scholarly journals 1575. Vancomycin Loading Doses and Nephrotoxicity on Medicine Teaching Services

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S575-S575
Author(s):  
Phillip Wagner ◽  
Jon Arnold ◽  
Kathleen R Sheridan
Keyword(s):  
Drug Exposure ◽  
Standard Dose ◽  
Medical Center ◽  
Academic Medical Center ◽  
Kidney Injury ◽  
Loading Dose ◽  
Academic Medical ◽  
Trough Concentrations ◽  
Seriously Ill Patients ◽  
The Relationship

Abstract Background IDSA guidelines recommend the usage of a loading dose when using vancomycin for seriously ill patients to rapidly achieve adequate trough concentrations. While the relationship between vancomycin and nephrotoxicity is the focus of many studies, and with the strength of that relationship still debated, few studies have examined the relationship between vancomycin loading doses and nephrotoxicity. Methods We performed a retrospective cohort study examining vancomycin dosing for internal medicine teaching services’ patients over the 2014–15 academic year at one academic medical center. We generated a list of all hospitalized patients aged 18–85 who received vancomycin and were admitted to a teaching service. Patient data were extracted from the inpatient EMR via manual chart review. Patients were excluded if their pretreatment calculated glomerular filtration rate (GFR) was less than 50 mL/minute, if they received less than three doses of vancomycin, or if their initial dose was subtherapeutic (<10 mg/kg). Nephrotoxicity was determined by 7-day acute kidney injury (AKI) rate. Patients in the loading dose (>20 mg/kg) cohort were compared with those in the standard dose cohort (10–20 mg/kg). Our primary modeling used multi-variable logistic regression with AKI as our outcome of interest. Results 438 of the initial 804 patients were enrolled. The loading dose (n = 365, 83%) and standard dosing (n = 73, 17%) cohorts were not significantly different regarding demographics, GFR, nephrotoxic drug exposure, total vancomycin received, trough levels, or comorbidities, and were only significantly different regarding body mass index (BMI). The 7-day AKI rate was not significantly different between the two arms (6.3% in the standard dosing arm and 8.2% in the loading dose arm P = 0.6). AKI rate significantly increased in both arms in the setting of concurrent piperacillin–tazobactam and vancomycin administration (OR 2.5, P = .04). There was no association between BMI and AKI. Conclusion Few studies have examined the relationship between nephrotoxicity and vancomycin loading doses. The results of this study provide evidence that the use of loading doses is not significantly associated with increased 7-day AKI rate. Disclosures All authors: No reported disclosures.

scholarly journals 1310. Implementation of AUC:MIC Pharmacy to Dose in an Academic Medical Center: A Pilot Study

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S667-S668
Author(s):  
Ann-Marie Idusuyi ◽  
Maureen Campion ◽  
Kathleen Belusko
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Area Under The Curve ◽  
Kidney Injury ◽  
Retrospective Chart Review ◽  
Total Daily Dose ◽  
Therapeutic Goals ◽  
Academic Medical ◽  
Progress Notes ◽  
Implementation Period

Abstract Background The new ASHP/IDSA consensus guidelines recommend area under the curve (AUC) monitoring to optimize vancomycin therapy. Little is known about the ability to implement this recommendation in a real-world setting. At UMass Memorial Medical Center (UMMMC), an AUC pharmacy to dose protocol was created to manage infectious diseases (ID) consult patients on vancomycin. The service was piloted by the pharmacy residents and 2 clinical pharmacists. The purpose of this study was to determine if a pharmacy to dose AUC protocol can safely and effectively be implemented. Methods A first-order kinetics calculator was built into the electronic medical record and live education was provided to pharmacists. Pharmacists ordered levels, wrote progress notes, and communicated to teams regarding dose adjustments. Patients were included based upon ID consult and need for vancomycin. After a 3-month implementation period, a retrospective chart review was completed. Patients in the pre-implementation group were admitted 3 months prior to AUC pharmacy to dose, had an ID consult and were monitored by trough (TR) levels. The AUC group was monitored with a steady state peak and trough level to calculate AUC. The primary outcome evaluated time to goal AUC vs. time to goal TR. Secondary outcomes included number of dose adjustments made, total daily dose of vancomycin, and incidence of nephrotoxicity. Results A total of 64 patients met inclusion criteria, with 37 patients monitored by TR and 27 patients monitored by AUC. Baseline characteristics were similar except for weight in kilograms (TR 80.0 ±25.4 vs AUC 92.0 ±26.7; p=0.049). The average time to goal AUC was 4.13 (±2.08) days, and the average time to goal TR was 4.19 (±2.30) days (p=0.982). More dose adjustments occurred in the TR group compared to the AUC (1 vs 2; p=0.037). There was no difference between the two groups in dosing (TR 15.8 mg/kg vs AUC 16.4 mg/kg; p=0.788). Acute kidney injury occurred in 5 patients in the AUC group and 11 patients in the TR group (p=0.765). Conclusion Fewer dose adjustments and less nephrotoxicity was seen utilizing an AUC based protocol. Our small pilot has shown that AUC pharmacy to dose can be safely implemented. Larger studies are needed to evaluate reduction in time to therapeutic goals. Disclosures All Authors: No reported disclosures

