Research from a recent study indicates that the antibiotic vancomycin is associated with a significantly higher risk of acute kidney injury (AKI) compared to alternative antibiotics like clindamycin and linezolid. Conducted by a team led by Izak Yasrebi-de Kom, PhD, at the Amsterdam University Medical Center, this study underscores the need for strict adherence to established prevention strategies in intensive care units (ICUs).
The investigation assessed the impact of initiating vancomycin versus various minimally nephrotoxic alternatives on the 14-day risk of AKI among adult ICU admissions. The findings revealed a pronounced risk linked to vancomycin, prompting the researchers to recommend measures such as adjusting vancomycin dosing according to renal function, implementing therapeutic drug monitoring, and considering non-nephrotoxic alternatives when appropriate.
“AKI is a frequent syndrome in ICU patients and is often caused by drugs,” the authors noted in their study. “Optimizing pharmacotherapy may reduce the risk of drug-induced AKI and associated negative outcomes.”
Vancomycin, a tricyclic glycopeptide antibiotic commonly used to treat severe gram-positive bacterial infections, has been previously associated with several side effects, including nephrotoxicity and hypotension. However, the evidence regarding its potential to cause AKI in adult ICU patients has been inconsistent.
To clarify this issue, the research team conducted a target trial emulation study using data collected from 15 Dutch ICUs between January 2010 and December 2019. They focused on adult, non-dialysis dependent patients who were AKI-free upon ICU admission and had a suspected bacterial infection treatable with either vancomycin or one of six alternative antibiotics: clindamycin, linezolid, teicoplanin, meropenem, cefazolin, or daptomycin.
Eligible patients were those admitted to ICUs for at least 24 hours but not more than 7 days prior to treatment assignment. A baseline serum creatinine measurement within the first 24 hours of admission was also necessary for inclusion in the study.
The follow-up periods varied based on treatment assignment, concluding upon AKI diagnosis, loss to follow-up, initiation of a different treatment strategy, initiation of kidney replacement therapy (KRT) without preceding AKI, death, or 14 days after treatment assignment—whichever occurred first. The outcome of interest was AKI, defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 criteria.
Among the 176,489 ICU admissions evaluated, 30,510 patients initiated one of the treatment strategies, with 1,809 meeting all eligibility criteria. Of these, 887 began treatment with vancomycin, while 922 initiated an alternative antibiotic.
After adjusting for relevant factors, the study found that initiating vancomycin was linked to a higher risk of AKI at the 14-day follow-up compared to the alternatives. The risk difference was noted as 0.11 (95% CI, 0.04 to 0.19), while no significant difference was observed at the 2-day follow-up.
Further analysis revealed that both higher and lower doses of vancomycin were associated with an increased risk of AKI at the 14-day mark compared to the initiation of alternative antibiotics. Notably, the higher dose of vancomycin presented a greater risk difference point estimate of 0.17 (95% CI, 0.05 to 0.25).
The researchers concluded that their findings indicate a higher risk of AKI associated with vancomycin compared to the alternative antibiotics studied. They emphasized the importance of clinicians adhering to vancomycin-induced AKI prevention strategies and called for future research to explore dose-response relationships.
The study has been published in the journal PDS, highlighting the critical need for continued investigation into the safety profiles of antibiotics used in ICU settings.
