Acute Kidney Injury During Vancomycin Therapy in Critically Ill Children

Totapally, Balagangadhar; Machado, Jacqueline; Lee, Helen; Paredes, Ana; Raszynski, André

doi:10.1002/phar.1259

Cited by 54 publications

(90 citation statements)

References 37 publications

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“…1 Estimates of the incidence of AKI associated with vancomycin in pediatrics range from 5% to 27.2%. [4][5][6][7][8][9] However, evidence is conflicting regarding the relationship between PICU admission, vancomycin use, and AKI. McKamy et al 4 studied children on vancomycin in all hospital wards (n = 167) and defined AKI as a 50% baseline increase in serum creatinine (SCr) or an increase of 0.5 mg/dL.…”

Section: Pediatric Acute Kidney Injury and Vancomycinmentioning

confidence: 99%

Frequency of and Risk Factors for Acute Kidney Injury Associated With Vancomycin Use in the Pediatric Intensive Care Unit

Bonazza

Bresee

Kraft

et al. 2016

The Journal of Pediatric Pharmacology and Therapeutics

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BACKGROUND:Published information evaluating frequency of and risk factors for vancomycin-induced acute kidney injury (AKI) in the pediatric intensive care unit (PICU) population is conflicting. OBJECTIVES: The primary objective was to describe the proportion of our PICU patients who developed AKI with intravenous (IV) vancomycin. The secondary objective was to describe the associated potential risk factors. METHODS: Pediatric patients (0-18 years) who received their first IV vancomycin dose in the PICU were evaluated in this retrospective chart review. AKI was defined based on Pediatric-Modified RIFLE (pRIFLE) criteria. Patient demographics, vancomycin trough concentrations, concomitant nephrotoxins, and estimated creatinine clearance changes were analyzed. RESULTS: Of 265 patients included, the primary outcome of AKI (defined by meeting any pRIFLE criteria) occurred in 62 (23.4%) patients (48 category R, 11 category I, 3 category F). Patients who received vancomycin treatment for ≥ 5 days were more likely to develop AKI (unadjusted odds ratio [uOR]: 2.52; 95% confidence interval [CI]: 1.11-5.73), as were patients with a maximum vancomycin trough level ≥ 20 mg/L (OR: 2.99; 95% CI: 1.54-5.78) and patients on 1 (uOR: 2.29; 95% CI: 1.12-4.66) or more concurrent nephrotoxin (uOR: 3.11; 95% CI: 1.43-6.77). Among nephrotoxins, patients receiving furosemide concomitantly with vancomycin were more likely to develop AKI (uOR: 3.47; 95% CI: 1.92-6.27). After adjustment, only furosemide was a significant predictor of risk of AKI/AKI (adjusted OR: 3.52; 95% CI: 1.88-6.62). The study was limited by its retrospective and observational design, and confounding variables. CONCLUSIONS: Patients who were receiving vancomycin with concurrent furosemide were at highest risk of developing AKI.INDEX TERMS: acute kidney injury, critical illness, drug monitoring, pediatrics, vancomycin J Pediatr Pharmacol Ther 2016;21(6): [486][487][488][489][490][491][492][493]

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Section: Pediatric Acute Kidney Injury and Vancomycinmentioning

confidence: 99%

Frequency of and Risk Factors for Acute Kidney Injury Associated With Vancomycin Use in the Pediatric Intensive Care Unit

Bonazza

Bresee

Kraft

et al. 2016

The Journal of Pediatric Pharmacology and Therapeutics

View full text Add to dashboard Cite

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“…While there is much debate and perseveration regarding renal injury associated with vancomycin, our data from our previous [15] and current investigation suggests the incidence and risk is not greater than that associated with other β-lactam antimicrobials, which are commonly used in pediatric intensive care units and don't engender the same debate or concern for renal injury. As previously mentioned, there have been two investigations evaluating whether vancomycin trough levels are associated with renal injury across an entire pediatric population and three specifically evaluating varying pediatric ICU populations [14][15][16][17][18]. While ICU admission and vancomycin troughs ≥15 mcg/mL were identified as risk factors, thus far, none of the three investigations of pediatric ICU patients validate the finding of increased renal injury with vancomycin trough levels ≥15 mcg/mL [15,16,18].…”

