A Multicenter Evaluation of Vancomycin-Associated Acute Kidney Injury in Hospitalized Patients with Acute Bacterial Skin and Skin Structure Infections.

Sarah C J Jorgensen,Jessica K Ortwine,Michael P Veve,Kyle P Murray,Samuel P Simon,Jerod Nagel,Abdalhamid M Lagnf,James Truong,David B Huang,Muhammad-Daniayl Shamim,Susan L Davis,Karen S Williams,Jordan R Smith,Sarah Melvin,Karrine D Brade,Sahil Bhatia,Michael J Rybak

doi:10.1007/s40121-019-00278-1

Abstract

BackgroundWe sought to determine the real-world incidence of and risk factors for vancomycin-associated acute kidney injury (V-AKI) in hospitalized adults with acute bacterial skin and skin structure infections (ABSSSI).MethodsRetrospective, observational, cohort study at ten U.S. medical centers between 2015 and 2019. Hospitalized patients treated with vancomycin (≥ 72 h) for ABSSSI and ≥ one baseline AKI risk factor were eligible. Patients with end-stage kidney disease, on renal replacement therapy or AKI at baseline, were excluded. The primary outcome was V-AKI by the vancomycin guidelines criteria.ResultsIn total, 415 patients were included. V-AKI occurred in 39 (9.4%) patients. Independent risk factors for V-AKI were: chronic alcohol abuse (aOR 4.710, 95% CI 1.929–11.499), no medical insurance (aOR 3.451, 95% CI 1.310–9.090), ICU residence (aOR 4.398, 95% CI 1.676–11.541), Gram-negative coverage (aOR 2.926, 95% CI 1.158–7.392) and vancomycin duration (aOR 1.143, 95% CI 1.037–1.260). Based on infection severity and comorbidities, 34.7% of patients were candidates for oral antibiotics at baseline and 39.3% had non-purulent cellulitis which could have been more appropriately treated with a beta-lactam. Patients with V-AKI had significantly longer hospital lengths of stay (9 vs. 6 days, p = 0.001), higher 30-day readmission rates (30.8 vs. 9.0%, p < 0.001) and increased all-cause 30-day mortality (5.1 vs. 0.3%, p = 0.024)ConclusionsV-AKI occurred in approximately one in ten ABSSSI patients and may be largely prevented by preferential use of oral antibiotics whenever possible, using beta-lactams for non-purulent cellulitis and limiting durations of vancomycin therapy.Electronic supplementary materialThe online version of this article (10.1007/s40121-019-00278-1) contains supplementary material, which is available to authorized users.

Highlights

Acute bacterial skin and skin structure infections (ABSSSIs) are the most common infections encountered in both the ambulatory and inpatient settings [1,2,3,4]
The increases in ABSSSI incidence and severity have been linked to the emergence, spread and persistence of community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) as a predominant pathogen [7]
A clear distinction can be made between a patient presenting with necrotizing fasciitis and a stable patient with an uncomplicated abscess, the vast majority of ABSSSIs fall within a gray area between these entities, and clinicians may err on the side of caution with a more intensive vancomycin dosing schedule

Summary

Introduction

Acute bacterial skin and skin structure infections (ABSSSIs) are the most common infections encountered in both the ambulatory and inpatient settings [1,2,3,4]. Patients have multiple risk factors, are frequently on concomitant nephrotoxic medications, and intravenous (IV) antibiotics are often continued long after patients became candidates for oral therapy [6, 19, 25, 26]. This is concerning, because some studies have shown that the risk of V-AKI increases with longer durations of therapy [19]. We sought to determine the realworld incidence of and risk factors for vancomycin-associated acute kidney injury (V-AKI) in hospitalized adults with acute bacterial skin and skin structure infections (ABSSSI).

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