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Supratherapeutic vancomycin levels after trauma predict acute kidney injury and mortality
Eric J Ley1, Douglas Z Liou, Matthew B Singer
1Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA. Eric.Ley@cshs.org
Introduction:
High-dose vancomycin is increasingly prescribed for critically ill trauma patients at risk for methicillin-resistant Staphylococcus aureus pneumonia. Although trauma patients have multiple known risk factors for acute kidney injury (AKI), a link between vancomycin and AKI or mortality has not been established. We hypothesize that high vancomycin trough concentration (VT) after trauma is associated with AKI and increased mortality.
Methods:
This was a retrospective analysis from a single institution Level I trauma center. Data were reviewed for all adult trauma patients who were admitted between 2006 and 2010. Patients were included if they received intravenous vancomycin, had serum creatinine levels before and after vancomycin administration, and had at least one recorded VT. Patients were stratified by VT into four groups: VT1 = 0-10 mg/L, VT2 = 10.1-15 mg/L, VT3 = 15.1-20 mg/L, VT4 >20 mg/L. Multivariable logistic regression was performed to determine the association between VT, AKI, and mortality.
Results:
Of the 6781 trauma patients reviewed, 263 (3.9%) fit inclusion criteria. Ninety-seven (36.9%) patients developed AKI and 25 (9.5%) died. AKI and mortality increased progressively with VT. Ninety-one patients (34.6%) had troughs >20 mg/L and VT4 was independently associated with AKI (AOR 4.7, P < 0.01) and mortality (AOR 4.8, P = 0.05).
Conclusion:
AKI is common in trauma patients who receive intravenous vancomycin. A supratherapeutic trough level of >20 mg/L is an independent predictor of AKI and mortality in trauma patients.
Insights
High vancomycin trough concentrations in trauma patients are linked to acute kidney injury (AKI) and increased mortality. Monitoring vancomycin levels is crucial for preventing adverse outcomes in critically ill trauma patients.
Area of Science:
- Critical Care Medicine
- Pharmacology
- Nephrology
Background:
- High-dose vancomycin is frequently used for methicillin-resistant Staphylococcus aureus pneumonia in critically ill trauma patients.
- Trauma patients have numerous risk factors for acute kidney injury (AKI).
- The association between vancomycin and AKI or mortality in trauma patients remains unclear.
Purpose of the Study:
- To investigate the relationship between high vancomycin trough concentrations (VT) and the incidence of AKI and mortality in adult trauma patients.
- To determine if elevated VT is an independent predictor of adverse outcomes in this population.
Main Methods:
- Retrospective analysis of adult trauma patients admitted between 2006 and 2010 at a Level I trauma center.
- Inclusion criteria: intravenous vancomycin administration, pre- and post-vancomycin serum creatinine levels, and at least one recorded VT.
- Patients stratified into four VT groups (0-10, 10.1-15, 15.1-20, >20 mg/L); multivariable logistic regression used to assess associations.
Main Results:
- Out of 6781 trauma patients, 263 met inclusion criteria; 36.9% developed AKI, and 9.5% died.
- AKI and mortality rates increased progressively with higher VT.
- Vancomycin trough levels >20 mg/L were independently associated with AKI (AOR 4.7) and mortality (AOR 4.8).
Conclusions:
- Acute kidney injury is a frequent complication in trauma patients receiving intravenous vancomycin.
- Supratherapeutic vancomycin trough levels (>20 mg/L) are an independent predictor of AKI and mortality in trauma patients.
- This highlights the importance of therapeutic drug monitoring for vancomycin in this vulnerable patient group.
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