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Reducing acute kidney injury due to vancomycin in trauma patients
Ara Ko1, Megan Y Harada, Galinos Barmparas
1From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
Background:
Supratherapeutic vancomycin trough levels are common after trauma and associated with both increased acute kidney injury (AKI) and mortality. We sought to limit the adverse effects of vancomycin in trauma patients through more frequent trough monitoring.
Methods:
Beginning in January 2011, trauma patients treated with vancomycin had trough levels (VT) monitored daily until steady state was reached. Trauma patients admitted from January 2011 to May 2015 (POST) were compared with those admitted from January 2006 to December 2010 (PRE). Inclusion criteria required administration of intravenous vancomycin, admission serum creatinine (SCr), and SCr within 72 hours of highest VT. Acute kidney injury was defined as an increase in SCr of at least 0.3 mg/dL or 50% from admission to post-vancomycin administration. Those in the POST group were prospectively followed up until discharge or death.
Results:
Two hundred sixty-three patients met inclusion criteria in the PRE-phase and 115 in the POST-phase. The two groups were similar in age, gender, race, body mass index, pre-existing comorbidities, admission systolic blood pressure, Glasgow Coma Scale, and head Abbreviated Injury Scale. Injury Severity Score was higher in the POST cohort (18 PRE vs. 25 POST, p < 0.001). Compared with PRE, the POST cohort had lower rates of supratherapeutic VT (>20 mg/L) (34.6% PRE vs. 22.6% POST, p = 0.02) and AKI (30.4% PRE vs. 19.1% POST, p = 0.026). After adjusting for confounders, the POST group had a significantly lower risk of AKI with an adjusted odds ratio of 0.457 (p = 0.027). There was a trend toward decreased mortality in the POST cohort, but this did not reach significance (10% PRE vs. 5.2% POST, p = 0.162).
Conclusions:
A reduction in AKI was observed in trauma patients with daily vancomycin trough levels monitored until steady state. Increased awareness regarding closer surveillance of VT in trauma patients may limit the incidence of vancomycin-related nephrotoxicity.
Level Of Evidence:
Therapeutic study, level IV.
Insights
Frequent vancomycin trough monitoring in trauma patients reduced acute kidney injury (AKI) rates. This closer surveillance of vancomycin levels can help prevent nephrotoxicity and improve patient outcomes.
Area of Science:
- Trauma Care
- Pharmacology
- Nephrology
Background:
- Supratherapeutic vancomycin trough levels are common in trauma patients.
- These high levels are linked to increased acute kidney injury (AKI) and mortality.
- Frequent monitoring aims to mitigate these adverse effects.
Purpose of the Study:
- To evaluate the impact of daily vancomycin trough level monitoring on AKI rates in trauma patients.
- To assess if intensified monitoring reduces vancomycin-associated nephrotoxicity.
Main Methods:
- A comparative study of trauma patients before (PRE) and after (POST) implementing daily vancomycin trough level monitoring.
- AKI defined by serum creatinine increase (≥0.3 mg/dL or 50%).
- Patients monitored until vancomycin trough levels reached a steady state.
Main Results:
- The POST cohort (daily monitoring) showed lower rates of supratherapeutic vancomycin trough levels (22.6% vs. 34.6%).
- AKI incidence was significantly reduced in the POST cohort (19.1% vs. 30.4%, p=0.026).
- Adjusted analysis confirmed a lower risk of AKI in the POST group (OR=0.457, p=0.027).
Conclusions:
- Daily vancomycin trough level monitoring in trauma patients is associated with a reduction in AKI.
- Increased vigilance in monitoring vancomycin levels can decrease nephrotoxicity.
- This strategy may improve outcomes for trauma patients receiving vancomycin.
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