculated by both one- and two-point sampling methods, and were evaluated for the predictability of AKI. Among the AUC0-24 cutoff comparisons, the threshold value of 500 mg*h/L in the two sampling methods was statistically significant (P = 0.042) when evaluated for the predictability of AKI. Analysis by an receiver operating characteristic curve estimated an AUC0-24 cutoff value of 563.45 mg*h/L as a predictor of AKI, and was proposed as the upper limit of TDM target.
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Affiliation(s)
- Byungwook Kim
- Department of Clinical Pharmacology and Therapeutics, Seoul National University Hospital, Seoul National University College of Medicine Seoul, Korea
| | - Sejung Hwang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University Hospital, Seoul National University College of Medicine Seoul, Korea
| | - Eunjeong Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyung-Sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jongtak Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyunghoon Lee
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong Su Park
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Junghan Song
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joon Hee Lee
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae-Yong Chung
- Department of Clinical Pharmacology and Therapeutics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
| | - Seonghae Yoon
- Department of Clinical Pharmacology and Therapeutics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
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22
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Chiu CY, Sarwal A. Evaluating the Nephrotoxicity of Area-under-the-Curve-Based Dosing of Vancomycin with Concomitant Antipseudomonal Beta-Lactam Antibiotics: A Systematic Review and Meta-Analysis. Medicina (B Aires) 2023; 59:medicina59040691. [PMID: 37109649 PMCID: PMC10146400 DOI: 10.3390/medicina59040691] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
Background and Objectives: Vancomycin combined with piperacillin/tazobactam (vancomycin + piperacillin/tazobactam) has a higher risk of acute kidney injury (AKI) than vancomycin combined with cefepime or meropenem. However, it is uncertain if applying area under the curve (AUC)-based vancomycin dosing has less nephrotoxicity than trough-based dosing in these combinations. Materials and Methods: We searched PubMed, Embase, Cochrane Library, and ClinicalTrials.gov from inception to December 2022. We examined the odds ratio (OR) of AKI between vancomycin + piperacillin/tazobactam and the control group. The control group was defined as vancomycin combined with antipseudomonal beta-lactam antibiotics, except for piperacillin-tazobactam. Results: The OR for AKI is significantly higher in vancomycin + piperacillin/tazobactam compared with the control group (3 studies, 866 patients, OR of 3.861, 95% confidence interval of 2.165 to 6.887, p < 0.05). In the sample population of patients who received vancomycin + piperacillin/tazobactam (2 studies, 536 patients), the risk of AKI (OR of 0.715, 95% CI of 0.439 to 1.163, p = 0.177) and daily vancomycin dose (standard mean difference—0.139, 95% CI—0.458 to 0.179; p = 0.392) are lower by AUC-based dosing than trough-based dosing, although it is not statistically significant. Conclusions: Nephrotoxicity is higher when combined with piperacillin/tazobactam than other antipseudomonal beta-lactam antibiotics (cefepime or meropenem) using the AUC-based dosing. However, applying the AUC-based dosing did not eliminate the risk of AKI or significantly reduce thedaily vancomycin dose compared with the trough-based dosing in the available literature.
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23
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Garufi A, Pistritto G, D’Orazi G. HIPK2 as a Novel Regulator of Fibrosis. Cancers (Basel) 2023; 15:1059. [PMID: 36831402 PMCID: PMC9954661 DOI: 10.3390/cancers15041059] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Fibrosis is an unmet medical problem due to a lack of evident biomarkers to help develop efficient targeted therapies. Fibrosis can affect almost every organ and eventually induce organ failure. Homeodomain-interacting protein kinase 2 (HIPK2) is a protein kinase that controls several molecular pathways involved in cell death and development and it has been extensively studied, mainly in the cancer biology field. Recently, a role for HIPK2 has been highlighted in tissue fibrosis. Thus, HIPK2 regulates several pro-fibrotic pathways such as Wnt/β-catenin, TGF-β and Notch involved in renal, pulmonary, liver and cardiac fibrosis. These findings suggest a wider role for HIPK2 in tissue physiopathology and highlight HIPK2 as a promising target for therapeutic purposes in fibrosis. Here, we will summarize the recent studies showing the involvement of HIPK2 as a novel regulator of fibrosis.
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Affiliation(s)
- Alessia Garufi
- Unit of Cellular Networks, Department of Research and Advanced Technologies, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy
| | - Giuseppa Pistritto
- Centralized Procedures Office, Italian Medicines Agency (AIFA), 00187 Rome, Italy
| | - Gabriella D’Orazi
- Unit of Cellular Networks, Department of Research and Advanced Technologies, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy
- Department of Neurosciences, Imaging and Clinical Sciences, University “G. D’Annunzio”, 66013 Chieti, Italy
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24
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DeKerlegand A, Johnston E, Mellor B, Schrack MR, O’Neal C. Implementation of MRSA Nasal Swabs as an Antimicrobial Stewardship Intervention to Decrease Anti-MRSA Therapy in COVID-19 Infection. Antibiotics (Basel) 2023; 12:253. [PMID: 36830164 PMCID: PMC9952464 DOI: 10.3390/antibiotics12020253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/21/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023] Open
Abstract
In the early stages of treating patients with SARS-CoV-2, limited information was available to guide antimicrobial stewardship interventions. The COVID-19 Task Force and Antimicrobial Stewardship Committee, at a 988-bed academic medical center, implemented the use of methicillin-resistant Staphylococcus aureus (MRSA) nasal swab polymerase chain reaction (PCR) testing to assist with the de-escalation of anti-MRSA therapy in patients with suspected superimposed bacterial pneumonia in COVID-19. A retrospective study was conducted to evaluate the impact of MRSA nasal swab PCR testing on the rate of anti-MRSA therapy between 13 April 2020 and 26 July 2020. A total of 122 patients were included in the analysis. Of the patients included in the final analysis, 58 (47.5%) had anti-MRSA therapy discontinued and 41 (33.6%) avoided anti-MRSA therapy completely due to a negative swab result. With the implementation of MRSA nasal swab PCR testing in COVID-19 patients, anti-MRSA therapy was reduced in 81% of patients in this study. In patients who continued with anti-MRSA therapy, nasal swabs were either positive for MRSA or an alternative indication for anti-MRSA therapy was noted. Only three patients in the cohort had MRSA identified in a sputum culture, all of whom had anti-MRSA therapy continued. MRSA nasal swab PCR testing may serve as an effective antimicrobial stewardship tool in COVID-19 pneumonia.