Section: Discussionmentioning

confidence: 99%

“…The rate of renal injury in this population was estimated at 7%, which closely resembles the rate of 8.8% in the Cies [15] investigation. Further, Totapally [16] and colleagues did not observe a relationship between renal injury and the total vancomycin dose, the peak vancomycin level or the trough vancomycin level in their pediatric ICU population.…”

Section: Discussionmentioning

confidence: 99%

“…As previously mentioned, there have been two investigations evaluating whether vancomycin trough levels are associated with renal injury across an entire pediatric population and three specifically evaluating varying pediatric ICU populations [14][15][16][17][18]. While ICU admission and vancomycin troughs ≥15 mcg/mL were identified as risk factors, thus far, none of the three investigations of pediatric ICU patients validate the finding of increased renal injury with vancomycin trough levels ≥15 mcg/mL [15,16,18]. The pediatric intensive care unit is a very dynamic setting and there are many factors that could be associated with and contribute to renal injury such as vasoactive medications, contrast dye, other nephrotoxic medications, reduced cardiac output, fluid restriction, and overall reduced body perfusion in pediatric patients that are critically ill.…”

Section: Discussionmentioning

confidence: 99%

“…The current adult literature suggests an increased incidence of renal injury with increasing vancomycin trough levels, especially when other risk factors are present including: intensive care unit admission, prolonged duration of vancomycin therapy, concurrent nephrotoxic medications, increased age, and obesity [6,[11][12][13]. There is some level of disagreement in the pediatric literature evaluating risk factors for renal injury with higher vancomycin trough concentrations as compared with the adult literature [6,[11][12][13][14][15][16][17][18].…”

Section: Introductionmentioning

confidence: 99%

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Antimicrobial Renal Injury in a Pediatric Intensive Care Unit: β-Lactams vs. Vancomycin

2014

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Vancomycin trough (Vt) concentrations of 15-20 mcg/mL have been associated with an increased rate of renal injury in adults. Current data in pediatrics suggests Vts of 15-20 mcg/mL do not increase the risk of renal injury in children admitted to a pediatric intensive care unit (PICU). The primary objective was to determine if a difference exists in the incidence of renal injury in PICU patients receiving a β-lactam as compared with vancomycin therapy with Vts of 15-20 mcg/mL. This was a retrospective cohort study conducted within a PICU within a freestanding tertiary care pediatric hospital. The records of children admitted to the PICU between 10/2008-6/2009 who received vancomycin for ≥48 h targeting higher Vt concentrations of ≥15 mcg/mL for pneumonia, bacteremia, and meningitis were reviewed. This cohort (V group) was compared to children admitted from July 2009-July 2013 who received cefepime or piperacillin/tazobactam for ≥72 h (B group). Serum creatinine values were collected from 48 h before until 48 h after discontinuation of therapy for calculation of estimated glomerular filtration rate. Renal injury was categorized according to pRIFLE. 57 and 112 patients were included in the V and B groups, respectively. OPEN ACCESSPharmacy 2014, 2 277The mean (SD) therapeutic dose of vancomycin was 63.5(17.3) mg/kg/day and the mean (SD) trough was 17.8(3.1). The mean (SD) dose of cefepime was 51(26) mg/kg/dose with an every 8 h interval. The mean (SD) dose of piperacillin/tazobactam was 77(22) mg/kg/dose with an every 6 h interval. The mean (SD) PRISM scores were 10.9(10.2), 4.24(6.4) for the V and B groups, respectively (p < 0.001). Five of 57 and 10 of 112 patients in the V and B groups, respectively, were classified as having injury according to pRIFLE. No patient was classified as having a degree of renal injury greater than the pRIFLE injury. The incidence of renal injury was 8.8% in the V group and 8.9% in the B group, respectively (p = 1). Our observations suggest that maintaining Vt concentrations ≥15 mcg/mL is not associated with an increased rate of renal injury as compared with β-lactam monotherapy in a PICU population.

