Vancomycin Dosing and Its Association With Acute Kidney Injury in Pediatric Cardiac Intensive Care Patients Under 3 Months of Age

Author:

Ashkenazi-Hoffnung Liat123ORCID,Schiller Ofer24,Krubiner Mor4,Dagan Ovadia24,Haskin Orly25,Manor-Shulman Orit4,Feinstein Yael24,Shochat Tzippy26,Shostak Eran24,Yarden-Bilavsky Havatzelet27

Affiliation:

1. From the Department of Day Hospitalization, Schneider Children’s Medical Center, Petach Tikva, Israel

2. Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel

3. Pediatric Infectious Diseases Unit, Schneider Children’s Medical Center, Petach Tikva, Israel

4. Pediatric Cardiac Intensive Care Unit, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel

5. Pediatric Institute of Nephrology, Schneider Children’s Medical Center, Petach Tikva, Israel

6. Statistical Consultant, Clinical Research Authority, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel

7. Pediatric Clinical Pharmacology Unit, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel.

Abstract

Background: The standard vancomycin regimen for term neonates is 45 mg/kg/day. However, the optimal starting vancomycin dosing for achieving therapeutic levels in young infants in cardiac intensive care units remains unknown. Moreover, data on the association of supratherapeutic vancomycin levels with acute kidney injury (AKI) are limited. Methods: Retrospective study of infants ≤3 months old, receiving vancomycin following congenital heart surgery at postoperative intensive care unit admission. Assessed were vancomycin dosing, achievement of therapeutic trough concentration of 10–20 mg/L and development of AKI, based on the modified Kidney Disease Improving Global Outcomes criteria. Results: Inclusion criteria were met by 109 patients with a median age of 8 days (IQR: 6–16). The mean (SD) vancomycin dose required for achieving therapeutic concentration was 28.9 (9.1) mg/kg at the first postoperative day. Multivariate logistic regression identified higher preoperative creatinine levels and shorter cardiopulmonary bypass time as predictors of supratherapeutic vancomycin concentrations (c-index 0.788). During the treatment course, 62 (56.9%) developed AKI. Length of stay and mortality were higher in those who developed AKI as compared with those who did not. Multivariate logistic regression identified higher vancomycin concentration as a predictor for postoperative AKI, OR, 3.391 (95% CI: 1.257–9.151), P = 0.016 (c-index 0.896). Conclusion: Our results support a lower starting vancomycin dose of ~30 mg/kg/day followed by an early personalized therapeutic approach, to achieve therapeutic trough concentrations of 10–20 mg/L in cardiac postoperative term infants. Supratherapeutic concentrations are associated with an increased risk for AKI, which is prevalent in this population and associated with adverse outcomes.

Publisher

Ovid Technologies (Wolters Kluwer Health)

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