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Empiric weight-based vancomycin in intensive care unit patients with methicillin-resistant Staphylococcus aureus
Carlos A Alvarez1, Christopher A Giuliano, Krystal K Haase
1Department of Pharmacy Practice (CAA, KAT, SDB, RGH), Texas Tech University Health Sciences Center, School of Pharmacy, Dallas, Texas; Departments of Clinical Sciences (CAA, EMM, RGH) and Internal Medicine (EMM, RJB), University of Texas Southwestern, Dallas, Texas; Department of Pharmacy Practice (CAG, KKH), Texas Tech University Health Sciences Center, School of Pharmacy, Amarillo, Texas; Wayne State University, Eugene Applebaum College of Pharmacy and Health Sciences (CAG), Wayne State University (CAG), Department of Pharmacy Practice; OU Medical System (KAT), Department of Pharmacy; Mission Regional Medical Center (NAF), Department of Pharmacy; University of Kentucky Healthcare (SDB), Department of Pharmacy; Detroit, Michigan; OU Medical System (KAT), Oklahoma City, Oklahoma; Division of Pharmacotherapy (CRF, NAF), University of Texas, Austin, Texas; Mission Regional Medical Center (NAF), Mission, Texas; University of Kentucky Healthcare (SDB), Lexington, Kentucky; Section of General Internal Medicine (EMM), VA North Texas Health Care System, Dallas, Texas; Department of Internal Medicine (TB), Texas Tech University Health Sciences Center, School of Medicine, Amarillo, Texas; and Texas Tech University Health Sciences Center (NMT), School of Pharmacy, Dallas, Texas.
Background:
Previous studies were conducted in all hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia to determine safety and effectiveness of guideline-recommended, weight-based dosing of vancomycin. In these studies, it was observed that severely ill patients (Pitt bacteremia score ≥4 or intensive care unit [ICU] patients) were at an increased risk of mortality and/or nephrotoxicity. Therefore, a subanalysis of the effect of guideline-recommended vancomycin dosing on in-hospital mortality and nephrotoxicity in ICU patients with MRSA bacteremia was conducted.
Methods:
This multicenter, retrospective, cohort study was conducted in a subset of ICU patients from a previous MRSA bacteremia study. Patients were ≥18 years old and received ≥48 hours of empiric vancomycin from July 1, 2002, to June 30, 2008. The incidence of nephrotoxicity and in-hospital mortality was compared in patients who received guideline-recommended dosing (at least 15 mg/kg per dose) to patients who received non-guideline-recommended dosing of vancomycin. Multivariable generalized linear mixed-effects models were constructed to determine independent risk factors for in-hospital mortality and nephrotoxicity.
Results:
Guideline-recommended dosing was received by 34% of patients (n = 137). Nephrotoxicity occurred in 35% of patients receiving guideline-recommended dosing and 39% receiving non-guideline-recommended dosing (P = 0.67). In-hospital mortality rate was 24% among patients who received guideline-recommended dosing compared with 31% for non-guideline-recommended dosing (P = 0.40). Guideline-recommended dosing was not associated with nephrotoxicity (odds ratio: 1.10; 95% confidence interval: 0.43-2.79) or in-hospital mortality (odds ratio: 0.54; 95% confidence interval: 0.22-1.36) in the multivariable analysis.
Conclusions:
Guideline-recommended dosing of vancomycin in ICU patients with MRSA bacteremia is not significantly associated with nephrotoxicity or in-hospital mortality. However, the 7% absolute difference for in-hospital mortality suggests that larger studies are needed.
Insights
Guideline-recommended vancomycin dosing for methicillin-resistant Staphylococcus aureus bacteremia in ICU patients showed no significant increase in nephrotoxicity or mortality. Further research is suggested due to a notable mortality difference.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Pharmacology
Background:
- Previous studies on vancomycin dosing for MRSA bacteremia identified increased risks in critically ill patients.
- A subanalysis focused on intensive care unit (ICU) patients to assess outcomes of guideline-recommended vancomycin dosing.
Purpose of the Study:
- To evaluate the impact of guideline-recommended vancomycin dosing on in-hospital mortality and nephrotoxicity in ICU patients with MRSA bacteremia.
- To identify independent risk factors for mortality and nephrotoxicity in this patient population.
Main Methods:
- A multicenter, retrospective cohort study of ICU patients receiving vancomycin for MRSA bacteremia.
- Comparison of nephrotoxicity and in-hospital mortality rates between patients receiving guideline-recommended (≥15 mg/kg per dose) versus non-guideline-recommended vancomycin dosing.
- Multivariable generalized linear mixed-effects models were used for risk factor analysis.
Main Results:
- 34% of patients received guideline-recommended vancomycin dosing.
- Nephrotoxicity rates were similar: 35% with guideline dosing vs. 39% without (P=0.67).
- In-hospital mortality was 24% with guideline dosing vs. 31% without (P=0.40); multivariable analysis found no significant association with guideline dosing for either outcome.
Conclusions:
- Guideline-recommended vancomycin dosing in ICU patients with MRSA bacteremia was not significantly associated with increased nephrotoxicity or in-hospital mortality.
- A 7% absolute difference in in-hospital mortality warrants further investigation in larger studies.
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