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Affiliation(s)
- Alaina DeKerlegand
- Pharmacy Department, Methodist University Hospital, Memphis, TN 38104, USA
| | - Emily Johnston
- Pharmacy Department, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA 70808, USA
| | - Britney Mellor
- Pharmacy Department, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA 70808, USA
| | - Melanie Rae Schrack
- Pharmacy Department, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA 70808, USA
| | - Catherine O’Neal
- Medical Staff Office, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA 70808, USA
- Louisiana State University Health Sciences Center, Baton Rouge, LA 70808, USA
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25
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Das K, Muthukumar A, Almuqbil M, Imran M, Rabaan AA, Halwani MA, Garout M, Alsaleh AA, Alissa M, Alwashmi ASS, Alshehri AA, Alsayyah A, Bhavani K, Mittal S, Gayathri R, Alomar NF, Rabbani SI, Basheeruddin Asdaq SM. Nephroprotective potential of Polyalthia longifolia roots against vancomycin-induced renal toxicity in experimental animals. Front Pharmacol 2023; 14:1107435. [PMID: 36755952 PMCID: PMC9900101 DOI: 10.3389/fphar.2023.1107435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/09/2023] [Indexed: 01/24/2023] Open
Abstract
This study was done to investigate the possible nephroprotective effect of an ethanolic root extract of Polyalthia Longifolia (PL) on vancomycin-induced nephrotoxicity using curative and protective models. Vancomycin (150 mg/kg, intravenous) was given to healthy Wistar albino rats in the curative model before the start of treatment, whereas the protective group received vancomycin at the conclusion of the 10-day treatment procedure. Animals were divided into six groups for both models; group I served as the normal control, while groups II, III, IV, V, and VI were kept as toxic control, standard (selenium, 6 mg/kg), LDPL (low dose of PL 200 mg/kg), HDPL (high dose of PL 400 mg/kg), and HDPL + selenium (interactive) groups, respectively. Renal biomarkers [(uric acid, creatinine, blood urea nitrogen (BUN), serum proteins], and blood electrolyte levels were measured for all tested groups. When compared to the vancomycin group, the HDPL significantly (p < 0.01) showed greater effectiveness in lowering the BUN, potassium, and calcium levels. Additionally, in the curative model, there was a significant (p < 0.05) decrease in the blood levels of uric acid, creatinine, BUN, potassium, and calcium in the animals who received the combination of selenium and HDPL. Both LDPL and HDPL did not provide any distinguishable effect in the protective model, but groups that received HDPL with selenium did provide detectable protection by significantly lowering their levels of uric acid, BUN, serum potassium, and total serum protein in comparison to the vancomycin control group. These findings indicate that, whether administered before or after renal damage is induced, the Polyalthia longifolia root extract provided only modest protection to nephrons, which require selenium support to prevent vancomycin-induced kidney damage.
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Affiliation(s)
- Kuntal Das
- Nitte College of Pharmaceutical Science, Yelahanka, Bangalore, India
| | - A. Muthukumar
- Central Animal House, Department of Pharmacology, Al-Ameen College of Pharmacy, Bangalore, India,*Correspondence: Syed Mohammed Basheeruddin Asdaq, /; A. Muthukumar,
| | - Mansour Almuqbil
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mohd. Imran
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Northern Border University, Rafha, Saudi Arabia
| | - Ali A. Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia,Department of Public Health and Nutrition, The University of Haripur, Haripur, Pakistan
| | - Muhammad A. Halwani
- Department of Medical Microbiology, Faculty of Medicine, Al Baha University, Al Baha, Saudi Arabia
| | - Mohammed Garout
- Department of Community Medicine and Healthcare for Pilgrims, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Abdulmonem A. Alsaleh
- Clinical Laboratory Science Department, Mohammed Al-Mana College for Medical Sciences, Dammam, Saudi Arabia
| | - Mohammed Alissa
- Department of Medical Laboratory Sciences, College of Applied Medical Sciences, Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Ameen S. S. Alwashmi
- Department of Medical Laboratories, College of Applied Medical Sciences, Qassim University, Buraydah, Saudi Arabia
| | - Ahmad A. Alshehri
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Najran University, Najran, Saudi Arabia
| | - Ahmed Alsayyah
- Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | | | - Swati Mittal
- Central Animal House, Department of Pharmacology, Al-Ameen College of Pharmacy, Bangalore, India
| | - R. Gayathri
- Department of Pharmaceutics, KMCH College of Pharmacy, Coimbatore, India
| | | | - Syed Imam Rabbani
- Department of Pharmacology and Toxicology, College of Pharmacy, Qassim University, Buraydah, Saudi Arabia
| | - Syed Mohammed Basheeruddin Asdaq
- Department of Pharmacy Practice, College of Pharmacy, AlMaarefa University, Riyadh, Saudi Arabia,*Correspondence: Syed Mohammed Basheeruddin Asdaq, /; A. Muthukumar,
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26
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Zhao X, Lu Y, Li S, Guo F, Xue H, Jiang L, Wang Z, Zhang C, Xie W, Zhu F. Predicting renal function recovery and short-term reversibility among acute kidney injury patients in the ICU: comparison of machine learning methods and conventional regression. Ren Fail 2022; 44:1326-1337. [PMID: 35930309 PMCID: PMC9359199 DOI: 10.1080/0886022x.2022.2107542] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is one of the most frequent complications of critical illness. We aimed to explore the predictors of renal function recovery and the short-term reversibility after AKI by comparing logistic regression with four machine learning models. METHODS We reviewed patients who were diagnosed with AKI in the MIMIC-IV database between 2008 and 2019. Recovery from AKI within 72 h of the initiating event was typically recognized as the short-term reversal of AKI. Conventional logistic regression and four different machine algorithms (XGBoost algorithm model, Bayesian networks [BNs], random forest [RF] model, and support vector machine [SVM] model) were used to develop and validate prediction models. The performance measures were compared through the area under the receiver operating characteristic curve (AU-ROC), calibration curves, and 10-fold cross-validation. RESULTS A total of 12,321 critically ill adult AKI patients were included in our analysis cohort. The renal function recovery rate after AKI was 67.9%. The maximum and minimum serum creatinine (SCr) within 24 h of AKI diagnosis, the minimum SCr within 24 and 12 h, and antibiotics usage duration were independently associated with renal function recovery after AKI. Among the 8364 recovered patients, the maximum SCr within 24 h of AKI diagnosis, the minimum Glasgow Coma Scale (GCS) score, the maximum blood urea nitrogen (BUN) within 24 h, vasopressin and vancomycin usage, and the maximum lactate within 24 h were the top six predictors for short-term reversibility of AKI. The RF model presented the best performance for predicting both renal functional recovery (AU-ROC [0.8295 ± 0.01]) and early recovery (AU-ROC [0.7683 ± 0.03]) compared with the conventional logistic regression model. CONCLUSIONS The maximum SCr within 24 h of AKI diagnosis was a common independent predictor of renal function recovery and the short-term reversibility of AKI. The RF machine learning algorithms showed a superior ability to predict the prognosis of AKI patients in the ICU compared with the traditional regression models. These models may prove to be clinically helpful and can assist clinicians in providing timely interventions, potentially leading to improved prognoses.
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Affiliation(s)
- Xiujuan Zhao
- Department of Intensive Care Medicine, Trauma Center, Peking University People's Hospital, Beijing, PR China
| | - Yunwei Lu
- Department of Intensive Care Medicine, Trauma Center, Peking University People's Hospital, Beijing, PR China
| | - Shu Li
- Department of Intensive Care Medicine, Trauma Center, Peking University People's Hospital, Beijing, PR China
| | - Fuzheng Guo
- Department of Intensive Care Medicine, Trauma Center, Peking University People's Hospital, Beijing, PR China
| | - Haiyan Xue
- Department of Intensive Care Medicine, Trauma Center, Peking University People's Hospital, Beijing, PR China
| | - Lilei Jiang
- Department of Intensive Care Medicine, Trauma Center, Peking University People's Hospital, Beijing, PR China
| | - Zhenzhou Wang
- Department of Intensive Care Medicine, Trauma Center, Peking University People's Hospital, Beijing, PR China
| | - Chong Zhang
- Department of Yunnan Baiyao Group Medicine Electronic Commerce Co., Ltd, Beijing, PR China
| | - Wenfei Xie
- Department of Yunnan Baiyao Group Medicine Electronic Commerce Co., Ltd, Beijing, PR China
| | - Fengxue Zhu
- Department of Intensive Care Medicine, Trauma Center, Peking University People's Hospital, Beijing, PR China
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27
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Mu F, Cui C, Tang M, Guo G, Zhang H, Ge J, Bai Y, Zhao J, Cao S, Wang J, Guan Y. Analysis of a machine learning-based risk stratification scheme for acute kidney injury in vancomycin. Front Pharmacol 2022; 13:1027230. [PMID: 36506557 PMCID: PMC9730034 DOI: 10.3389/fphar.2022.1027230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022] Open
Abstract
Vancomycin-associated acute kidney injury (AKI) continues to pose a major challenge to both patients and healthcare providers. The purpose of this study is to construct a machine learning framework for stratified predicting and interpreting vancomycin-associated AKI. Our study is a retrospective analysis of medical records of 724 patients who have received vancomycin therapy from 1 January 2015 through 30 September 2020. The basic clinical information, vancomycin dosage and days, comorbidities and medication, laboratory indicators of the patients were recorded. Machine learning algorithm of XGBoost was used to construct a series risk prediction model for vancomycin-associated AKI in different underlying diseases. The vast majority of sub-model performed best on the corresponding sub-dataset. Additionally, the aim of this study was to explain each model and to explore the influence of clinical variables on prediction. As the results of the analysis showed that in addition to the common indicators (serum creatinine and creatinine clearance rate), some other underappreciated indicators such as serum cystatin and cumulative days of vancomycin administration, weight and age, neutrophils and hemoglobin were the risk factors for cancer, diabetes mellitus, heptic insufficiency respectively. Stratified analysis of the comorbidities in patients with vancomycin-associated AKI further confirmed the necessity for different patient populations to be studied.