scholarly journals Influence of β-Lactam Infusion Strategy on Acute Kidney Injury

2017 ◽  
Vol 61 (10) ◽  
Author(s):  
Sarah E. Cotner ◽  
W. Cliff Rutter ◽  
Donna R. Burgess ◽  
Katie L. Wallace ◽  
Craig A. Martin ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Medical Center ◽  
Academic Medical Center ◽  
Kidney Injury ◽  
Intermittent Infusion ◽  
Prolonged Infusion ◽  
Infusion Group ◽  
Academic Medical ◽  
Baseline Creatinine ◽  
End Stage

ABSTRACT Limited literature is available assessing nephrotoxicity with prolonged β-lactam infusions. This study compared the incidence of acute kidney injury (AKI) associated with a prolonged β-lactam infusion or an intermittent infusion. This was a retrospective, matched-cohort study at an academic medical center from July 2006 to September 2015. Adult patients who received piperacillin-tazobactam (TZP), cefepime (FEP), or meropenem (MEM) for at least 48 h were evaluated. Patients were excluded for preexisting renal dysfunction or pregnancy. The primary outcome was difference in incidence of AKI evaluated using the RIFLE (risk, injury, failure, loss, and end-stage) criteria. Patients in the intermittent group were matched 3:1 to patients in the prolonged-infusion group based on the following: β-lactam agent, age, gender, Charlson comorbidity index, baseline creatinine clearance, hypotension, receipt of vancomycin, and treatment in an intensive care unit. A total of 2,390 patients were included in the matched analysis, with 1,700 receiving intermittent infusions and 690 receiving prolonged infusion. The incidence of AKI was similar in the prolonged-infusion group to that in the intermittent-infusion group (21.6% versus 18.6%; P = 0.1). After multivariate regression, prolonged infusion was not associated with increased odds of AKI (odds ratio [OR], 1.07; 95% confidence interval [95% CI], 0.83 to 1.39). Independent predictors of AKI included TZP therapy, concomitant nephrotoxins, hypotension, and heart failure. Although AKIs were numerically more common in patients receiving prolonged β-lactam infusions than those receiving intermittent infusions, prolonged infusion was not an independent risk factor for AKI.

Vancomycin Area Under the Curve Dosing and Monitoring at an Academic Medical Center: Transition Strategies and Lessons Learned

2019 ◽  
Vol 33 (6) ◽  
pp. 774-778 ◽  
Author(s):  
Eric R. Gregory ◽  
Donna R. Burgess ◽  
Sarah E. Cotner ◽  
Jeremy D. VanHoose ◽  
Alexander H. Flannery ◽  
...  
Keyword(s):  
Technology Development ◽  
Medical Center ◽  
Academic Medical Center ◽  
Area Under The Curve ◽  
Kidney Injury ◽  
Lessons Learned ◽  
Academic Medical ◽  
Transition Strategies ◽  
Evaluation Stage ◽  
Information Technology Development

Due to the inconsistent correlation of vancomycin trough concentrations with 24-hour area under the curve (AUC) and a desire to reduce rates of vancomycin-associated acute kidney injury, an institutional guideline was implemented by the Antimicrobial Stewardship Team in September 2017 to monitor vancomycin using AUC. Three stages were utilized to organize the process: preparation, implementation, and evaluation. The preparation stage was used to present literature to key stakeholders, and pharmacy meetings focused on the development of a dosing and monitoring guideline. Along with institution-wide education, the implementation stage included information technology development and support. The evaluation stage was comprised of quality improvement and clinical research. Future plans include dissemination of the results and analyses. Numerous lessons were learned due to barriers experienced during the process, but the transition was successful.

