Acute kidney injury risk with piperacillin‐tazobactam and vancomycin combination therapy: single centre retrospective study

Abstract

Aim: To evaluate the risk of acute kidney injury (AKI) in patients who receive vancomycin (VNC) and piperacillin-tazobactam (PTZ) combination therapy. Method: A single centre, retrospective audit of adult patients treated with VNC alone and in combination with PTZ between 2014-2015. Data was extracted from digital medical records and therapeutic drug monitoring sheets completed by clinical pharmacists. Rates of AKI and duration of combination therapy were analysed by chi-square, with logistic regression analysis completed to control for nephrotoxins, intensive care unit admission, use of inotropes and pre-existing chronic kidney disease. Results: Out of 525 vancomycin courses, that met the inclusion criteria, 211 had PTZ co-prescribed during the study period. Combination therapy was significantly both associated with an increased rate of AKI compared to VNC use alone (17.5% vs 10.5%, P = 0.02). The mean duration of combination therapy was 4 days (1-17 days). Increased duration of exposure to combination therapy was also associated with a higher incidence of AKI (3.8 days vs. 5.2 days, P = 0.014). VNC-TPZ combination was identified to be an independent risk factor for AKI (OR 1.73, 95% CI 1.01-2.96, P = 0.046) after adjusting for other known risk factors for AKI, including vasopressor use and intensive care unit admission. Conclusion: Combined use of VNC-PTZ, as well as the duration of combination therapy are both associated with an increased risk of AKI compared with VNC alone. The results are similar to previous literature reports of AKI from the combination of antibiotics. Healthcare providers need to be vigilant and limit the exposure to this combination as clinically appropriate.

Risk factors for vancomycin‐associated acute kidney injury: A systematic review and meta‐analysis

“…Among these, 261 studies were excluded for the following reasons: evaluating antibiotics other than vancomycin ( n = 104), evaluating outcomes other than AKI ( n = 45), not assessing risk factors ( n = 68), not original articles ( n = 4), involving paediatric patients ( n = 8), involving nonhuman subjects ( n = 12), overlapping study population ( n = 3), not a patient‐level analysis ( n = 1), involving patients who underwent renal replacement therapy ( n = 4), and data extraction not possible or feasible ( n = 12). Finally, 53 studies were included in the meta‐analysis 6–8,10–12,21–67 . A flow diagram summarizing the study selection process is shown in Figure 1.…”

Assessing the impact of an electronic therapeutic drug monitoring record in the management of vancomycin through pharmacist intervention: a single‐centre study

“…Vancomycin requires careful dosing and therapeutic drug monitoring (TDM) for optimal therapeutic effect and to minimise toxicity 1 . Therapeutic ranges are defined using a target range of 15–20 mg/L for non‐central nervous system (non‐CNS) infections and 20–25 mg/L for CNS‐related infections 2 . While measurement of the area under the curve over minimum inhibitory concentrations (AUC/MIC) is currently being implemented in healthcare organisations as a more optimal method of TDM, 1,2 it is not widely available.…”

“…Therapeutic ranges are defined using a target range of 15–20 mg/L for non‐central nervous system (non‐CNS) infections and 20–25 mg/L for CNS‐related infections 2 . While measurement of the area under the curve over minimum inhibitory concentrations (AUC/MIC) is currently being implemented in healthcare organisations as a more optimal method of TDM, 1,2 it is not widely available. Additionally, several studies have shown poor adherence with vancomycin guidelines despite prescriber awareness of local guidelines 2 .…”

“…While measurement of the area under the curve over minimum inhibitory concentrations (AUC/MIC) is currently being implemented in healthcare organisations as a more optimal method of TDM, 1,2 it is not widely available. Additionally, several studies have shown poor adherence with vancomycin guidelines despite prescriber awareness of local guidelines 2 . Documentation of vancomycin dosing, TDM tracking, pharmacist interpretation, and recommendation were recorded on a paper‐based form at our organisation.…”

“…Documentation of vancomycin dosing, TDM tracking, pharmacist interpretation, and recommendation were recorded on a paper‐based form at our organisation. This led to important vancomycin management information such as dosing, concentration interpretation, and tracking being unavailable to other healthcare personnel 2 . In addition, the unofficial paper‐based form was not scanned into the digital health records, thus important clinical pharmacy information and work completed by clinical pharmacists was not documented in individual patients' healthcare records.…”