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Attributable nephrotoxicity of vancomycin in critically ill patients: a marginal structural model study

Frederico Carlos de Sousa Arnaud1, Alexandre Braga Libório1

  • 1Medical Sciences Postgraduate Program, Universidade de Fortaleza - UNIFOR, Fortaleza, Ceara, Brazil.

The Journal of Antimicrobial Chemotherapy
|January 7, 2020
PubMed
Abstract

Insights

Vancomycin-associated acute kidney injury (AKI) risk in critically ill patients is lower than previously thought. Severe AKI is linked to vancomycin only when serum levels exceed 20 mg/L.

Area of Science:

  • Critical care medicine
  • Nephrology
  • Pharmacology

Background:

  • Determining vancomycin's specific contribution to acute kidney injury (AKI) in critically ill patients is challenging due to multiple potential causes.
  • Existing data may overestimate vancomycin-induced nephrotoxicity in this vulnerable population.

Purpose of the Study:

  • To quantify the risk of AKI attributable to vancomycin in critically ill patients.
  • To identify specific vancomycin exposure parameters associated with AKI and severe AKI.

Main Methods:

  • Utilized a large public database to extract time-fixed and time-varying variables for 26,865 patients.
  • Analyzed vancomycin exposure, serum trough levels (>15 and >20 mg/L), and combination therapy with piperacillin/tazobactam.
  • Employed inverse probability of treatment weighting and marginal structural models to assess AKI, severe AKI, and renal replacement therapy (RRT) need.

Main Results:

  • Vancomycin exposure was associated with an increased risk of AKI (HR=1.24) but not severe AKI or RRT.
  • Vancomycin trough levels >20 mg/L significantly increased the risk of AKI (HR=1.90) and severe AKI (HR=1.69).
  • Concomitant vancomycin and piperacillin/tazobactam did not elevate AKI risk compared to vancomycin alone.

Conclusions:

  • The attributable nephrotoxicity of vancomycin in critically ill patients is lower than previously suggested.
  • Severe AKI is primarily associated with vancomycin when serum trough levels consistently exceed 20 mg/L.
  • Current guidelines for vancomycin dosing and monitoring in critically ill patients may need refinement.

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