When Is Vancomycin Nephrotoxic in Critically Ill Patients?

Thomas Glück, MD

Parameters significantly associated with nephrotoxicity were higher median vancomycin serum trough levels, concomitant vasopressor use, longer duration of therapy, and intermittent infusion.

Vancomycin is standard treatment for multidrug-resistant gram-positive pathogens, including methicillin-resistant Staphylococcus aureus. However, despite dosing adjusted according to renal function and vancomycin trough levels, nephrotoxicity remains a concern. The likelihood of such nephrotoxicity may increase now that current guidelines recommend higher trough serum concentrations (15–20 mg/L, rather than 5–10 mg/L) for treatment of severe infections.

To determine factors associated with vancomycin nephrotoxicity, researchers conducted a retrospective cohort study involving critically ill patients who received vancomycin therapy at one U.K. hospital between December 2004 and August 2009 (N=1430).

Multivariate analysis identified longer duration of therapy (odds ratio for each additional day, 1.04; P<0.001), simultaneous treatment with vasopressors (OR, 1.63; P<0.001), and higher median vancomycin trough concentrations in serum (OR for each 1 mg/L increase in concentration, 1.11; P<0.001) as independent predictors of nephrotoxicity. Intermittent vancomycin infusion was associated with a greater risk for nephrotoxicity than continuous infusion (OR, 8.20; P<0.001), even though patients on continuous infusion received higher daily doses.

Citation(s):

Hanrahan TP et al. Vancomycin-associated nephrotoxicity in the critically ill: A retrospective multivariate regression analysis. Crit Care Med 2014 Jul 31; [e-pub ahead of print].