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Affiliation(s)
- Fei Mu
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Chen Cui
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Meng Tang
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Guiping Guo
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Haiyue Zhang
- Department of Health Statistics, School of Preventive Medicine, Fourth Military Medical University, Xi’an, China
| | - Jie Ge
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yujia Bai
- Department of Urology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jinyi Zhao
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Shanshan Cao
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jingwen Wang
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi’an, China,*Correspondence: Jingwen Wang, ; Yue Guan,
| | - Yue Guan
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi’an, China,*Correspondence: Jingwen Wang, ; Yue Guan,
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28
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Sahraei Z, Saffaei A, Alavi Darazam I, Salamzadeh J, Shabani M, Shokouhi S, Sarvmeili N, Hajiesmaeili M, Zangi M. Evaluation of vancomycin pharmacokinetics in patients with augmented renal clearances: A randomized clinical trial. Front Pharmacol 2022; 13:1041152. [DOI: 10.3389/fphar.2022.1041152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 10/31/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose: Vancomycin is a narrow therapeutic window glycopeptide antibiotic that acts against Gram-positive bacteria. As it is renally eliminated, therapeutic drug monitoring is recommended for vancomycin, especially in case of kidney function alteration. Augmented renal clearance (ARC), defined as a creatinine clearance of more than 130 ml/min, is a risk factor for sub-therapeutic concentrations of vancomycin. This study aimed to evaluate the vancomycin pharmacokinetics following the administration of two different regimens in ARC patients.Methods: A randomized clinical trial (IRCT20180802040665N1) was conducted on patients in need of vancomycin therapy. Eight hours of urine was collected and 56 patients divided into two groups with creatinine clearance of more than 130 ml/min were included in the study. The first group received 15 mg/kg of vancomycin every 12 h and the second group 15 mg/kg every 8 h. After four doses, the peak and trough concentrations were measured from two blood samples. The primary outcome was the percentage of patients who attainted AUC more than 400. The occurrence of acute kidney injury also was evaluated after seven days.Results: The mean age of patients in the every 12 h and every 8 h groups was 44.04 ± 16.55 and 42.86 ± 11.83 years, respectively. While neurosurgical issues were the most common causes of hospitalization, central nervous infections were the most common indications for vancomycin initiation. Urinary creatinine clearance was 166.94 ± 41.32 ml/min in the every 12 h group and 171.78 ± 48.56 ml/min in the every 8 h group. 46.42% of patients in the every 12 h group and 82.14% of patients in the every 8 h group attained AUC/MIC of more than 400 mg × hr/L. None of the patients in the every 12 h group reached more than 15 mcg/ml concentration. At the 7-day follow-up, 10.7% patients in the BD group and 28.6% patients in the TDS group developed acute kidney injury (p = 0.089).Conclusion: Administration of vancomycin at a dose of 15 mg/kg every 8 h is associated with higher pharmacokinetic attainment in ARC patients. The occurrence of acute kidney injury also was not significantly higher in this therapeutic regimen. AUC/MIC monitoring is necessary in this population.
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29
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Mullaney SR. Vancomycin Should Be Considered a Nephrotoxic Antimicrobial Agent: CON. KIDNEY360 2022; 3:1488-1490. [PMID: 36245666 PMCID: PMC9528368 DOI: 10.34067/kid.0007932021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/24/2022] [Indexed: 11/27/2022]
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30
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Perazella MA. Vancomycin Should Be Considered a Nephrotoxic Antimicrobial Agent: COMMENTARY. KIDNEY360 2022; 3:1491-1493. [PMID: 36250736 PMCID: PMC9528384 DOI: 10.34067/kid.0008112021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 11/27/2022]
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31
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Marinucci V, Louzon PR, Carr AL, Hayes J, Lopez-Ruiz A, Sniffen J. Pharmacist-Driven Methicillin-Resistant S. aureus Polymerase Chain Reaction Testing for Pneumonia. Ann Pharmacother 2022; 57:560-569. [PMID: 36039495 DOI: 10.1177/10600280221121144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nasal colonization with methicillin-resistant Staphylococcus aureus (MRSA) can be detected using nasal swab polymerase chain reaction (PCR) assay and is associated with clinical MRSA infection. The MRSA nasal PCR has a rapid turnaround time and a negative predictive value for MRSA pneumonia of >98%; however, data are limited in critically ill patients. OBJECTIVE The purpose of this study is to determine the impact of a pharmacist-driven algorithm, utilizing MRSA PCR nasal screening on duration of anti-MRSA therapy in patients admitted to the intensive care unit (ICU) with suspected pneumonia. METHODS A single-center pre/post study was conducted in 4 ICUs at a large tertiary care community hospital. Adult patients admitted to the ICU initiated on vancomycin or linezolid for pneumonia managed using a pharmacist-driven MRSA PCR algorithm were included in the algorithm cohort. A historical cohort with standard management was matched 1:1 by age, type of pneumonia, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The primary outcome was duration of anti-MRSA therapy. Secondary outcomes included MRSA rates, number of vancomycin levels, new onset of acute kidney injury (AKI), ICU length of stay (LOS), hospital LOS, and mortality. RESULTS Of the 245 patients screened, 50 patients met inclusion criteria for the algorithm cohort and were matched to 50 patients in the historical cohort. The duration of anti-MRSA therapy was significantly lower compared with the historical cohort (47 vs 95 hours; P < 0.001). Secondary outcomes were similar between groups for MRSA rates, new onset of AKI, LOS, and mortality. There were less vancomycin levels ordered in the algorithm cohort (2 vs 3, P = 0.026). CONCLUSIONS A pharmacist-driven MRSA PCR algorithm significantly reduced anti-MRSA duration of therapy in critically ill patients with pneumonia. Future studies should validate these results in critically ill populations and in settings where MRSA pneumonia is more prevalent.
