The influence of severe hypoalbuminemia on the half-life of vancomycin in elderly patients with methicillin-resistant Staphylococcus aureus hospital-acquired pneumonia

Abstract

BackgroundVancomycin (VCM) treatment outcomes depend on the characteristics of the patient, and it is well known that hypoalbuminemia is a risk factor for poor treatment outcomes, as reported in a previous study. However, the reason that severe hypoalbuminemia has an influence on the treatment outcome of VCM remains unknown.ObjectiveTo elucidate the association between severe hypoalbuminemia and VCM treatment outcomes, we examined pharmacokinetic/pharmacodynamic (PK/PD) parameters in elderly patients with severe hypoalbuminemia.MethodsWe conducted a retrospective observational study of 94 patients with methicillin-resistant Staphylococcus aureus (MRSA) hospital-acquired pneumonia who had been treated with VCM between January 2006 and December 2012. The 94 patients were divided into severe hypoalbuminemia and non-severe hypoalbuminemia groups. The PK/PD parameters and treatment outcomes of VCM were compared between the two groups.ResultsThe half-life of VCM in the severe hypoalbuminemia group was significantly longer than in the non-severe hypoalbuminemia group (33.2 + 5.4 vs 24.9 + 1.6; P = 0.049). Area under the concentration curve (AUC)/minimum inhibitory concentration (MIC) values of 250–450 and >450 μg × h/mL were significantly associated with 28-day mortality in the severe hypoalbuminemia group (P < 0.001), whereas AUC/MIC values of <250 μg × h/mL were not associated. We also detected a significant difference in the increased percentage of nephrotoxicity in the severe hypoalbuminemia group (6 of 23 patients [26%]) compared with the non-severe hypoalbuminemia group (6 of 71 patients [8%]; P < 0.001).ConclusionThese findings indicate that severe hypoalbuminemia influences the half-life of VCM and treatment outcomes in elderly patients (≥75 years of age). To establish a more effective and safer treatment protocol, the issue of malnutrition in elderly patients needs to be addressed and improved.

Pulmonary Fungal Diseases in Immunocompetent Hosts: A Single-Center Retrospective Analysis of 35 Subjects

“…Albumin has essential physiologic effects necessary for health such as vasodilatation, inhibition of endothelial cell apoptosis, antioxidant effects, reduced platelet aggregation, and marker of inflammation in acute phase response [42][43][44]. Hypoalbuminemia may acts via effects on antibiotics [45], malnutrition after surgery, or the underlying cause of hypoalbuminemia reduces survival.…”

Development of a teicoplanin loading regimen that rapidly achieves target serum concentrations in critically ill patients with severe infections

“…The multivariate analysis showed that serum albumin of 1.84 g/dl was a risk factor for nephrotoxicity. With VCM, the risk of nephrotoxicity is reported to increase in hypoalbuminemia patients due to elevated free serum concentrations and prolonged serum half-life [19]. Similarly, TEIC reduces PBR and increases free serum concentrations in low albumin environments, which are expected to increase the risk of nephrotoxicity.…”

Intravenous Vancomycin Dosing in the Elderly: A Focus on Clinical Issues and Practical Application

“…An analysis of risk factors for long-term (≥14 days) anti-MRSA therapy identified albumin ≤2.5 g/dL as an independent risk factor in a cohort of 71 patients [18]. A study evaluating the impact of albumin on vancomycin in patients 75 years or older with MRSA pneumonia demonstrated worse clinical outcomes for patients with severe (<2.5 g/dL) versus non-severe hypoalbuminemia [19]. Severe hypoalbuminemia was associated with increased 28-day mortality, and nephrotoxicity was associated with an increase in vancomycin half-life.…”

“…Conversely, it is important to remember that elderly patients with low albumin are at risk for longer vancomycin therapy [18]. Furthermore, elderly patients with MRSA pneumonia also have the potential to have worse clinical outcomes despite adequate vancomycin therapy, in part due to low albumin [19]. Therefore, if practicing at an institution that utilizes loading doses, consider a lower empiric maintenance dose to account for the serum accumulation over time, while still adjusting further maintenance dosing by utilizing serum concentrations or calculated AUC/MIC ratio of vancomycin [29, 68, 73].…”