Recent changes in vancomycin use in renal failure

Abstract

Vancomycin is a key tool in the treatment of serious Gram-positive infections. A progressive increase in vancomycin resistance with consequent treatment failure has been observed in staphylococci. Therefore, new dosing guidelines advocating much higher vancomycin doses have been issued. Target trough levels of 15-20 microg/ml are proposed. Whether and how these targets can be achieved in patients with chronic kidney disease or those on dialysis are still under evaluation. The higher vancomycin doses to achieve these treatment targets carry a substantial risk for nephrotoxicity. This risk is incremental with higher trough levels and longer duration of vancomycin use. Critically ill patients, patients receiving concomitant nephrotoxic agents, and patients with already compromised renal function are particularly at risk for vancomycin-induced nephrotoxicity.

Prevalence and Outcomes of Antimicrobial Treatment for Staphylococcus aureus Bacteremia in Outpatients with ESRD

“…Thus, renal failure substantially increases the half-life of vancomycin, which allows the drug to be conveniently administered three times per week with routine outpatient dialysis. [25][26][27] Among hemodialysis patients with MSSA bloodstream infection, most outpatients were initially administered vancomycin when blood specimens were collected. Unfortunately, most outpatients also remained on the drug 1 week later, a time when antibiotic susceptibilities were available.…”

Detección del gen mecA en cepas de Staphylococcus coagulasa positiva aisladas desde gatos

“…Debido a que las penicilinas semi-sintéticas poseen múltiples usos terapéuticos en gatos, como en infecciones del tracto respiratorio anterior y enfermedades cutáneas 47 , esto podría estar promoviendo una alta presión de selección para dichos antimicrobianos 48 . Por el contrario, en este estudio no se detectaron cepas resistentes a vancomicina; más aún, considerando que este glicopéptido es sólo de uso intrahospitalario en medicina humana 49 , era esperable que ninguna cepa de origen animal expresase resistencia a este fármaco. En este contexto, han aumentado los reportes de S. aureus resistentes a vancomicina en el mundo 50,51 y se está transformando en una preocupación emergente en medicina veterinaria 52 .…”

Vancomycin: The Tale of the Vanquisher and the Pyrrhic Victory

“…The impact of vancomycin exposure in general and of the higher dosing regimens in particular on residual renal function in hemodialysis or PD patients has not been systematically examined. However, the special vulnerability of patients with already compromised renal function to vancomycin-induced renal failure is well-recognized (30). Repercussions of vancomycin overdosing on residual renal function can therefore be expected, and nephrologists should intently monitor vancomycin levels in their patients.…”

“…These mixed clinical outcomes data warrant scrutiny of the guidelines for vancomycin administration presented by the ISPD. Vancomycin has a molecular weight of approximately 1500 Da (30). After intraperitoneal administration, 30% -70% of the dose will be absorbed into the systemic circulation at the end of a 4-to 6-hour dwell, regardless of whether the peritoneal membrane is inflamed (42)(43)(44)(45)(46)(47)(48)(49)(50).…”