Vancomycin Use in Patients with Acute Kidney Injury

Introduction to Vancomycin Use

The Kidney International guideline recommends avoiding vancomycin in patients with acute kidney injury (AKI) if possible, and considering alternative antibiotics, but if necessary, requires close therapeutic drug monitoring with dose adjustments based on renal function and daily trough levels until steady state is reached 1
The Clinical Infectious Diseases guideline suggests monitoring serum creatinine at baseline and at least every 48 hours during therapy, and monitoring vancomycin trough levels daily until steady state is reached, and more frequently in patients with unstable renal function 2

The Kidney International guideline recommends monitoring vancomycin trough levels daily until steady state is reached, and when treatment with multiple daily dosing is used for more than 24 hours, and when treatment with single-daily dosing is used for more than 48 hours 1
The Clinical Infectious Diseases guideline suggests monitoring vancomycin trough levels more frequently in patients with unstable renal function 2
Target trough levels of 10-15 mg/L for most infections, and higher trough levels (15-20 mg/L) may be necessary for serious infections (endocarditis, osteomyelitis, meningitis) 1

The Kidney International guideline recommends avoiding combination with other nephrotoxic agents when possible, particularly aminoglycosides and amphotericin B 1
The American Journal of Transplantation guideline suggests avoiding combination with NSAIDs and piperacillin-tazobactam (significantly higher AKI risk compared to other beta-lactams) 3
The Clinical Gastroenterology and Hepatology guideline recommends considering cefepime or meropenem instead of piperacillin-tazobactam (lower nephrotoxicity risk) if combination therapy is necessary 4

If AKI develops during vancomycin therapy, reassess necessity, adjust therapy, and provide supportive care, including ensuring adequate hydration, discontinuing other nephrotoxic medications, and monitoring fluid status and electrolytes 1
Consider holding doses until renal function improves, significantly reduce dose and/or extend intervals if continued therapy is essential, and switch to an alternative antibiotic if possible 2

Recent evidence suggests that AUC/MIC-guided dosing (rather than trough-based dosing) may be associated with lower rates of supratherapeutic levels and potentially lower AKI rates, and requires calculating the area under the curve (AUC) using two levels (peak and trough), and targeting an AUC/MIC ratio of 400-600 for most infections 3