Vancomycin With a β-Lactam: Comparing Acute Kidney Injury Rates of Trough vs AUC Dosing

Using an area under the curve (AUC) rather than a trough-dosing strategy for vancomycin in combination with piperacillin-tazobactam could help avoid negative clinical outcomes such as acute kidney injury (AKI), according to a poster presented at the Making a Difference in Infectious Disease (MAD-ID) 2022 annual meeting, held May 18-21, 2022, in Orlando, Florida.

Sara Alosaimy, PharmD, who completed the research during her time as a research scientist at Wayne State University, discussed her findings in a video interview with Contagion®.

This transcript has been edited for clarity and length.

Contagion®: Can you talk a bit about what the motivation behind the study was?

Alosaimy: The motivation was related to the change in the guideline of vancomycin dosing and monitoring where there was a switch recommendation from trough-associated monitoring to AUC [area under the curve]. The aim of the switch was to reduce the incidence of AKI. However, there are combinations, specifically β-lactamwith vancomycin, that are generally more associated with an increased incidence of AKI. So the idea was, could vancomycin dosing strategy have an impact in the drug interaction that we know already of vancomycin and piperacillin-tazobactam.

Contagion®: Can you summarize the results?

Alosaimy: What we hypothesized is that vancomycin AUC monitoring will reduce the incidence of AKI in a similar manner to what we've noticed in the guideline, when using vancomycin alone. We did see a reduction in acute kidney injury, however, it was minimal and not statistically significant, regardless of the method of monitoring.

Contagion®: What is the key takeaway for clinicians?

Alosaimy: One more thing that I think it would be important to highlight, because it's very related to the key message is, although we were not able to see a statistically significant reduction using the AUC-based monitoring, we did notice that the trough-monitored patients have had more advanced stages of acute kidney injury. When you compared it to the AUC-related patients, their acute kidney injury and the damages were actually more on the initial and primary manageable adverse drug reactions. So that was interesting because, as you know, the more advanced acute kidney injuries you get, then it's related with more permanent side effects, and also more consultations and renal replacement therapy.

To circle back to your question, I think the take home message is to keep collecting the data as AUC monitoring becomes the standard of care in the guideline and see how that impacts any vancomycin-related drug interaction, not just with piperacillin-tazobactam, because it might have an impact into renal disease progression when it occurs because of this drug interaction.

Contagion®: Are there any plans for future research?

Alosaimy: We plan on continuing to expand the sample size of the study and then to look specifically into the patient's related factors for acute kidney injury to make sure that there were no confounding variables that may have prevented us from seeing the actual impact of the monitoring method, regardless of the patient group.

Contagion®: Taking a step back, what do you think the biggest challenge facing antimicrobial stewardship right now is?

Alosaimy: I think the biggest challenge is that there are a lot of stakeholders when it comes to antimicrobial stewardship and these stakeholders, we need to know what their responsibilities are and how we can both help each other because there are different challenges related to the type of institution and there are different stakeholders regardless of what the institution is. It is very difficult to have one standardized approach for everyone, regardless who that stakeholder is and where you coming from.