Vanc and zosyn AKI

The Article:

Are Patients Receiving the Combination of Vancomycin and Piperacillin-Tazobactam at Higher Risk for Acute Renal Injury?

Luther MK, Timbrook TT, Caffrey AR, et al. Vancomycin plus piperacillin-tazobactam and acute kidney injury in adults: a systematic review and metaanalysis. Crit Care Med. 2018;46:12-20

The Idea:

Vanc and zosyn in combination is a common regimen for broad-spectrum antimicrobial therapy, especially in critically ill patients. Studies have shown a 6.5-fold increase in mortality among hospitalized and critically ill patients with AKI. Many medications, including vancomycin have been associated with AKI. Rates of AKI increase wit illness severity, comorbities and concomitant medication use.

The Study:

1. 2 authors independently searched PubMed, EMBASE, Web of Science, and Cochrane databases and manually searched reference lists of included studies and abstracts for other relevant studies

2. authors included RCTs and observational studies evaluating nephrotoxicity or AKI in patients aged 18 years or older treated with the combination of vancomycin and pip-tazo and either vanc or pip-tazo monotherapy, or vanc plus another beta-lactam

3. included studies defined AKI according to serum Cr level, urine output, or need for dialysis or renal replacement therapy

4. the authors calculated the percentage of patients with AKI after antibiotic treatment and time to AKI

5. calculated pooled odds ratios and mean differences in tiem to AKI, using random-effects models

6. they performed a secondary analysis for critically ill patients in the ICU

The Results:

1. included 15 published studies and 17 abstracts

2. 24,799 patients total

3. 6 studies compared vanc and pip-tazo with vanc monotherapy

4. 8 compared vanc and pip-tazo with vanc plus another beta-lactam

5. 4 compared vanc and pip-tazo with pi-tazo monotherapy

6. 3 made multiple comparisons

7. AKI occurred in 2% of patients treated with vanc and zosyn, compared with 12.9% in patients with other antibiotic regimens

8. Vanc and zosyn increased the odds of AKI compared with each regimen

9. Vanc and zosyn had a number needed to harm of 11 for AKI

10. In subgroup analysis of critically ill patients, vanc and zosyn vs. vanc monotherapy had an odds ratio of 9.62 for AKI

11. 968 patients

12. difference in time to AKI was not statistically significant between antibiotic regimens

Limitations:

1. antibiotic administration, comorbidities, infection type, and conocomitant infections varied across included studies, only some studies attempted to match risk factors to control for potential confounders

2. also included conference abstracts, which may have poor quality, lack of peer review, and insufficient information

3. time to AKI was not available for ICU patients

4. what is the clinical significance?

The Takeaway:

There is an increased risk of AKI with the combination of vanc and zosyn, compared with vanc or zosyn monotherapy, or vanc combined with another beta-lactam, but it is unclear how clinically significant this is.

#Infectious #RenalGenitourinary