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32
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Laou E, Mavridis T, Papagiannakis N, Pais G, Chighine A, Chang J, Locci E, D’Aloja E, Scheetz M, Chalkias A, Xanthos T. Blood Biomarkers and Metabolomic Profiling for the Early Diagnosis of Vancomycin-Associated Acute Kidney Injury: A Systematic Review and Meta-Analysis of Experimental Studies. J Pers Med 2022; 12:1397. [PMID: 36143182 PMCID: PMC9505572 DOI: 10.3390/jpm12091397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND several blood-based biomarkers have been proposed for predicting vancomycin-associated kidney injury (VIKI). However, no systematic analysis has compared their prognostic value. OBJECTIVE this systematic review and meta-analysis was designed to investigate the role of blood biomarkers and metabolomic profiling as diagnostic and prognostic predictors in pre-clinical studies of VIKI. METHODS a systematic search of PubMed was conducted for relevant articles from January 2000 to May 2022. Animal studies that administered vancomycin and studied VIKI were eligible for inclusion. Clinical studies, reviews, and non-English literature were excluded. The primary outcome was to investigate the relationship between the extent of VIKI as measured by blood biomarkers and metabolomic profiling. Risk of bias was assessed with the CAMARADES checklist the SYRCLE's risk of bias tool. Standard meta-analysis methods (random-effects models) were used. RESULTS there were four studies for the same species, dosage, duration of vancomycin administration and measurement only for serum creatine and blood urea nitrogen in rats. A statistically significant increase was observed between serum creatinine in the vancomycin group compared to controls (pooled p = 0.037; Standardized Mean Difference: 2.93; 95% CI: 0.17 to 5.69; I2 = 92.11%). Serum BUN levels were not significantly different between control and vancomycin groups (pooled p = 0.11; SMD: 3.05; 95% CI: 0.69 to 6.8; I2 = 94.84%). We did not identify experimental studies using metabolomic analyses in animals with VIKI. CONCLUSIONS a total of four studies in rodents only described outcomes of kidney injury as defined by blood biomarkers. Blood biomarkers represented included serum creatinine and BUN. Novel blood biomarkers have not been explored.
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Affiliation(s)
- Eleni Laou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
| | - Theodoros Mavridis
- First Department of Neurology, Eginition University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Nikolaos Papagiannakis
- First Department of Neurology, Eginition University Hospital, Medical School, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Gwendolyn Pais
- Department of Pharmacy Practice, Pharmacometric Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, IL 60515, USA
| | - Alberto Chighine
- Department of Medical Sciences and Public Health, Section of Legal Medicine, University of Cagliari, 09124 Cagliari, Italy
| | - Jack Chang
- Department of Pharmacy Practice, Pharmacometric Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, IL 60515, USA
- Northwestern Memorial Hospital, Chicago, IL 60611, USA
| | - Emanuela Locci
- Department of Medical Sciences and Public Health, Section of Legal Medicine, University of Cagliari, 09124 Cagliari, Italy
| | - Ernesto D’Aloja
- Department of Medical Sciences and Public Health, Section of Legal Medicine, University of Cagliari, 09124 Cagliari, Italy
| | - Marc Scheetz
- Department of Pharmacy Practice, Pharmacometric Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, IL 60515, USA
- Northwestern Memorial Hospital, Chicago, IL 60611, USA
| | - Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Theodoros Xanthos
- School of Health sciences, University of West Attica, 12243 Athens, Greece
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Zhang S, Wu QJ, Liu SX. A methodologic survey on use of the GRADE approach in evidence syntheses published in high-impact factor urology and nephrology journals. BMC Med Res Methodol 2022; 22:220. [PMID: 35948868 PMCID: PMC9367121 DOI: 10.1186/s12874-022-01701-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background To identify and describe the use of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for rating the certainty of systematic reviews (SRs) evidence published in urology and nephrology journals. Methods SRs that were published in the top ten "urology and nephrology" journals with the highest impact factor according to the 2020 Journal Citation Reports (covering 2016–2020) were systematically searched and evaluated using the GRADE approach. Results A total of 445 SRs were researched. Sixty SRs of randomized control trials (RCTs) and/or non-randomized studies (NRSs) were evaluated using the GRADE approach. Forty-nine SRs (11%) rated the outcome-specific certainty of evidence (n = 29 in 2019–2020). We identified 811 certainty of evidence outcome ratings (n = 544 RCT ratings) as follows: very low (33.0%); low (32.1%); moderate (24.5%); and high (10.4%). Very low and high certainty of evidence ratings accounted for 55.0% and 0.4% of ratings in SRs of NRSs compared to 23.0% and 15.3% in SRs of RCTs. The certainty of evidence for RCTs and NRSs was downgraded most often for risk of bias and imprecision. Conclusions We recommend increased emphasis on acceptance of the GRADE approach, as well as optimal use of the GRADE approach, in the synthesis of urinary tract evidence. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01701-x.
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Affiliation(s)
- Shuang Zhang
- Department of Nephrology, Dalian Municipal Central Hospital, No.826, Xinan Road, Dalian, Liaoning, 116033, China.,Dalian Key Laboratory of Intelligent Blood Purification, Dalian Municipal Central Hospital, No.826, Xinan Road, Dalian, Liaoning, 116033, China
| | - Qi-Jun Wu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shu-Xin Liu
- Department of Nephrology, Dalian Municipal Central Hospital, No.826, Xinan Road, Dalian, Liaoning, 116033, China. .,Dalian Key Laboratory of Intelligent Blood Purification, Dalian Municipal Central Hospital, No.826, Xinan Road, Dalian, Liaoning, 116033, China.
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Wolfe A, Bowling J, Short MR, Mateyoke G, Berger SC. Assessing Nephrotoxicity Associated With Different Vancomycin Dosing Modalities in Obese Patients at a Community Hospital. Hosp Pharm 2022; 57:532-539. [PMID: 35898248 PMCID: PMC9310323 DOI: 10.1177/00185787211055791] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Background: Vancomycin requires therapeutic drug monitoring (TDM) based on its pharmacokinetic properties, and guidelines have shifted to analyzing area under the curve over 24 hours (AUC24) rather than trough concentrations due to nephrotoxicity concerns and correlation to efficacy. Obesity is an established risk factor for vancomycin-induced nephrotoxicity due to increased drug exposure based on dosing calculations and volume of distribution estimation. The aim of this study is to assess the relationship between AUC-based versus trough-based dosing and nephrotoxicity among obese patients receiving vancomycin. Methods: This research project was conducted as a retrospective, observational, single-centered study which included obese adults who received at least 48 hours of vancomycin. The electronic medical record provided data for patients with vancomycin pharmacokinetic consults either evaluated with trough-only or AUC-based dosing. The primary objective was to compare the development of nephrotoxicity after vancomycin initiation, while secondary objectives included vancomycin loading dose exposure, total daily dose of vancomycin, and whether target TDM was attained. Nominal data were evaluated utilizing the chi-square test and continuous data using the independent samples t-test or Mann-Whitney test. The a priori level of significance was .05. Data analysis was performed using Microsoft Excel and SAS statistical software. Results: Two hundred fifty-four patients were included in the primary analysis. Four patients in the AUC cohort (6.3%) developed nephrotoxicity compared to 32 (17.4%) in the trough cohort (P = .035). Both cohorts received a median of 4 days of therapy; however, the median loading dose per actual body weight in the AUC cohort was 20 mg/kg as compared to 16 mg/kg in the trough cohort. Of the 130 patients with available TDM in the trough cohort, 97 (74.6%) did not meet target attainment as compared to 15 of the 57 in the AUC cohort (26.3%) (P < .001). Conclusions: AUC dosing was associated with a statistically significant reduction in AKI occurrence despite overall higher loading dose exposure as compared to the trough cohort. Though maintenance dose exposure was similar between both cohorts, patients in the AUC cohort maintained therapeutic concentrations at a higher percentage than the trough cohort.
