AJM onlineReviewVancomycin-Associated Nephrotoxicity: Grave Concern or Death by Character Assassination?
Section snippets
Vancomycin Nephrotoxicity in Recent Prospective Studies
Numerous clinical trials of anti–methicillin-resistant S. aureus medications have used vancomycin 1 g every 12 hours as the comparator (Table).14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 Most studies did not state a target vancomycin trough concentration and allowed vancomycin dosing adjustments according to the local standard of care. Two studies evaluating nosocomial pneumonia targeted vancomycin trough concentrations of 5 to 10 μg/mL.25 These clinical trials confirm that nephrotoxicity occurs
Retrospective Studies of Vancomycin Nephrotoxicity
Greater emphasis has been placed on retrospective data because of the deficit of prospective studies evaluating nephrotoxicity with vancomycin dosages greater than 2 g per day (Table 1).12, 13 The following studies defined nephrotoxicity as an increase in serum creatinine of 0.5 mg/dL or a more than 50% increase from baseline serum creatinine. This definition is based on a retrospective study that noted increases in serum creatinine of 0.5 mg/dL or more in hospitalized patients to be associated
Discussion
Although vancomycin-associated nephrotoxicity has been studied in humans and animals, its exact mechanism remains to be elucidated. Le Moyec et al30 assessed aminoglycoside and glycopeptide renal toxicity in intensive care patients. The study concluded that toxicity from vancomycin and aminoglycosides are not confined to the proximal tubules but might involve the medullary region of the nephron. However, the authors did not specify which patients were receiving concomitant or monotherapy. A
Conclusions
Increased vancomycin trough concentrations have been recommended based on expert opinion by several Infectious Diseases Society of America-endorsed guidelines. Three published studies have suggested that there is a significant association between increased vancomycin trough concentrations and nephrotoxicity. There are currently insufficient data to identify the true incidence of nephrotoxicity associated with aggressive vancomycin dosing. Limitations of the existing data include the following:
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Funding: Dr Hall's involvement in this publication was supported by Grant Number KL2RR024983, titled, “North and Central Texas Clinical and Translational Science Initiative” (Milton Packer, MD, PI) from the National Center for Research Resources, a component of the National Institutes of Health, and National Institutes of Health Roadmap for Medical Research, and its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Research Resources or National Institutes of Health. Information on National Center for Research Resources is available at http://www.ncrr.nih.gov/. Information on Re-engineering the Clinical Research Enterprise can be obtained from http://nihroadmap.nih.gov/clinicalresearch/overview-translational.asp.
Conflict of Interest: None of the authors have any conflicts of interest associated with the work presented in this manuscript.
Authorship: All authors had access to the data and played a role in writing this manuscript.