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Association of Acute Kidney Injury With Concomitant Vancomycin and Piperacillin/Tazobactam Treatment Among Hospitalized Children

et al. 2017

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IMPORTANCE β-Lactam antibiotics are often coadministered with intravenous (IV) vancomycin hydrochloride for children with suspected serious infections. For adults, the combination of IV vancomycin plus piperacillin sodium/tazobactam sodium is associated with a higher risk of acute kidney injury (AKI) compared with vancomycin plus 1 other β-lactam antibiotic. However, few studies have evaluated the safety of this combination for children. OBJECTIVE To assess the risk of AKI in children during concomitant therapy with vancomycin and 1 antipseudomonal β-lactam antibiotic throughout the first week of hospitalization. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study focused on children hospitalized for 3 or more days who received IV vancomycin plus 1 other antipseudomonal β-lactam combination therapy at 1 of 6 large children's hospitals from January 1, 2007, through December 31, 2012. The study used the Pediatric Health Information System Plus database, which contains administrative and laboratory data from 6 pediatric hospitals in the United States. Patients with underlying kidney disease or abnormal serum creatinine levels on hospital days 0 to 2 were among those excluded. Patients 6 months to 18 years of age who were admitted through the emergency department of the hospital were included. Data were collected from July 2015 to March 2016. Data analysis took place from April 2016 through July 2017. (Exact dates are not available because the data collection and analysis processes were iterative.) MAIN OUTCOMES AND MEASURESThe primary outcome was AKI on hospital days 3 to 7 and within 2 days of receiving combination therapy. Acute kidney injury was defined using KDIGO criteria and was based on changes in serum creatinine level from hospital days 0 to 2 through hospital days 3 to 7. Multiple logistic regression was performed using a discrete-time failure model to test the association between AKI and receipt of IV vancomycin plus piperacillin/tazobactam or vancomycin plus 1 other antipseudomonal β-lactam antibiotic.RESULTS A total of 1915 hospitalized children who received combination therapy were identified. Of the 1915 patients, a total of 866 (45.2%) were female and 1049 (54.8%) were male, 1049 (54.8%) were identified as white in race/ethnicity, and the median (interquartile range) age was 5.6 (2.1-12.7) years. Among the cohort who received IV vancomycin plus 1 other antipseudomonal β-lactam antibiotic, 157 patients (8.2%) had antibiotic-associated AKI. This number included 117 of 1009 patients (11.7%) who received IV vancomycin plus piperacillin/tazobactam combination therapy. After adjustment for age, intensive care unit level of care, receipt of nephrotoxins, and hospital, IV vancomycin plus piperacillin/ tazobactam combination therapy was associated with higher odds of AKI each hospital day compared with vancomycin plus 1 other antipseudomonal β-lactam antibiotic combination (adjusted odds ratio, 3.40; 95% CI, 2.26-5.14).CONCLUSIONS AND RELEVANCE Coadministration of IV vancomycin and piperacillin/...

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Acute Kidney Injury During Vancomycin Therapy in Critically Ill Children

Abstract: In critically ill children, the development of reversible AKI during vancomycin therapy is associated with administration of nephrotoxic drugs and an elevated BUN: Scr ratio.

Cited by 54 publications

References 37 publications

Frequency of and Risk Factors for Acute Kidney Injury Associated With Vancomycin Use in the Pediatric Intensive Care Unit

Frequency of and Risk Factors for Acute Kidney Injury Associated With Vancomycin Use in the Pediatric Intensive Care Unit

Antimicrobial Renal Injury in a Pediatric Intensive Care Unit: β-Lactams vs. Vancomycin

Association of Acute Kidney Injury With Concomitant Vancomycin and Piperacillin/Tazobactam Treatment Among Hospitalized Children

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