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Roebke AJ, Malik AT, Khan SN, Yu E. Does a Reported Penicillin Allergy Affect Outcomes Following Elective Posterior Lumbar Fusions? Int J Spine Surg 2022; 16:1023-1028. [PMID: 35831066 PMCID: PMC9807058 DOI: 10.14444/8326] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Patients with a reported penicillin allergy (PA) receive alternative antibiotics that may not be as effective as cephalosporins for surgical site infection (SSI) prophylaxis. While patient-reported PA has been correlated to increased complications in other fields, this has not been conclusively shown in spine surgery. We investigate the impact of PA on 90-day complications and inpatient charges/costs after elective posterior lumbar fusion between PA and non-PA cohorts. METHODS The 2005 to 2014 SAF100 database was queried using International Classification of Diseases, Ninth Edition (ICD-9) procedure codes to identify patients undergoing elective posterior lumbar fusions. The reported PA ICD-9 code was used to divide the study sample into a PA cohort and non-PA cohort. Multivariate logistic regression analyses were used to assess significant differences in 90-day complications between PA and non-PA groups after controlling for confounding factors. Generalized linear regression modeling was used to assess for differences in inpatient charges and costs. RESULTS A total of 286,042 patients, 7497 (2.6%) of whom reported a PA, who underwent elective posterior lumbar fusions were included. Following adjustment for confounding factors, patients in the PA group had significantly higher odds of experiencing SSIs (3.8% vs 3.1%, OR 1.20 [95% CI 1.07-1.36]; P = 0.002), urinary tract infections (12.3% vs 10.0%, OR 1.16 [95% CI 1.08-1.24]; P < 0.001), sepsis (1.5% vs 1.2%, OR 1.24 [95% CI 1.02-1.50]; P = 0.026), acute kidney injuries (3.8% vs 3.2%, OR 1.19 [95% CI 1.05-1.34]; P = 0.006), readmissions (9.8% vs 8.5%, OR 1.15 [95% CI 1.07-1.25]; P < 0.001), increased inpatient charges (+$4340; P < 0.001), and increased reimbursements (+$1221; P < 0.001). CONCLUSIONS Patients with a reported PA experienced significantly higher rates of 90-day complications and cost following elective posterior lumbar fusion. The findings of the study highlight the importance of preoperative PA testing to minimize the use of alternative antibiotics and potentially improve patient outcomes. CLINICAL RELEVANCE Patients should be tested for penicillin allergy to minimize the use of alternative antibiotics among patients with a reported PA. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Austin J. Roebke
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Azeem T. Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Safdar N. Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Elizabeth Yu
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA, Elizabeth Yu, Department of Orthopaedics, Division of Spine, Director of the Orthopaedic Minimally Invasive Spine Surgery Service, 376 W 10th Ave, Columbus, OH 43210, USA;
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Mally A, Jarzina S. Mapping Adverse Outcome Pathways for Kidney Injury as a Basis for the Development of Mechanism-Based Animal-Sparing Approaches to Assessment of Nephrotoxicity. FRONTIERS IN TOXICOLOGY 2022; 4:863643. [PMID: 35785263 PMCID: PMC9242087 DOI: 10.3389/ftox.2022.863643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/11/2022] [Indexed: 02/04/2023] Open
Abstract
In line with recent OECD activities on the use of AOPs in developing Integrated Approaches to Testing and Assessment (IATAs), it is expected that systematic mapping of AOPs leading to systemic toxicity may provide a mechanistic framework for the development and implementation of mechanism-based in vitro endpoints. These may form part of an integrated testing strategy to reduce the need for repeated dose toxicity studies. Focusing on kidney and in particular the proximal tubule epithelium as a key target site of chemical-induced injury, the overall aim of this work is to contribute to building a network of AOPs leading to nephrotoxicity. Current mechanistic understanding of kidney injury initiated by 1) inhibition of mitochondrial DNA polymerase γ (mtDNA Polγ), 2) receptor mediated endocytosis and lysosomal overload, and 3) covalent protein binding, which all present fairly well established, common mechanisms by which certain chemicals or drugs may cause nephrotoxicity, is presented and systematically captured in a formal description of AOPs in line with the OECD AOP development programme and in accordance with the harmonized terminology provided by the Collaborative Adverse Outcome Pathway Wiki. The relative level of confidence in the established AOPs is assessed based on evolved Bradford-Hill weight of evidence considerations of biological plausibility, essentiality and empirical support (temporal and dose-response concordance).
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Corbin CK, Sung L, Chattopadhyay A, Noshad M, Chang A, Deresinksi S, Baiocchi M, Chen JH. Personalized antibiograms for machine learning driven antibiotic selection. COMMUNICATIONS MEDICINE 2022; 2:38. [PMID: 35603264 PMCID: PMC9053259 DOI: 10.1038/s43856-022-00094-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 02/25/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Background
The Centers for Disease Control and Prevention identify antibiotic prescribing stewardship as the most important action to combat increasing antibiotic resistance. Clinicians balance broad empiric antibiotic coverage vs. precision coverage targeting only the most likely pathogens. We investigate the utility of machine learning-based clinical decision support for antibiotic prescribing stewardship.
Methods
In this retrospective multi-site study, we developed machine learning models that predict antibiotic susceptibility patterns (personalized antibiograms) using electronic health record data of 8342 infections from Stanford emergency departments and 15,806 uncomplicated urinary tract infections from Massachusetts General Hospital and Brigham & Women’s Hospital in Boston. We assessed the trade-off between broad-spectrum and precise antibiotic prescribing using linear programming.
Results
We find in Stanford data that personalized antibiograms reallocate clinician antibiotic selections with a coverage rate (fraction of infections covered by treatment) of 85.9%; similar to clinician performance (84.3% p = 0.11). In the Boston dataset, the personalized antibiograms coverage rate is 90.4%; a significant improvement over clinicians (88.1% p < 0.0001). Personalized antibiograms achieve similar coverage to the clinician benchmark with narrower antibiotics. With Stanford data, personalized antibiograms maintain clinician coverage rates while narrowing 69% of empiric vancomycin+piperacillin/tazobactam prescriptions to piperacillin/tazobactam. In the Boston dataset, personalized antibiograms maintain clinician coverage rates while narrowing 48% of ciprofloxacin to trimethoprim/sulfamethoxazole.
Conclusions
Precision empiric antibiotic prescribing with personalized antibiograms could improve patient safety and antibiotic stewardship by reducing unnecessary use of broad-spectrum antibiotics that breed a growing tide of resistant organisms.
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Bian X, Qu X, Zhang J, Nang SC, Bergen PJ, Tony Zhou Q, Chan HK, Feng M, Li J. Pharmacokinetics and pharmacodynamics of peptide antibiotics. Adv Drug Deliv Rev 2022; 183:114171. [PMID: 35189264 PMCID: PMC10019944 DOI: 10.1016/j.addr.2022.114171] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 01/23/2022] [Accepted: 02/16/2022] [Indexed: 01/05/2023]
Abstract
Antimicrobial resistance is a major global health challenge. As few new efficacious antibiotics will become available in the near future, peptide antibiotics continue to be major therapeutic options for treating infections caused by multidrug-resistant pathogens. Rational use of antibiotics requires optimisation of the pharmacokinetics and pharmacodynamics for the treatment of different types of infections. Toxicodynamics must also be considered to improve the safety of antibiotic use and, where appropriate, to guide therapeutic drug monitoring. This review focuses on the pharmacokinetics/pharmacodynamics/toxicodynamics of peptide antibiotics against multidrug-resistant Gram-negative and Gram-positive pathogens. Optimising antibiotic exposure at the infection site is essential for improving their efficacy and minimising emergence of resistance.
