Impact of an Antibiotic Stewardship Program on the Incidence of Vancomycin-Associated Acute Kidney Injury in Hospitalized Children.

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Vancomycin causes considerable acute kidney injury (AKI) in children, particularly in the setting of troughs of 15 to 20 mg/L. We sought to determine whether the addition of prospective audit and feedback to a preauthorization and therapeutic drug monitoring (TDM) program further reduces the incidence of AKI. We conducted a quasiexperimental study of children admitted to The Johns Hopkins Hospital receiving vancomycin for ≥48 hours. The incidence of AKI was compared between the preintervention and intervention periods. Additional risk factors for vancomycin-associated AKI were also explored. A total of 386 courses of vancomycin therapy met eligibility criteria (200 in the preintervention vs 186 in the intervention period). The incidence of vancomycin-associated AKI did not differ between the preintervention and intervention periods, 8% vs 9%, respectively. On multivariable analysis, the number of concurrent nephrotoxins was found to be an independent predictor of vancomycin-associated AKI, with each additional nephrotoxin increasing the risk of AKI by 40% (adjusted OR, 1.40; 95% CI, 1.06-1.85; p = 0.019). Specific nephrotoxins that increased the risk of vancomycin-associated AKI included piperacillin/tazobactam, liposomal amphotericin B, and ibuprofen. The addition of prospective audit and feedback to a preauthorization and TDM program did not result in further AKI reduction. Prospective audit and feedback is a resource-intensive intervention. If preauthorization restrictions and TDM are already in place, our findings suggest stewardship efforts may be more effective if redirected to focus on other modifiable risk factors for vancomycin-associated AKI, such as minimizing additional nephrotoxins.