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Monitoring vancomycin AUCs may prevent kidney injury

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February 12, 2019

Marc H. Scheetz, PharmD, MSc
Marc H. Scheetz

The risk for acute kidney injury may be reduced if vancomycin area under the curve dosing measured within the first or second 24 hours is lower than approximately 650 mg*h/L, according findings from a systematic review and meta-analysis.

Vancomycin — a “drug of choice” for infections caused by MRSA, according to the study — is known to damage the kidney, explained Marc H. Scheetz, PharmD, MSc, professor of pharmacy practice and director of the Pharmacometric Center of Excellence at Midwestern University Chicago College of Pharmacy and infectious disease pharmacist at Northwestern Medicine.

“Vancomycin therapeutic drug monitoring was previously suggested as a means to ensure efficacy and safety of therapy,” Scheetz told Infectious Disease News. “Specifically, the old vancomycin guidelines suggested monitoring trough concentrations to ensure appropriate vancomycin exposures — ie, area under the curve (AUC). Recent research suggests that vancomycin trough concentrations are imprecise for estimating AUCs, and it is anticipated that the new guidelines will recommend monitoring vancomycin AUCs. However, it is not clear at what value the vancomycin AUCs are unsafe for the patient’s kidney.”

For their review, Scheetz and colleagues included randomized, cohort and case-control studies that reported vancomycin AUCs and risk for acute kidney injury (AKI). The included studies were compiled from Medline, PubMed and Scopus and conducted from Jan. 1, 1990, to Jan. 31, 2018. The primary outcome was AKI defined as an increase of 0.5 mg/L or more in serum creatinine or a 50% increase from baseline on two or more consecutive measurements, Scheetz and colleagues explained.

They identified eight eligible observational studies that included 2,491 patients overall. Among them, five studies reported AUCs collected during the first 24-hour period (AUC0-24) and AKI, two studies reported AUCs collected during the second 24-hour period (AUC24-48) and AKI, and two studies reported AKI associated with AUC vs. trough-guided monitoring, the researchers explained.

According to study findings, for AUCs determined within the first 24 hours or 48 hours, the risk for AKI was significantly reduced when the AUC was less than approximately 650 mg*h/L (AUC0-24 OR = 0.36; 95% CI, 0.23-0.56; AUC24-48 OR = 0.45; 95% CI, 0.27-0.75). AKI was significantly lower with AUC monitoring strategy compared with trough-guided monitoring (OR = 0.68; 95% CI, 0.46-0.99), according to Scheetz and colleagues.

The findings suggest that AKI is associated with higher vancomycin exposures and that an AUC monitoring strategy could significantly lower vancomycin-associated AKI, the researchers said. They recommended further investigations among larger patient populations.

“Monitoring vancomycin AUCs for the patient may be important to prevent kidney injury,” Scheetz said. “While there is increasing kidney injury with increasing vancomycin AUCs, kidney injury appears to be consistently more prevalent when AUCs exceed approximately 650 mg*h/L. These values should be considered when tailoring patient doses/exposures for vancomycin.” – by Marley Ghizzone

Disclosures: Scheetz reports numerous ties to industry. Please see the study for all other authors’ relevant financial disclosures.

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