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Affiliation(s)
- Xingchen Bian
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China
| | - Xingyi Qu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Sue C Nang
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Phillip J Bergen
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Meiqing Feng
- School of Pharmacy, Fudan University, Shanghai, China
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia.
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Oral antibiotics reduce voluntary exercise behavior in athletic mice. Behav Processes 2022; 199:104650. [DOI: 10.1016/j.beproc.2022.104650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 04/20/2022] [Accepted: 04/27/2022] [Indexed: 11/17/2022]
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Ferreira MD, Veiga SS, Dos Santos FA. Brown spider (Loxosceles sp.) bite and COVID-19: A case report. Toxicon 2022; 212:1-7. [PMID: 35346694 PMCID: PMC8957330 DOI: 10.1016/j.toxicon.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/17/2022] [Accepted: 03/23/2022] [Indexed: 01/03/2023]
Abstract
We present the case of a 32-year-old male patient hospitalized during the COVID-19 pandemic because of a Brown spider bite on his lower lip. The Brown spider accident occurred in southern Brazil; at hospital admission, the patient presented on his lip: edema, pustules, necrotic regions, and ulcerations. The patient complained of lower back pain, fever and dyspnea. Laboratory tests showed monocytosis, leukocytosis, neutrophilia, increased D-dimer levels, C-reactive protein, glutamate-pyruvate transaminase, delta bilirubin, creatine phosphokinase, procalcitonin, and fibrinogen. The patient was hospitalized and a multi-professional team carried out the treatment. The medical team diagnosed loxoscelism with moderate changes. The dentist treated the oral cavity. The patient began to develop nausea, vomiting, and desaturation episodes during hospitalization. A computed tomography of the chest was performed, which showed signs of viral infection. The RT-PCR test for COVID-19 was positive. The systemic conditions worsened (renal dysfunction, systemic inflammatory response, pulmonary complications). This condition may have resulted from the association of the two diseases (loxoscelism and COVID-19), leading to the patient's death. This case illustrates the difficulties and risks in treating patients with venomous animal accidents during the pandemic, and the importance of a multi-professional team in treating such cases.
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Affiliation(s)
- Marceli Dias Ferreira
- Department of Dentistry, School of Dentistry, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | | | - Fábio André Dos Santos
- Department of Dentistry, School of Dentistry, State University of Ponta Grossa, Ponta Grossa, PR, Brazil.
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Duffy CR, Huang Y, Andrikopoulou M, Stern-Ascher CN, Wright JD, D'Alton ME, Friedman AM. Vancomycin during delivery hospitalizations for women with group B streptococcus. J Matern Fetal Neonatal Med 2022; 35:898-906. [PMID: 32160789 PMCID: PMC7757725 DOI: 10.1080/14767058.2020.1733520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/07/2020] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Vancomycin use for intrapartum GBS prophylaxis is not well characterized. The objective of this study was to describe trends in the use of vancomycin among women undergoing vaginal delivery with group B Streptococcus (GBS) colonization. METHODS An administrative inpatient database that includes medications was analyzed to evaluate antibiotic use in women undergoing vaginal delivery hospitalizations complicated by GBS colonization from January 2006 to March 2015. Patients with other obstetric or infectious indications for antibiotics were excluded. Frequency of use of individual antibiotic agents was determined. The Cochran-Armitage test was used to assess temporal trends. An adjusted log-linear regression model accounting for demographic and hospital factors with vancomycin receipt as the outcome was performed with adjusted risk ratios (aRR) and 95% confidence intervals (CI) as the measure of effect. Hospital level variation in administration of vancomycin was also evaluated. RESULTS 469,717 deliveries met inclusion criteria and were included in this analysis. Use of vancomycin increased from 0.8% of patients in 2006 to 3.8% of patients in the first quarter of 2015. Comparing 2015 to 2006 both the unadjusted (relative risk 4.89 95% CI 4.26-5.60) and adjusted (aRR 4.52 95% 3.94-5.19) models demonstrated significantly increased likelihood of vancomycin administration. In evaluating hospital level vancomycin use, variation was noted with 8.0% of centers administering vancomycin to ≥6.0% of patients. CONCLUSIONS Vancomycin is becoming increasingly commonly used for intrapartum GBS prophylaxis. Further research and quality improvements initiatives are indicated to optimize intrapartum GBS antibiotic prophylaxis.
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Affiliation(s)
- Cassandra R Duffy
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Yongmei Huang
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Maria Andrikopoulou
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Conrad N Stern-Ascher
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jason D Wright
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Mary E D'Alton
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Alexander M Friedman
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Le P, Navaneethan SD, Yu PC, Pallotta AM, Rastogi R, Patel P, Brateanu A, Imrey PB, Rothberg MB. Association of antibiotic use and acute kidney injury in patients hospitalized with community-acquired pneumonia. Curr Med Res Opin 2022; 38:443-450. [PMID: 34714213 DOI: 10.1080/03007995.2021.2000716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common among hospitalized patients with community-acquired pneumonia (CAP). We aimed to estimate and compare the risk of AKI for various antibiotic combinations in adults hospitalized for CAP. METHODS We conducted a retrospective cohort study of the Premier Healthcare Database containing all admissions for 660 US hospitals from 2010 to 2015. We included adults aged ≥18 years hospitalized with CAP and considered 6 different antibiotic combinations based on continuous use in the first 3 hospital days. The primary outcome was incident AKI, defined by ICD-9 codes 584.5-584-9. We evaluated associations of AKI with in-hospital mortality and length-of-stay. We excluded patients who were admitted directly to the intensive care unit, had AKI codes present on admission or had dialysis in the first 2 days. We used generalized linear mixed models with the hospital as a random effect and covariate adjustment for patient demographics, comorbidities, other treatments on day 0/1, and hospital characteristics. RESULTS The total sample included 449,535 patients, 3.15% of whom developed AKI. All other regimens but fluoroquinolones exhibited higher AKI odds than 3rd generation cephalosporin with or without macrolide. The combination of piperacillin/tazobactam and vancomycin with or without other antibiotics was associated with the highest AKI odds (OR = 1.89; 95% CI: 1.73-2.06). Patients with incident AKI had an increased odds of hospital mortality (OR = 6.37; 95% CI: 6.07-6.69) and longer length-of-stay (mean multiplier = 1.84; 95% CI: 1.82, 1.86). CONCLUSION Compared to 3rd generation cephalosporin with or without macrolide, piperacillin/tazobactam, vancomycin, and their combination were associated with higher odds of developing AKI, which in turn were associated with worse clinical outcomes.
