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Published on: August 30, 2018
Impact of an Antibiotic Stewardship Program on the Incidence of Vancomycin-Associated Acute Kidney Injury in
Insights
Adding prospective audit and feedback did not reduce vancomycin-associated acute kidney injury (AKI) in children. Focus on minimizing other nephrotoxins, as they independently increase AKI risk.
Area of Science:
- Pediatric Nephrology
- Clinical Pharmacy
- Antimicrobial Stewardship
Background:
- Vancomycin is a critical antibiotic for pediatric infections.
- High vancomycin trough levels are associated with increased risk of acute kidney injury (AKI).
- Existing stewardship programs include preauthorization and therapeutic drug monitoring (TDM).
Purpose of the Study:
- To evaluate if prospective audit and feedback further reduces vancomycin-associated AKI in children.
- To identify additional risk factors for vancomycin-associated AKI.
Main Methods:
- A quasiexperimental study compared AKI incidence before and after implementing prospective audit and feedback.
- The study included children receiving vancomycin for at least 48 hours.
- Multivariable analysis identified independent predictors of AKI.
Main Results:
- The incidence of vancomycin-associated AKI was similar between the preintervention (8%) and intervention (9%) periods.
- Concurrent nephrotoxin exposure was an independent predictor of AKI (aOR, 1.40).
- Piperacillin/tazobactam, liposomal amphotericin B, and ibuprofen increased AKI risk.
Conclusions:
- Prospective audit and feedback did not significantly reduce vancomycin-associated AKI when added to existing preauthorization and TDM programs.
- Stewardship efforts may be better directed towards minimizing concurrent nephrotoxin exposure.
- Reducing exposure to nephrotoxic agents is crucial for preventing vancomycin-associated AKI.
Objective:
Vancomycin causes considerable acute kidney injury (AKI) in children, particularly in the setting of troughs of 15 to 20 mg/L. We sought to determine whether the addition of prospective audit and feedback to a preauthorization and therapeutic drug monitoring (TDM) program further reduces the incidence of AKI.
Methods:
We conducted a quasiexperimental study of children admitted to The Johns Hopkins Hospital receiving vancomycin for ≥48 hours. The incidence of AKI was compared between the preintervention and intervention periods. Additional risk factors for vancomycin-associated AKI were also explored.
Results:
A total of 386 courses of vancomycin therapy met eligibility criteria (200 in the preintervention vs 186 in the intervention period). The incidence of vancomycin-associated AKI did not differ between the preintervention and intervention periods, 8% vs 9%, respectively. On multivariable analysis, the number of concurrent nephrotoxins was found to be an independent predictor of vancomycin-associated AKI, with each additional nephrotoxin increasing the risk of AKI by 40% (adjusted OR, 1.40; 95% CI, 1.06-1.85; p = 0.019). Specific nephrotoxins that increased the risk of vancomycin-associated AKI included piperacillin/tazobactam, liposomal amphotericin B, and ibuprofen.
Conclusion:
The addition of prospective audit and feedback to a preauthorization and TDM program did not result in further AKI reduction. Prospective audit and feedback is a resource-intensive intervention. If preauthorization restrictions and TDM are already in place, our findings suggest stewardship efforts may be more effective if redirected to focus on other modifiable risk factors for vancomycin-associated AKI, such as minimizing additional nephrotoxins.
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