Vancomycin-associated nephrotoxicity: grave concern or death by character assassination?
Vancomycin-associated nephrotoxicity: grave concern or death by character assassination?
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DOI：
10.1016/j.amjmed.2009.05.031
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发表时间：
2010-02
影响因子：
5.9
通讯作者：
Hall, Ronald G.
中科院分区：
文献类型：
--
作者：
Hazlewood, Kathleen A.;Brouse, Sara D.;Pitcher, William D.;Hall, Ronald G.
20世纪80年代，0-5%的患者报告了万古霉素相关性肾毒性。在食品和药物管理局(FDA)批准的1g q12h剂量下，将新型抗甲氧西林耐药金黄色葡萄球菌(MRSA)药物与万古霉素进行比较的许多临床试验已经证实了这一点。尽管在体外对万古霉素敏感，但已有报道称万古霉素在MRSA感染患者中治疗失败。这些失败导致万古霉素的使用量高于FDA批准的剂量。为了达到美国传染病学会认可的几个临床实践指南推荐的10-20μg/ml的万古霉素浓度，正在实施更高剂量的万古霉素。最近的研究表明，肾毒性的增加与积极的万古霉素剂量有关。伴随的肾毒素、肾功能不全和/或血流动力学的改变使这些增加的比率变得混乱。这些研究还表明，在没有肾毒性危险因素的患者中，万古霉素的肾毒性风险是最小的。临床医生不愿根据临床实践指南服用万古霉素，应使用替代药物，因为剂量不足会增加选择耐异耐药MRSA菌株的可能性。
Vancomycin-associated nephrotoxicity was reported in 0-5% of patients in the 1980s. This has been confirmed by numerous clinical trials comparing novel anti-methicillin-resistant Staphylococcus aureus (MRSA) agents to vancomycin at the Food and Drug Administration (FDA) approved dose of 1 g q12h. Treatment failures of vancomycin in patients with MRSA infections have been reported despite in vitro susceptibility. These failures have led to the utilization of vancomycin doses higher than those approved by the FDA. Higher doses are being administered to achieve goal vancomycin trough concentrations of 10-20 μg/mL recommended by several Infectious Diseases Society of America (IDSA) endorsed clinical practice guidelines. Recent studies suggest that increased rates of nephrotoxicity are associated with aggressive vancomycin dosing. These increased rates are confounded by concomitant nephrotoxins, renal insufficiency, and/or changing hemodynamics. These studies have also demonstrated that vancomycin's nephrotoxicity risk is minimal in patients without risk factors for nephrotoxicity. Clinicians unwilling to dose vancomycin in accordance with clinical practice guidelines should use an alternative agent since inadequate dosing increases the likelihood of selecting heteroresistant MRSA isolates.
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