Risk factors for acute kidney injury associated with the treatment of bacterial endocarditis at a tertiary academic medical center

2017 ◽  
Vol 29 (5) ◽  
pp. 292-298 ◽  
Author(s):  
Brianne M. Ritchie ◽  
Beth A. Hirning ◽  
Craig A. Stevens ◽  
Steven A. Cohen ◽  
Jeremy R. DeGrado
Keyword(s):  
Risk Factors ◽  
Acute Kidney Injury ◽  
Medical Center ◽  
Academic Medical Center ◽  
Kidney Injury ◽  
Bacterial Endocarditis ◽  
Academic Medical

Impact of an innovative partnership in patient care between an academic medical center department of pharmacy and a school of pharmacy

2019 ◽  
Vol 76 (24) ◽  
pp. 2070-2076
Author(s):  
Mary-Haston Vest ◽  
Mary G Petrovskis ◽  
Scott W Savage ◽  
Nicole R Pinelli ◽  
Ashley L Pappas ◽  
...  
Keyword(s):  
Patient Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Lessons Learned ◽  
Residency Programs ◽  
Pharmacy Department ◽  
Academic Medical ◽  
American Society ◽  
The Impact ◽  
The Relationship

Abstract Purpose Pharmacy departments and schools of pharmacy have long held professional affiliations. However, the success of each entity is often not interdependent and aligned. In 2010, our institutions found ourselves in a position where the complementary motivations of each aligned to support a more meaningful and committed engagement, leading to the development of the Partnership in Patient Care. The impact of the partnership was evaluated 7 years postimplementation, and both the successes realized and the lessons learned are described. Summary The partnership provided many advantages to our pharmacy department and the school of pharmacy. This initial iteration of the partnership was a strong proof of concept that an intentional approach to the relationship between a school of pharmacy and a pharmacy department can lead to substantive improvements in a wide array of meaningful outcomes. We experienced an increase in the number of student rotation months completed, growth in the American Society of Health-System Pharmacists–accredited residency programs, and enhanced clinical services. However, the partnership was not without challenges. For instance, lack of a formalized tracking method made certain outcomes difficult to track. Conclusion The purposeful establishment of the Partnership in Patient Care, built on the needs of a school of pharmacy and an academic medical center pharmacy department, allowed our institutions to develop an intertwined mission and vision. Over the initial years of the partnership, many successes were realized and lessons were learned. Both the successes and the challenges are serving as the foundation for future iterations of the partnership.

scholarly journals Elevated FGF23 Levels Are Associated with Impaired Calcium-Mediated Suppression of PTH in ESRD

2010 ◽  
Vol 24 (12) ◽  
pp. 2406-2407
Author(s):  
James B. Wetmore ◽  
Peter Santos ◽  
Jonathan D. Mahnken ◽  
Ron Krebill ◽  
Rochelle Menard ◽  
...  
Keyword(s):  
Parathyroid Gland ◽  
Medical Center ◽  
Fibroblast Growth Factor 23 ◽  
Academic Medical Center ◽  
Positive Association ◽  
Calcium Sensing ◽  
Academic Medical ◽  
High Calcium ◽  
Gland Function ◽  
The Relationship

Abstract Context: The positive association of elevated fibroblast growth factor-23 (FGF23) with PTH levels in the setting of secondary hyperparathyroidism is paradoxical to the purported effects of FGF23 to suppress PTH secretion. Objective: We used dynamic calcium-mediated suppression of PTH levels in hemodialysis (HD) patients to determine the relationship between FGF23 levels and parathyroid gland function. Design: HD patients with elevated PTH were washed out of vitamin D analogs and/or calcimimetics and then exposed them to a high-calcium dialysate bath designed to suppress PTH. Setting: The study was conducted at an outpatient HD unit of an academic medical center. Participants: Eighteen maintenance HD patients with elevated PTH levels participated in the study. Main Outcome Measures: Ionized calcium (iCa), PTH, and FGF23 levels were measured during HD. The slope of the relationship between iCa and PTH (a marker of parathyroid gland mass) and the iCa level required for a 50% reduction in PTH were determined, and the association of these with FGF23 levels was determined. Results: Increased baseline log FGF23 levels were associated with putative alterations in gland mass as estimated by significantly shallower slopes of the iCa/PTH suppression curves (P = 0.0004), but there was no association between FGF23 and calcium sensing as measured by ionized Ca associated with a 50% suppression of PTH (P = 0.38). FGF23 levels decreased significantly during HD, but this change was not correlated with decrements in either renal phosphate or PTH. Conclusions: High FGF23 levels may be a marker for parathyroid gland hyperplasia in HD patients. Acute reductions in neither PTH nor renal phosphate during dialysis correlated with PTH suppression.

