Aminoglycoside impregnated cement spacer precipitating acute kidney injury requiring hemodialysis

Abstract

The current standard of care for prosthetic joint infection includes two-stage arthroplasty, with antibiotic-impregnated cement spacers (ACS) utilized between the stages. We report a 75-year-old woman with previously normal renal function, who developed acute kidney injury (AKI) secondary to biopsy-proven acute tubular necrosis and acute interstitial nephritis after ACS placement containing tobramycin and vancomycin. Peak tobramycin level measured 25.3 mcg/mL, the highest value reported in the literature after ACS placement. Intermittent hemodialysis was initiated with subsequent full recovery of renal function. This paper reviews the published literature regarding the accumulation, toxicity and removal dynamics of aminoglycoside (AG) antibiotics and vancomycin in renal patients. Obtaining serum AG level should be strongly considered in patients experiencing AKI after ACS.Renal replacement therapy may assist in reducing toxic AG levels.

Acute Renal Failure due to a Tobramycin and Vancomycin Spacer in Revision Two-Staged Knee Arthroplasty

“…Antibiotic spacers used to treat PJI have their own host of side effects. In our case, both vancomycin and tobramycin have known nephrotoxicity, which most likely contributed to our patient's ARF (Naranjo Score=6) [ 12 – 14 ]. Antibiotic choice within the spacer is a crucial step to successful treatment of PJI.…”

“…Doses of tobramycin >4.8 g increased odds of AKI in patients by 5.87 (95% CI, 1.43-24.19; P = .01) and may be dosage dependent, with every 1 g increase of antibiotic increasing the odds of AKI by 1.24 (95% CI, 1.00-1.52; P = .049) [ 6 ]. General guidelines suggest low dose spacers contain <2.0 g of antibiotic per 40 g of cement, and high dose spacers contain >3.6 g of antibiotic per 40 g of cement [ 14 ]. There is data to suggest a lower dose spacer increases the risk of reinfection, with Geller et al suggesting the odds of failure are higher (OR, 0.82; 95% CI, 0.70- 0.96; P = .01) with low dose antibiotics at 1 year and 2 years (OR, 0.83; 95% CI, 0.71-0.96; P = .01) [ 8 ].…”

“…Patients experiencing severe AKI may progress to acute tubular necrosis (ATN) and acute renal failure [ 5 , 6 ]. Our patient may have experienced ATN and progressed to ARF due to direct nephrotoxicity of tobramycin and vancomycin as they reached nephrotoxic levels within the serum [ 5 , 6 , 10 , 14 , 22 ]. Treatment for ARF includes determining the etiology and treating or removing inciting factors, optimizing fluids and electrolytes and occasionally hemodialysis [ 5 , 6 ].…”

Acute Tubular Necrosis Associated With High Serum Vancomycin and Tobramycin Levels After Revision of Total Knee Arthroplasty With Antibiotic-Containing Calcium Sulfate Beads

“…The interplay of elevated systemic vancomycin levels on aminoglycoside toxicity is also unclear. It has been noted that vancomycin administration may worsen aminoglycoside toxicity by facilitating the adhesion of the brush border membrane of the proximal tubules to aminoglycosides or by addictive effects at similar places in the tubules [11–13].…”

Antibiotic Choice: The Synergistic Effect of Single vs Dual Antibiotics

“…However, several concerns have been raised regarding antibiotic utilization in ALCs. The levels of antibiotics necessary to achieve therapeutic concentrations can be quite high, and renal injury could occur with sustained exposure in the weeks subsequent to ALC implantation, in addition to the risk of antibiotic resistance [12,13].…”