Relationships between creatinine increase and mortality rates in patients given vancomycin in 76 hospitals: The increasing role of infectious disease pharmacists

• Published in: American journal of health-system pharmacy Vol. 78; no. 23; pp. 2116 - 2125
• Main Authors: Yu, Kalvin C, Yamaga, Cynthia, Vankeepuram, Latha, Tabak, Ying P
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 01-12-2021
• Subjects: Adult; Communicable Diseases - drug therapy; Creatinine; Hospitals; Humans; Pharmacists; Retrospective Studies; Vancomycin; mortality; renal function; vancomycin; infectious disease pharmacist; stewardship
• ISSN: 1079-2082; 1535-2900
• DOI: 10.1093/ajhp/zxab247

Abstract
Purpose
Vancomycin is a commonly used antimicrobial with the potential for renal toxicity. We evaluated vancomycin duration, changes in renal function after vancomycin initiation (“post-vancomycin” renal function changes), and associated mortality risk among hospitalized patients.
Methods
We analyzed data from 76 hospitals and excluded patients with a baseline serum creatinine concentration (SCr) of >3.35 mg/dL. We estimated mortality risk relative to vancomycin duration and the magnitude of post-vancomycin SCr change, controlling for demographics, baseline SCr, underlying diseases, clinical acuity, and comorbidities.
Results
Among 128,993 adult inpatients treated with vancomycin, 49.0% did not experience SCr elevation. Among the remaining patients, 26.0%, 11.4%, 8.8% and 4.8% experienced increases in post-vancomycin SCr of 1% to 20%, 21% to 40%, 41% to 100%, and greater than 100%, respectively. Compared to mortality risk among patients with a vancomycin therapy duration between 4 and 5 days (the lowest-mortality group), longer vancomycin therapy duration was not independently associated with higher mortality risk after adjusting for confounders. In contrast, there was a graded relationship between post-vancomycin SCr elevation and mortality. Multivariable adjusted mortality odds ratios ranged from 1.60 to 13.66, corresponding to SCr increases of 10% and greater than 200%, respectively.
Conclusion
Half of patients given vancomycin did not experience SCr elevation and had the lowest mortality, suggesting that vancomycin can be used safely if renal function is stabilized. In the large study cohort, vancomycin duration itself was not an independent predictor of mortality. Post-vancomycin SCr elevation appeared to be a driver of in-hospital mortality. Even a 10% post-vancomycin SCr increase was associated with an increased mortality risk. This finding stresses the importance of closely monitoring renal function and may support the value of pharmacokinetic dosing.