Prospective Comparison of Acute Kidney Injury During Treatment With the Combination of Piperacillin-Tazobactam and Vancomycin Versus the Combination of Cefepime or Meropenem and Vancomycin

2016 ◽  
Vol 30 (2) ◽  
pp. 209-213 ◽  
Author(s):  
Vincent Peyko ◽  
Samantha Smalley ◽  
Henry Cohen
Keyword(s):  
Acute Kidney Injury ◽  
Work Group ◽  
Medical Center ◽  
Academic Medical Center ◽  
Kidney Injury ◽  
Adult Patients ◽  
Open Label ◽  
Prospective Comparison ◽  
Academic Medical ◽  
Vancomycin Group

Purpose: To prospectively evaluate the observed incidence of acute kidney injury (AKI) in adult patients receiving the combination of piperacillin-tazobactam and vancomycin versus the combination of cefepime or meropenem and vancomycin for greater than 72 hours. Methods: This was a prospective, open-label cohort study at a community academic medical center involving adult patients over a 3-month time period who received either the combination of piperacillin-tazobactam and vancomycin or the combination of cefepime or meropenem and vancomycin for greater than 72 hours. The patients were evaluated for AKI, defined using specific criteria introduced by Kidney Disease: Improving global outcomes (KDIGO) acute kidney injury work group in 2012. Results: A total of 85 patients receiving either antimicrobial combination were evaluated for AKI. The incidence of AKI was significantly higher in the piperacillin-tazobactam and vancomycin group (37.3%) compared with the cefepime or meropenem and vancomycin group (7.7%; χ2 = 7.80, P = .005). Conclusion: The result of this study suggests that the risk of developing AKI is increased in patients receiving the combination of piperacillin-tazobactam and vancomycin versus those receiving the combination of cefepime or meropenem and vancomycin.

scholarly journals 1102. Evaluation of Vancomycin Accumulation in Patients with Obesity

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S642-S643
Author(s):  
Maha Assadoon ◽  
Jeffrey C Pearson ◽  
David W Kubiak ◽  
Mary P Kovacevic ◽  
Brandon Dionne
Keyword(s):  
Severe Renal Impairment ◽  
Medical Center ◽  
Academic Medical Center ◽  
Kidney Injury ◽  
Volume Of Distribution ◽  
Obesity Class ◽  
Factors Associated ◽  
Days Of Therapy ◽  
Trough Concentrations ◽  
Potential Factors

Abstract Background Current vancomycin guidelines recommend using actual body weight for dosing. However, in patients with obesity, this may result in lower initial vancomycin concentrations that can accumulate with continued doses due to differences in volume of distribution. The objective of this study is to evaluate the incidence of vancomycin accumulation in patients with obesity and identify potential factors associated with accumulation. Methods This is a single-center, retrospective, observational study at a tertiary academic medical center. Adult patients with a BMI ≥ 30 kg/m2 and with ≥ 2 vancomycin serum trough concentrations within the same encounter in 2019 were screened. Patients were excluded if they were pregnant, had unstable renal function or severe renal impairment, received &lt; 3 doses before a concentration was drawn, or had inconsistent dosing prior to a concentration draw. Linear kinetics were used to correct for differences in timing of concentration or dose changes. The major endpoint was the incidence of vancomycin accumulation, defined as a 20% increase in trough concentration between the first and any subsequent trough concentrations within the first 10 days of therapy. Minor endpoints included the percentage of supratherapeutic concentrations and the incidence of acute kidney injury (AKI). Descriptive statistics were used to evaluate endpoints and multivariable logistic regression was used to evaluate factors associated with accumulation. Results We screened 543 patients, and 162 were included in our analysis. The median age was 56.5 years (interquartile range [IQR] 43 - 65.3), and 62.3% were male. The median weight was 112.7 kg (IQR 99.8 - 122.6) and the median BMI was 36.8 kg/m2 (IQR 33.1 - 41). The median total daily vancomycin dose at initiation was 28.7 mg/kg/day (IQR 25.4 - 31.2). Vancomycin accumulation occurred in 99 patients (61.1%) within the first 10 days of therapy and AKI occurred in 21 patients (14.9%). No factors studied, including age, gender, obesity class, initial dose, SCr, or frequency were associated with accumulation. Conclusion Most patients with obesity experienced vancomycin accumulation within the first 10 days of therapy. Providers should be cautious when assessing a vancomycin concentration early in the treatment course. Disclosures All Authors: No reported disclosures

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