Nefrotoxicidad en pacientes ingresados a la UCI con monitorización de niveles de vancomicina

[Nephrotoxicity in patients admitted to ICU with monitorization of levels of vancomycin]

Autores/as

  • Jhoel Amores Hospital Santo Tomás, Panamá

Palabras clave:

nefrotoxicidad, niveles, vancomicina

Keywords:

nephrotoxicity, levrels, vancomycin,

Resumen

En el 2009 un grupo de tareas encabezado por la Sociedad Americana de Enfermedades Infecciosas (IDSA) recomendó niveles de vancomicina entre 15-20 mg/L para asegurar efectividad ante el aumento de las concentraciones mínimas inhibitorias del Staphylococcus aureus resistente a Meticilina (MRSA). No existe evidencia concluyente sobre el impacto de estos nuevos niveles terapéuticos en el riesgo de nefrotoxicidad. Objetivo: determinar si existe una asociación entre los niveles plasmáticos valle de vancomicina y el desarrollo de nefrotoxicidad, independientemente de la presencia o no de otros factores de riesgo para lesión renal. Metodología: se realizó un estudio de cohorte retrospectivo. Se estudiaron pacientes ingresados a UCI del Hospital Santo Tomás, entre el 01 de enero del 2018 y el 31 de diciembre del 2018, que fueron tratados con vancomicina. Se realizó análisis bivariado y multivariante. Resultados: 54 pacientes entraron al análisis; se inició la monitorización de niveles plasmáticos principalmente después de la cuarta dosis (77.78%); 13 pacientes (24.07%) desarrollaron nefrotoxicidad por vancomicina; en el análisis bivariado la única variable con una relación estadísticamente significativa con nefrotoxicidad fue tener niveles valle >15 mg/L (P=0.003). El análisis de regresión logística multivariante mostró que los niveles valle >15 mg/L tienen una asociación estadísticamente significativa con nefrotoxicidad (OR, 15.20 [95% IC, 1.48-156.11]; P=0.022), la cual es independiente de otros confusores. Conclusiones: Los niveles valle de vancomicina >15 mg/L se asociaron de forma independiente a nefrotoxicidad por vancomicina. Se deben realizar estudios prospectivos para definir la asociación de niveles valle de vancomicina con el desarrollo de nefrotoxicidad.


Abstract

In 2009 a task force led by the Infectious Diseases Society of America (IDSA) recommended vancomycin levels between 15-20 mg/L to ensure effectiveness in the face of increasing minimum inhibitory concentrations of methicillin-resistant Staphylococcus aureus (MRSA). There is no conclusive evidence on the impact of these new therapeutic levels on the risk of nephrotoxicity. Objective: to determine whether there is an association between vancomycin trough plasma levels and the development of nephrotoxicity, independently of the presence or absence of other risk factors for renal injury. Methodology: a retrospective cohort study was carried out. Patients admitted to the ICU of Hospital Santo Tomás, between January 01, 2018 and December 31, 2018, who were treated with vancomycin were studied. Bivariate and multivariate analysis was performed. Results: 54 patients entered the analysis; monitoring of plasma levels was initiated mainly after the fourth dose (77.78%); 13 patients (24.07%) developed vancomycin nephrotoxicity; in the bivariate analysis the only variable with a statistically significant relationship with nephrotoxicity was having trough levels >15 mg/L (P=0.003). Multivariate logistic regression analysis showed that trough levels >15 mg/L have a statistically significant association with nephrotoxicity (OR, 15.20 [95% CI, 1.48-156.11]; P=0.022), which is independent of other confounders. Conclusions: Vancomycin trough levels >15 mg/L were independently associated with vancomycin nephrotoxicity. Prospective studies should be performed to define the association of vancomycin trough levels with the development of nephrotoxicity.

Citas

Selby AR, Hall RG. Utilizing the Patient Care Process to Minimize the Risk of Vancomycin-Associated Nephrotoxicity. J Clin Med. 2019 Jun; 8(6): 781.

Rybak M, Lomaestro B, Rotschafer J, Moellering Jr. R, Craig W, Billeter M, Dalovisio JR, Levine DP. Therapeutic monitoring of vancomycin in adult patients: A consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health-Syst Pharm. 2009; 66:82-98.

Hirai T, Hanada K, Kanno A, Akashi M, Itoh T. Risk Factors for vancomycin nephrotoxicity and time course of renal function during vancomycin treatment. Eur J Clin Pharmacol. 2019 Jun;75(6):859-866.

Van Hal SJ; Paterson DL; Lodise TP. Systematic Review and Meta-Analysis of Vancomycin-Induced Nephrotoxicity Associated with Dosing Schedules That Maintain Troughs between 15 and 20 Milligrams per Liter. Antimicrob Agents Chemother. 2013 Feb; 57(2): 734–744.

Rutter WC, Burgess DR, Talbert JC, Burgess DS. Acute kidney injury in patients treated with vancomycin and piperacillin-tazobactam: A retrospective cohort analysis. J Hosp Med. 2017 Feb;12(2):77-82

Hazlewood KA, Brouse SD, Pitcher WD, Hall RG. Vancomycin-associated nephrotoxicity: Grave concern or death by character assassination?. Am J Med. 2010 Feb; 123(2): 182.e1.

Davies SW, Guidry CA, Petroze RT, Hranjec T, Sawyer RG. Vancomycin and nephrotoxicity; just another myth? J Trauma Acute Care Surg. 2013 Nov; 75(5):830-5.

Kovacevic T, Miljkovic B, Mikov M, Stojisavljevic Satara S, Dragic S, Momcicevic D, Kovacevic P. The effect of Hypoalbuminemia on the Therapeutic Concentration and dosage of Vancomycin in Critically Ill Septic Patients in Low-Resource Countries. Dose Response. 2019 May 20; 17(2).

Mañes Sevilla M, Labrador Andújar N, Arias Moya MA, Prats Oliván P, Guitérrez Ortega C, Montenegro Álvarez de Tejera P. Incidencia de nefrotoxicidad en pacientes monitorizados en tratamiento con vancomicina. Rev. O.F.I.L. 2015, 25;4:209-215.

Bosso JA, Nappi J, Rudisill C, Wellein M, Bookstaver PB, Swindler J, Mauldin PD. Relationship between Vancomycin Trough Concentrations and Nephrotoxicity: a Prospective Multicenter Trial. Antimicrob Agents Chemother. 2011 Dec; 55(12):5475-9.

Cano EL, Haque NZ, Welch VL, Cely CM, Peyrani P, Scerpella EG, Ford KD, Zervos MJ, Ramírez JA, Kett DH. Incidence of Nephrotoxicity and Association With Vancomycin Use in Intensive Care Unit Patients With Pneumonia: Retrospective Analysis of the IMPACT-HAP Database. Clinical Therapeutics/Volume 34, Number 1, 2012; 34(1), 149–157.

Da Fonseca Pestana Ribeiro JM, Park M. Less empiric broad-spectrum antibiotics is more in the ICU. Intensive Care Medicine volume 46, pages783–786(2020).

Obara VY, Petrus Zacas C, Dantas de Maio Carriho CM, Alvares Delfino VD. Currently used dosage regimens of vancomycin fail to achieve therapeutic levels in approximately 40% of intensive care unit patients. Rev Bras Ter Intensiva. 2016 Oct-Dec; 28(4): 380–386.

DOI:

10.37980/im.journal.rmdp.20211774

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Publicado

2021-06-15

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