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Affiliation(s)
- Phuc Le
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Sankar Dass Navaneethan
- Section of Nephrology, Michael E. DeBakey VA Medical Center, Section of Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Pei-Chun Yu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | - Radhika Rastogi
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Preethi Patel
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Andrei Brateanu
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Peter B Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Michael B Rothberg
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, USA
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Vancomycin-Associated Acute Kidney Injury: A Narrative Review from Pathophysiology to Clinical Application. Int J Mol Sci 2022; 23:ijms23042052. [PMID: 35216167 PMCID: PMC8877514 DOI: 10.3390/ijms23042052] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 12/12/2022] Open
Abstract
Vancomycin is the most frequently used antibiotic, accounting for up to 35% of hospitalized patients with infection, because of its optimal bactericidal effectiveness and relatively low price. Vancomycin-associated AKI (VA-AKI) is a clinically relevant but not yet clearly understood entity in critically ill patients. The current review comprehensively summarizes the pathophysiological mechanisms of, biomarkers for, preventive strategies for, and some crucial issues with VA-AKI. The pathological manifestations of VA-AKI include acute tubular necrosis, acute tubulointerstitial nephritis (ATIN), and intratubular crystal obstruction. The proposed pathological mechanisms of VA-AKI include oxidative stress and allergic reactions induced by vancomycin and vancomycin-associated tubular casts. Concomitant administration with other nephrotoxic antibiotics, such as piperacillin–tazobactam, high vancomycin doses, and intermittent infusion strategies compared to the continuous infusion are associated with a higher risk of VA-AKI. Several biomarkers could be applied to predict and diagnose VA-AKI. To date, no promising therapy is available. Oral steroids could be considered for patients with ATIN, whereas hemodialysis might be applied to remove vancomycin from the patient. In the future, disclosing more promising biomarkers that could precisely identify populations susceptible to VA-AKI and detect VA-AKI occurrence early on, and developing pharmacological agents that could prevent or treat VA-AKI, are the keys to improve the prognoses of patients with severe infection who probably need vancomycin therapy.
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AbuSara AK, Abdelrahman DH, Habash KI, Al-Shaer MH, Le J, Nazer LH. Vancomycin therapeutic monitoring by measured trough concentration versus Bayesian-derived area under the curve in critically ill patients with cancer. Pharmacol Res Perspect 2022; 10:e00912. [PMID: 34990089 PMCID: PMC8929348 DOI: 10.1002/prp2.912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/17/2021] [Indexed: 11/16/2022] Open
Abstract
The updated vancomycin guideline and recent studies suggested that trough concentrations may result in underestimation of the actual area under the curve (AUC), leading to excessive dosing and nephrotoxicity. With limited data available on critically ill cancer patients, this study aimed to compare the two methods in this patient population. This was a 5‐year retrospective study on patients treated with vancomycin in the intensive care unit (ICU) of a comprehensive cancer center. The measured trough concentration was compared to Bayesian‐derived AUC/minimum‐inhibitory‐concentration (MIC), considering MIC as 1. Trough concentrations of 15–20 mg/L and AUC of 400–600 mg h/L were considered the targeted goal. Multivariate analysis was performed to identify factors associated with an AUC below the targeted goal. During the study period, 316 patients were included. The mean age was 54 years ±16 (SD); most patients had solid tumors (75%), and 11% had neutropenia. A targeted goal AUC and trough were recorded in 128 (41%) patients and in 64 (20%) patients, respectively. Of the 128 patients with targeted goal AUC, 31 (24%) had targeted goal trough concentrations and 91 (71%) had trough concentrations below 15 mg/L. Furthermore, among the patients with targeted goal trough concentration (n = 64), 33 (52%) had higher than targeted goal AUC. Augmented renal clearance (ARC), defined as a calculated creatinine‐clearance ≥130 ml/min, was associated with an AUC below the targeted goal. In a cohort of critically ill patients with cancer, over two‐thirds of the patients with a targeted goal Bayesian AUC/MIC had trough concentrations below the targeted goal. ARC was associated with AUC below the targeted goal.
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Affiliation(s)
- Aseel K AbuSara
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | | | - Khader I Habash
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | - Mohammad H Al-Shaer
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
| | - Lama H Nazer
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
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Chen J, Huang X, Bu S, Chen X, Zhou J, Liu X, Guo X, Li L, Zhang J. The relationship between vancomycin AUC/MIC and trough concentration, age, dose, renal function in Chinese critically ill pediatric patients. Pharmacol Res Perspect 2021; 9:e00885. [PMID: 34664790 PMCID: PMC8525138 DOI: 10.1002/prp2.885] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/02/2021] [Indexed: 12/16/2022] Open
Abstract
To assess the pharmacokinetic parameters of vancomycin in Chinese critically ill pediatric patients, children treated with vancomycin, hospitalized in the intensive care unit were included. Samples to determine peak and trough serum concentrations were obtained on the third day of treatment. Half-life was significantly longer in neonates and showed a decreasing trend in infants and children. In patients aged ≥1 month, AUC24 /MIC ≥400 was achieved in 31.8% at the dose of 40 mg/kg/d, and in 48.7% at the dose of 60 mg/kg/d with an assumed MIC of 1 mg/L. Augmented renal clearance (ARC) was present in 27.3% of children, which was associated with higher vancomycin clearance and lower AUC values. A good correlation was observed between trough concentration and AUC24 , and the trough concentration that correlated with AUC24 of 400 were varied according to the dosage regimens, 8.42 mg/L for 6-hintervals, and 6.63 mg/L for 8-h intervals. To conclude, vancomycin trough concentration that related to the AUC24 of 400 was much lower in critically ill children than that in adults. The dosage of 60 mg/kg/day did not enough for producing AUC24 in the range of 400-600 mg h/L in critically ill children, especially in those with ARC.
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Affiliation(s)
- Jihui Chen
- Department of PharmacyXinhua HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Xiaohui Huang
- Department of PharmacyXinhua HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Shuhong Bu
- Department of PharmacyXinhua HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Xiaoxiao Chen
- Department of Hematology/OncologyShanghai Children’s Medical CenterSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Jia Zhou
- Department of PharmacyXinhua HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Xinzhu Liu
- Department of PharmacyXinhua HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Xiaowen Guo
- Department of PharmacyXinhua HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Lixia Li
- Department of PharmacyXinhua HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Jian Zhang
- Department of PharmacyXinhua HospitalSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
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Stokes MB, Stevens JS. Vancomycin-Associated Cast Nephropathy: Reality or Fantasy? KIDNEY360 2021; 3:372-375. [PMID: 35373135 PMCID: PMC8967645 DOI: 10.34067/kid.0007282021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/30/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Michael B. Stokes
- Department of Pathology, College of Physicians and Surgeons, New York, New York
| | - Jacob S. Stevens
- Department of Medicine, College of Physicians and Surgeons, New York, New York
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Chinzowu T, Roy S, Nishtala PS. Risk of antimicrobial-associated organ injury among the older adults: a systematic review and meta-analysis. BMC Geriatr 2021; 21:617. [PMID: 34724889 PMCID: PMC8561875 DOI: 10.1186/s12877-021-02512-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/10/2021] [Indexed: 11/24/2022] Open
Abstract
Background Older adults (aged 65 years and above) constitute the fastest growing population cohort in the western world. There is increasing evidence that the burden of infections disproportionately affects older adults, and hence this vulnerable population is frequently exposed to antimicrobials. There is currently no systematic review summarising the evidence for organ injury risk among older adults following antimicrobial exposure. This systematic review and meta-analysis examined the relationship between antimicrobial exposure and organ injury in older adults. Methodology We searched for original research articles in PubMed, Embase.com, Web of Science core collection, Web of Science BIOSIS citation index, Scopus, Cochrane Central Register of Controlled Trials, ProQuest, and PsycINFO databases, using key words in titles and abstracts, and using MeSH terms. We searched for all available articles up to 31 May 2021. After removing duplicates, articles were screened for inclusion into or exclusion from the study by two reviewers. The Newcastle-Ottawa scale was used to assess the risk of bias for cohort and case-control studies. We explored the heterogeneity of the included studies using the Q test and I2 test and the publication bias using the funnel plot and Egger’s test. The meta-analyses were performed using the OpenMetaAnalyst software. Results The overall absolute risks of acute kidney injury among older adults prescribed aminoglycosides, glycopeptides, and macrolides were 15.1% (95% CI: 12.8–17.3), 19.1% (95% CI: 15.4–22.7), and 0.3% (95% CI: 0.3–0.3), respectively. Only 3 studies reported antimicrobial associated drug-induced liver injury. Studies reporting on the association of organ injury and antimicrobial exposure by age or duration of treatment were too few to meta-analyse. The funnel plot and Egger’s tests did not indicate evidence of publication bias. Conclusion Older adults have a significantly higher risk of sustaining acute kidney injury when compared to the general adult population. Older adults prescribed aminoglycosides have a similar risk of acute kidney injury to the general adult population. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02512-3.
