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Factors associated with vancomycin nephrotoxicity in the critically ill
T P Hanrahan1, C Kotapati2, M J Roberts3
1Co-First Author, Resident Medical Officer, Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital and Burns Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland.
Abstract:
Vancomycin is a glycopeptide antibiotic commonly used in the management of methicillin-resistant Staphylococcus aureus infection. The recent increase in prevalence of methicillin-resistant Staphylococcus aureus with reduced susceptibility to vancomycin has prompted experts to advocate for higher target trough serum concentrations. This study aimed to evaluate the potential consequences of more aggressive vancomycin therapy, by examining the association between higher serum concentrations and acute kidney injury (AKI) in a population of critically ill patients. We collected data for all patients who received vancomycin over a five-year period and evaluated the prevalence of new-onset AKI using the Risk, Injury, Failure, Loss and End-stage (RIFLE) kidney disease criteria. One-hundred and fifty-nine patients provided complete data, with 8.8% manifesting new onset AKI while receiving vancomycin. The median age was 57 (44 to 68) years, while the median trough serum concentration was 16 (10 to 19) mg/l. Multivariate logistic regression analysis identified mean trough concentration (OR=1.174, P=0.024), APACHE II score (OR=1.141, P=0.012) and simultaneous aminoglycoside prescription (OR=18.896, P=0.002) as significant predictors of AKI. These data suggest higher trough vancomycin serum concentrations are associated with greater odds of AKI in the critically ill.
Insights
Higher vancomycin levels in critically ill patients correlate with increased risk of acute kidney injury (AKI). This finding is crucial for optimizing antibiotic dosing to balance efficacy and safety in severe infections.
Area of Science:
- Pharmacology
- Nephrology
- Critical Care Medicine
Background:
- Vancomycin is a key antibiotic for methicillin-resistant Staphylococcus aureus (MRSA).
- Increasing MRSA vancomycin resistance necessitates higher drug concentrations.
- Potential for vancomycin nephrotoxicity requires careful evaluation.
Purpose of the Study:
- To investigate the association between elevated vancomycin serum concentrations and acute kidney injury (AKI).
- To assess the safety of more aggressive vancomycin dosing strategies in critically ill patients.
Main Methods:
- Retrospective analysis of vancomycin use over five years.
- Evaluation of new-onset AKI using Risk, Injury, Failure, Loss and End-stage (RIFLE) criteria.
- Multivariate logistic regression to identify AKI predictors.
Main Results:
- 8.8% of patients developed new-onset AKI.
- Significant predictors of AKI included mean trough vancomycin concentration (OR=1.174, P=0.024), APACHE II score (OR=1.141, P=0.012), and concurrent aminoglycoside use (OR=18.896, P=0.002).
- Median vancomycin trough concentration was 16 mg/l.
Conclusions:
- Higher vancomycin trough serum concentrations are linked to increased odds of AKI in critically ill patients.
- Clinical decisions on vancomycin dosing must consider the risk of nephrotoxicity.
- Further research may inform optimized dosing protocols for vancomycin therapy.
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