RESUMO
BACKGROUND: Recent evidence suggests that among patients receiving vancomycin, receipt of concomitant piperacillin-tazobactam increases the risk of nephrotoxicity. Well-controlled, adequately powered studies comparing rates of acute kidney injury (AKI) among patients receiving vancomycin + piperacillin-tazobactam (VPT) compared to similar patients receiving vancomycin + cefepime (VC) are lacking. In this study we compared the incidence of AKI among patients receiving combination therapy with VPT to a matched group receiving VC. METHODS: A retrospective, matched, cohort study was performed. Patients were eligible if they received combination therapy for ≥48 hours. Patients were excluded if their baseline serum creatinine was >1.2mg/dL or they were receiving renal replacement therapy. Patients receiving VC were matched to patients receiving VPT based on severity of illness, intensive care unit status, duration of combination therapy, vancomycin dose, and number of concomitant nephrotoxins. The primary outcome was the incidence of AKI. Multivariate modeling was performed using Cox proportional hazards. RESULTS: A total of 558 patients were included. AKI rates were significantly higher in the VPT group than the VC group (81/279 [29%] vs 31/279 [11%]). In multivariate analysis, therapy with VPT was an independent predictor for AKI (hazard ratio = 4.27; 95% confidence interval, 2.73-6.68). Among patients who developed AKI, the median onset was more rapid in the VPT group compared to the VC group (3 vs 5 days P =< .0001). CONCLUSION: The VPT combination was associated with both an increased AKI risk and a more rapid onset of AKI compared to the VC combination.
Assuntos
Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Antibacterianos/efeitos adversos , Cefalosporinas/efeitos adversos , Ácido Penicilânico/análogos & derivados , Vancomicina/efeitos adversos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/terapia , Adulto , Idoso , Antibacterianos/uso terapêutico , Cefepima , Cefalosporinas/uso terapêutico , Terapia Combinada , Quimioterapia Combinada , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Razão de Chances , Ácido Penicilânico/efeitos adversos , Piperacilina/efeitos adversos , Combinação Piperacilina e Tazobactam , Prognóstico , Estudos Retrospectivos , Risco , Índice de Gravidade de Doença , Vancomicina/uso terapêuticoRESUMO
Despite their common use as an empirical combination therapy for the better part of a decade, there has been a recent association between combination therapy with vancomycin and piperacillin-tazobactam and high rates of acute kidney injury (AKI). The reasons for this increased association are unclear, and this analysis was designed to investigate the association. Retrospective cohort and case-control studies were performed. The primary objective was to assess if there is an association between extended-infusion piperacillin-tazobactam in combination with vancomycin and development of AKI. The secondary objectives were to identify risk factors for AKI in patients on the combination, regardless of infusion strategy, and to evaluate the impact of AKI on clinical outcomes. AKI occurred in 105/320 (33%) patients from the cohort receiving combination therapy with vancomycin and piperacillin-tazobactam, with similar rates seen in those receiving intermittent (53/160 [33.1%]) and extended infusions (52/160 [32.5%]) of piperacillin-tazobactam. Independent risk factors for AKI in the cohort included having a documented Gram-positive infection, the presence of sepsis, receipt of a vancomycin loading dose (odds ratio [OR], 2.22; 95% confidence interval [CI], 1.05 to 4.71), and receipt of any concomitant nephrotoxin (OR, 2.44; 95% CI, 1.41 to 4.22). For at-risk patients remaining on combination therapy, the highest rates of AKI occurred on days 4 (10.7%) and 5 (19.3%). The incidence of AKI in patients on combination therapy with vancomycin and piperacillin-tazobactam is high, occurring in 33% of patients. Receipt of piperacillin-tazobactam as an extended infusion did not increase this risk. Modifiable risk factors for AKI include receipt of a vancomycin loading dose, concomitant nephrotoxins, and longer durations of therapy.
Assuntos
Injúria Renal Aguda/epidemiologia , Antibacterianos/efeitos adversos , Infecções por Bactérias Gram-Negativas/epidemiologia , Infecções por Bactérias Gram-Positivas/epidemiologia , Ácido Penicilânico/análogos & derivados , Vancomicina/efeitos adversos , Injúria Renal Aguda/induzido quimicamente , Injúria Renal Aguda/patologia , Adulto , Idoso , Antibacterianos/administração & dosagem , Estudos de Casos e Controles , Quimioterapia Combinada/efeitos adversos , Feminino , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Infecções por Bactérias Gram-Negativas/microbiologia , Infecções por Bactérias Gram-Negativas/patologia , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Infecções por Bactérias Gram-Positivas/microbiologia , Infecções por Bactérias Gram-Positivas/patologia , Humanos , Modelos Logísticos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Ácido Penicilânico/administração & dosagem , Ácido Penicilânico/efeitos adversos , Piperacilina/administração & dosagem , Piperacilina/efeitos adversos , Combinação Piperacilina e Tazobactam , Estudos Retrospectivos , Vancomicina/administração & dosagemRESUMO
The impact of the 2013 NHSN CAUTI definition on CAUTI rates was analyzed. A total of 107 CAUTI episodes were identified; 60 according to NHSN 2013 definitions only and 47 according to the 2012 and 2013 definitions. Physician-diagnosed "other infections" were more common among patients who had CAUTI only according to NHSN 2013 definitions (P<.001).
