Vancomycin for Acute Bacterial Skin and Skin Structure Infection

Using oral antibiotics when possible and limiting the durations of vancomycin treatment may decrease vancomycin-associated acute kidney injury (V-AKI) in patients with acute bacterial skin and skin structure infections (ABSSSI), according to results of a study published in Infectious Diseases Therapy.

In both inpatient and ambulatory settings, ABSSSIs are the most common encountered infections: approximately 3.4 million individuals required care in the emergency department for ABSSSI in 2013 in the United States. The long-standing standard therapy for serious ABSSSI caused by resistant Gram-positive bacteria has been vancomycin. Vancomycin is recommended as first-line treatment of ABSSSI resulting from suspected or confirmed methicillin-resistant Staphylococcus aureus. However, the recognition of side effects from treatment with vancomycin, including V-AKI, has caused experts to question its future role in ABSSSI treatment. Although typically reversible, V-AKI can cause complications and is associated with extended hospital and intensive care unit lengths of stay and increased overall mortality. These factors highlight the need to better characterize V-AKI. Therefore, this retrospective, observational, cohort study sought to determine the real-world incidence of and risk factors for V-AKI in hospitalized adults with ABSSSI.

In total, 415 patients who received care at 10 medical centers in the United States between 2015 and 2019 were included in the study. These patients were hospitalized and treated with vancomycin (≥72 hours) for ABSSSI and had ≥1 baseline AKI risk factor. The primary outcome was V-AKI according to the vancomycin guidelines criteria definition: an increase from baseline in serum creatinine of ≥0.5 mg/L or 50% on ≥2 consecutive measurements.

Results suggested that each additional day of vancomycin therapy beyond day 3 increased the odds of V-AKI by 14.3%. In total, V-AKI occurred in 39 (9.4%) patients, and independent risk factors for V-AKI included chronic alcohol abuse (adjusted odds ratio [aOR], 4.710), intensive care unit residency (aOR, 4.398), no medical insurance (aOR, 3.451), Gram-negative coverage (aOR, 2.926), and vancomycin duration (aOR, 1.143). Based on comorbidities and infection severity, 39.3% of patients had nonpurulent cellulitis, which could have been more appropriately treated with safer alternatives, such as a beta-lactam. Compared with patients who did not develop V-AKI, those who did had significantly longer hospital stay lengths (6 days vs 9 days; P =.001), higher 30-day readmission rates (9.0% vs 30.8%; P <.001), and increased all-cause 30-day mortality (0.3% vs 5.1%; P =.024).

The study authors acknowledged several limitations to the study, including the retrospective design, noninclusion of a control group, and the inability to enroll the target study cohort as a result of financial constraints.

Overall, the study authors concluded that, “V-AKI occurred in approximately one in ten ABSSSI patients and may be largely prevented by preferential use of oral antibiotics whenever possible, using beta-lactams for nonpurulent cellulitis and limiting durations of vancomycin therapy.”

Reference

Jorgensen SC, Murray KP, Lagnf AM, et al. A multicenter evaluation of vancomycin-associated acute kidney injury in hospitalized patients with acute bacterial skin and skin structure infections. Infect Dis Ther. 2020;9:89-106.