Augmented Renal Clearance in a Case of Sepsis Leading to Vancomycin Failure Despite Increasing Dose As per the Estimated Glomerular Filtration Rate

Abstract

Augmented renal clearance (ARC) is a unique clinical scenario observed in critically ill patients. We present a case of a 30-year-old male with sepsis secondary to methicillin-resistant Staphylococcus aureus (MRSA) bacteremia treated with vancomycin. ARC was observed in the patient with a maximum estimated glomerular filtration rate (eGFR) of 161.9 ml/min/1.73 m 2 , and therapeutic drug monitoring was used to adjust the vancomycin dosage. Despite the maximal recommended dose of vancomycin, the therapeutic vancomycin level was not achieved, leading to treatment failure and subsequent mortality. Our case report suggests the necessity of other strategies, such as early dose adjustment of vancomycin based on vancomycin clearance and continuous vancomycin infusion, not merely conventional adjustment based on eGFR and vancomycin levels.

Sudden Vasopressin Withdrawal Causing Transient Central Diabetes Insipidus: A Case Report

“…Nevertheless, it is important to be aware of these manifestations as fluctuations in serum sodium are associated with morbidity, including neurological dysfunction and atrial fibrillation [ 16 ]. Furthermore, increased urine output may affect the estimation of GFR and may result in suboptimal antimicrobial dosing [ 17 ].…”

Augmented Renal Clearance: An Under-Recognized Phenomenon Associated With COVID-19

“…With respect to the clinical implication of ARC, no study reported an impact on clinical outcomes. Four of the studies in septic patients reported an increase in renally eliminated drugs and commented on the need for increased drug dosing to achieve appropriate pharmacokinetic/pharmacodynamic; however, antibiotics is the only drug class studied to date ( 30 , 31 , 35 ).…”

“…First is the pronounced variation in onset of ARC. Patients with COVID-19 are reported to have a much-delayed onset of ARC compared with those without (13–28 d vs 1–3 d, respectively) ( 15 – 17 , 21 , 26 , 27 , 29 , 31 , 33 , 35 ). The duration of ARC has been less extensively studied; however, Murt et al ( 17 ) suggested ARC lasts 5 days in the COVID patients they studied, while the non-COVID-19 ARC population varies from 1 day to 3 weeks ( 15 – 17 , 21 , 22 , 26 , 27 , 29 , 31 , 33 , 35 ).…”

“…Most studies reported using measured urinary CrCl as a means to quantify renal function with collection times ranging from 4 to 24 hours; however, 24-hour collection was used in seven of the 16 studies. Prevalance of ARC among the included studies ranged from 24.9% to 67.4% (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35). Eight of the studies provided insight into the ARC onset and time course (Supplemental Table, http://links.lww.com/CCX/A898).…”

“…Regarding patients without COVID-19 exhibiting ARC, we searched for original research articles on November 29, 2021, that described ARC in a mixed ICU population and/or in patients with sepsis. A total of 16 articles were identified and included in the Supplemental Table (http://links.lww.com/CCX/A898) (20–35). The general consensus definition of ARC among these reviews is a CrCl greater than or greater than or equal to 130 mL/min/1.73 m 2 (20, 22–25, 28, 29, 31, 33–35); however, the two studies in pediatric patients used different definitions including CrCl or greater than or equal to 160 mL/min/1.73 m 2 (21) and measured CrCl exceeding age-adjusted reference values plus two sd s (26).…”