Empiric weight-based vancomycin in intensive care unit patients with methicillin-resistant Staphylococcus aureus bacteremia

Carlos A. Alvarez, Christopher A. Giuliano, Krystal K. Haase, Kathleen A. Thompson, Christopher R. Frei, Nicolas A. Forcade, Sara D. Brouse, Eric M. Mortensen, Todd Bell, Roger J. Bedimo, Nolan M. Toups, Ronald G. Hall

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    Abstract

    Background: Previous studies were conducted in all hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia to determine safety and effectiveness of guidelinerecommended, weight-based dosing of vancomycin. In these studies, it was observed that severely ill patients (Pitt bacteremia score ≥4 or intensive care unit [ICU] patients) were at an increased risk of mortality and/or nephrotoxicity. Therefore, a subanalysis of the effect of guidelinerecommended vancomycin dosing on in-hospital mortality and nephrotoxicity in ICU patients with MRSA bacteremia was conducted.

    Methods: This multicenter, retrospective, cohort study was conducted in a subset of ICU patients from a previous MRSA bacteremia study. Patients were ≥18 years old and received ≥48 hours of empiric vancomycin from July 1, 2002, to June 30, 2008. The incidence of nephrotoxicity and in-hospital mortality was compared in patients who received guideline-recommended dosing (at least 15 mg/kg per dose) to patients who received non-guideline-recommended dosing of vancomycin. Multivariable generalized linear mixed-effects models were constructed to determine independent risk factors for in-hospital mortality and nephrotoxicity.

    Results: Guidelinerecommended dosing was received by 34% of patients (n 5 137). Nephrotoxicity occurred in 35% of patients receiving guidelinerecommended dosing and 39% receiving non-guideline-recommended dosing (P 5 0.67). In-hospital mortality rate was 24% among patients who received guideline-recommended dosing compared with 31% for non-guideline-recommended dosing (P 5 0.40). Guidelinerecommended dosing was not associated with nephrotoxicity (odds ratio: 1.10; 95% confidence interval: 0.43-2.79) or in-hospital mortality (odds ratio: 0.54; 95% confidence interval: 0.22-1.36) in the multivariable analysis.

    Conclusions: Guideline-recommended dosing of vancomycin in ICU patients with MRSA bacteremia is not significantly associated with nephrotoxicity or in-hospital mortality. However, the 7% absolute difference for in-hospital mortality suggests that larger studies are needed.

    Original languageEnglish (US)
    Pages (from-to)371-376
    Number of pages6
    JournalAmerican Journal of the Medical Sciences
    Volume348
    Issue number5
    DOIs
    StatePublished - Jan 1 2014

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    Keywords

    • ICU
    • MRSA
    • Nephrotoxicity
    • Vancomycin
    • Weight

    ASJC Scopus subject areas

    • Medicine(all)

    Cite this

    Alvarez, C. A., Giuliano, C. A., Haase, K. K., Thompson, K. A., Frei, C. R., Forcade, N. A., Brouse, S. D., Mortensen, E. M., Bell, T., Bedimo, R. J., Toups, N. M., & Hall, R. G. (2014). Empiric weight-based vancomycin in intensive care unit patients with methicillin-resistant Staphylococcus aureus bacteremia. American Journal of the Medical Sciences, 348(5), 371-376. https://doi.org/10.1097/MAJ.0000000000000262