Impact of an Antibiotic Stewardship Program on the Incidence of Vancomycin-Associated Acute Kidney Injury in Hospitalized Children.
Impact of an Antibiotic Stewardship Program on the Incidence of Vancomycin-Associated Acute Kidney Injury in Hospitalized Children.
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DOI：
10.5863/1551-6776-24.5.416
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发表时间：
2019-09-01
期刊：
影响因子：
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通讯作者：
Tamma, Pranita D
中科院分区：
文献类型：
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作者：
Hsu, Alice Jenh;Tamma, Pranita D
目的：万古霉素对儿童造成严重的急性肾损伤（AKI），特别是在低浓度 15 至 20 mg/L 的情况下。我们试图确定在预授权和治疗药物监测 (TDM) 计划中添加前瞻性审核和反馈是否会进一步降低 AKI 的发生率。方法：我们对入住约翰·霍普金斯医院接受万古霉素≥48 小时的儿童进行了一项准实验研究。比较干预前和干预期间 AKI 的发生率。还探讨了万古霉素相关 AKI 的其他危险因素。 结果：总共 386 个疗程的万古霉素治疗符合资格标准（干预前 200 个疗程，干预期间 186 个疗程）。万古霉素相关 AKI 的发生率在干预前和干预期间没有差异，分别为 8% 和 9%。多变量分析发现，并发肾毒素的数量是万古霉素相关 AKI 的独立预测因子，每增加一个肾毒素，AKI 风险就会增加 40%（调整后 OR，1.40；95% CI，1.06-1.85；p = 0.019）。增加万古霉素相关 AKI 风险的特定肾毒素包括哌拉西林/他唑巴坦、脂质体两性霉素 B 和布洛芬。结论：在预授权和 TDM 计划中添加前瞻性审核和反馈并没有导致 AKI 进一步减少。前瞻性审计和反馈是一项资源密集型干预措施。如果预授权限制和 TDM 已经到位，我们的研究结果表明，如果将管理工作转移到万古霉素相关 AKI 的其他可改变风险因素（例如尽量减少额外的肾毒素）上，管理工作可能会更有效。
OBJECTIVE: Vancomycin causes considerable acute kidney injury (AKI) in children, particularly in the setting of troughs of 15 to 20 mg/L. We sought to determine whether the addition of prospective audit and feedback to a preauthorization and therapeutic drug monitoring (TDM) program further reduces the incidence of AKI.METHODS: We conducted a quasiexperimental study of children admitted to The Johns Hopkins Hospital receiving vancomycin for ≥48 hours. The incidence of AKI was compared between the preintervention and intervention periods. Additional risk factors for vancomycin-associated AKI were also explored.RESULTS: A total of 386 courses of vancomycin therapy met eligibility criteria (200 in the preintervention vs 186 in the intervention period). The incidence of vancomycin-associated AKI did not differ between the preintervention and intervention periods, 8% vs 9%, respectively. On multivariable analysis, the number of concurrent nephrotoxins was found to be an independent predictor of vancomycin-associated AKI, with each additional nephrotoxin increasing the risk of AKI by 40% (adjusted OR, 1.40; 95% CI, 1.06-1.85; p = 0.019). Specific nephrotoxins that increased the risk of vancomycin-associated AKI included piperacillin/tazobactam, liposomal amphotericin B, and ibuprofen.CONCLUSION: The addition of prospective audit and feedback to a preauthorization and TDM program did not result in further AKI reduction. Prospective audit and feedback is a resource-intensive intervention. If preauthorization restrictions and TDM are already in place, our findings suggest stewardship efforts may be more effective if redirected to focus on other modifiable risk factors for vancomycin-associated AKI, such as minimizing additional nephrotoxins.