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Affiliation(s)
- Tichawona Chinzowu
- Department of Pharmacy and Pharmacology & Centre for Therapeutic Innovation, University of Bath, Bath, BA2 7AY, UK.
| | - Sandipan Roy
- Department of Mathematical Science, University of Bath, Bath, BA2 7AY, UK
| | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology & Centre for Therapeutic Innovation, University of Bath, Bath, BA2 7AY, UK
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Legrand M, Bell S, Forni L, Joannidis M, Koyner JL, Liu K, Cantaluppi V. Pathophysiology of COVID-19-associated acute kidney injury. Nat Rev Nephrol 2021; 17:751-764. [PMID: 34226718 PMCID: PMC8256398 DOI: 10.1038/s41581-021-00452-0] [Citation(s) in RCA: 249] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 02/06/2023]
Abstract
Although respiratory failure and hypoxaemia are the main manifestations of COVID-19, kidney involvement is also common. Available evidence supports a number of potential pathophysiological pathways through which acute kidney injury (AKI) can develop in the context of SARS-CoV-2 infection. Histopathological findings have highlighted both similarities and differences between AKI in patients with COVID-19 and in those with AKI in non-COVID-related sepsis. Acute tubular injury is common, although it is often mild, despite markedly reduced kidney function. Systemic haemodynamic instability very likely contributes to tubular injury. Despite descriptions of COVID-19 as a cytokine storm syndrome, levels of circulating cytokines are often lower in patients with COVID-19 than in patients with acute respiratory distress syndrome with causes other than COVID-19. Tissue inflammation and local immune cell infiltration have been repeatedly observed and might have a critical role in kidney injury, as might endothelial injury and microvascular thrombi. Findings of high viral load in patients who have died with AKI suggest a contribution of viral invasion in the kidneys, although the issue of renal tropism remains controversial. An impaired type I interferon response has also been reported in patients with severe COVID-19. In light of these observations, the potential pathophysiological mechanisms of COVID-19-associated AKI may provide insights into therapeutic strategies.
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco, CA, USA.
- Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists network, Nancy, France.
| | - Samira Bell
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Lui Forni
- Intensive Care Unit, Royal Surrey Hospital NHS Foundation Trust, Surrey, UK
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Surrey, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Jay L Koyner
- Divisions of Nephrology, Departments of Medicine, University of Chicago, Chicago, IL, USA
| | - Kathleen Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of San Francisco, San Francisco, CA, USA
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
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Tantranont N, Hebert S, Truong LD. Vancomycin Nephrotoxicity Causing Renal Transplant Acute Kidney Injury. Transplant Proc 2021; 53:2913-2917. [PMID: 34728076 DOI: 10.1016/j.transproceed.2021.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
Nephrotoxicity is a rather frequent side effect of vancomycin treatment. Attributes of vancomycin nephrotoxicity (VN) are well documented, including its clinical manifestations and renal morphologic changes. However, VN has not been emphasized as the cause of acute kidney injury (AKI) in the renal transplant setting. We report the first 3 such cases. In each of these cases, AKI developed concurrently with vancomycin treatment and resolved after its cessation. As compared with the general population, VN in the renal transplant setting displayed some unusual clinical behaviors. Its development was rather capricious, being noted in some but not every episode of vancomycin treatment, even in the same individual. AKI developed gradually in conjunction with protracted vancomycin treatment, in contrast to a precipitous course in the nontransplant setting. However, renal transplant biopsies showed typical features of VN in each case. VN is an unusual but now well-documented cause of AKI in renal transplant recipients. VN in this setting may display some atypical features, setting it apart from that in the general population. However, renal transplant biopsy changes are characteristic and are amenable to a definitive diagnosis.
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Affiliation(s)
- Ngoentra Tantranont
- Department of Pathology and Genomic Medicine, The Houston Methodist Hospital, Houston, Texas; Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sean Hebert
- Department of Medicine, Section of Nephrology, The Houston Methodist Hospital, Houston, Texas
| | - Luan D Truong
- Department of Pathology and Genomic Medicine, The Houston Methodist Hospital, Houston, Texas.
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Liu K, Zhang Y, Xu X, Wu B, Ni J, Li T, Xing C, Mao H. Comparative Prevalence of Acute Kidney Injury in Chinese Patients Receiving Vancomycin with Concurrent β-Lactam Antibiotics: A Retrospective Cohort Study. Clin Ther 2021; 43:e319-e351. [PMID: 34579971 DOI: 10.1016/j.clinthera.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 08/07/2021] [Accepted: 08/16/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE The combination of vancomycin and piperacillin/tazobactam (VAN + PTZ) provides a broad spectrum of activity against multiple pathogens. However, a major issue in previous research concerned significant nephrotoxicity associated with this drug combination, and most studies have been conducted in American and European countries, with no similar data available from China. Therefore, this study evaluated the nephrotoxic effects of VAN + PTZ in a large-scale Chinese cohort to determine the prevalence of acute kidney injury (AKI) in this population by comparing PTZ and vancomycin monotherapies and the combined use of vancomycin and β-lactam antibiotics. METHODS This retrospective cohort study identified adult patients who received vancomycin either as monotherapy or in combination with PTZ or carbapenem (VAN + CAR) for at least 48 hours at Jiangsu Province Hospital from January 1, 2017, to December 31, 2018. Patients were also evaluated for the development of AKI, defined according to the Kidney Disease Improving Global Outcome criteria. Duration of vancomycin exposure, steady-state trough vancomycin concentrations, and other risk factors for AKI were assessed. A Bayesian network meta-analysis was conducted to validate our results and comparatively evaluate the nephrotoxicity of β-lactam antibiotics in combination with vancomycin. FINDINGS In all, 752 patients were included in the present study. The prevalence of AKI was higher in the VAN + PTZ group than in the VAN and VAN + CAR groups (15.2% vs 4.0% and 6.0%, respectively). After adjustment for confounding factors, VAN + PTZ was still related to AKI (odds ratio [OR] = 4.37; 95% CI, 1.65-11.59; P = 0.003). The network meta-analysis indicated that VAN + PTZ was associated with a significantly higher risk for AKI than was VAN (OR = 3.23; 95% CI, 2.50-4.35), PTZ (OR = 2.86; 95% CI, 1.92-4.12), VAN + cefepime (FEP) (OR = 2.37; 95% CI, 1.80-3.19), or VAN + CAR (OR = 2.28; 95% CI, 1.64-3.21). However, there was no significant difference with respect to AKI prevalence among the VAN, PTZ, VAN + FEP, and VAN + CAR groups. IMPLICATIONS The prevalence of AKI was higher with VAN + PTZ therapy than with VAN or PTZ monotherapy or with the concurrent use of VAN and FEP or CAR in our study. Clinicians should adequately assess renal function and consider this differential risk for nephrotoxicity when choosing empiric antibiotics in hospitalized patients to minimize the rates of AKI.
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Affiliation(s)
- Kang Liu
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Ying Zhang
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Xueqiang Xu
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Buyun Wu
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Juan Ni
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Ting Li
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Changying Xing
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China
| | - Huijuan Mao
- Department of Nephrology, Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University), Nanjing, China.
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