Renal insufficiency vancomycin

Antibiotics with activity against urease-producing bacteria, such as neomycin [42], paromomycin [44] or metronidazole [45], also reduce the production of intestinal ammonia and have proved to be of value. Vancomycin has also been used in patients with lactulose-resistant chronic encephalopathy [46]. The efficacy of neomycin is similar to that of lactulose [42]. However, a small percentage of this drug is absorbed from the gastrointestinal tract and may cause ototoxic and nephrotoxic effects, especially with continuous use over several months [47]. This drug should be used with particular caution by patients with renal insufficiency. The efficacy of metronidazole for... 

Vancomycin is not absorbed after oral administration and must be given intravenously. Oral administrations are used for intraluminal gastrointestinal infections such as antibiotic-associated pseudomembranous colitis produced by Clostridium difficile. Vancomycin is widely distributed in the body but does not cross the blood brain barrier and does not penetrate into bone. It is excreted mainly via the urine, resulting in accumulation in patients with renal insufficiency. Its elimination half-life is 4-11 hours but can increase to 6-10 days in renal failure. 

Vancomycin is poorly absorbed from the intestinal tract and is administered orally only for the treatment of antibiotic-associated enterocolitis caused by Clostridium difficile. Parenteral doses must be administered intravenously. A 1 hour intravenous infusion of 1 g produces blood levels of 15-30 jig/mL for 1-2 hours. The drug is widely distributed in the body. Cerebrospinal fluid levels 7-30% of simultaneous serum concentrations are achieved if there is meningeal inflammation. Ninety percent of the drug is excreted by glomerular filtration. In the presence of renal insufficiency, striking accumulation may occur (Table 43-2). In functionally anephric patients, the... 

A 58-year-old woman with end-stage renal insufficiency secondary to diabetic nephropathy developed abdominal wall cellulitis 4 days after insertion of a peritoneal dialysis catheter. She was given vancomycin, cefepime, and metronidazole in reduced doses (doses not stated) and 2 days later developed dysarthria, an intention tremor, dysmetria, and dysdiadochokinesia. Routine biochemical tests were unchanged and a CT scan of the brain was unremarkable, but an MRI scan showed cerebral and cerebellar atrophy with multifocal ischemic glial lesions. Metronidazole was withdrawn and 2 days later her symptoms and signs had completely resolved. 

A 14-month-old girl with chronic renal insufficiency due to renal dysplasia was empirically treated with ceftazidime and vancomycin for fever. Her calculated creatinine clearance was 10 ml/minute/1.73 m. She erroneously received vancomycin 1.5 g in 3 doses 6 hours apart. Her serum creatinine concentration increased and her vancomycin concentrations remained markedly high (338 mg/1 5 hours after the third dose). The half-Ufe of vancomycin was 145 hours. Hearing loss developed. Continued charcoal hemoperfusion and hemodialysis were used to treat the disorder. Thrombocytopenia was noted as significant consequence of hemoperfusion. The patient did not fully recover her previous renal function and became dialysis dependent. The audiogram normalized by 6 months. 

Vancomycin-induced neutropenia occurs in about 2% of treated patients, and complete recovery takes place in 2-5 days after withdrawal (43,44). It occurs after prolonged treatment with high doses in patients with normal renal function (for example more than 20 days of more than 15-20 mg/kg) or in the prolonged presence of high serum concentrations in patients with severe renal insufficiency (45). After withdrawal of vancomycin, neutropenia disappeared promptly. The bone marrow seemed to be unaffected. Other cases of agranulocytosis related to vancomycin therapy have been reported (46-48). 

An 87-year-old white woman treated with vancomycin and phenytoin and a 65-year-old white man with renal insufficiency developed linear immunoglobulin A bullous disease (79,80). 

In a 6-day-old neonate with a solitary hypodysplastic kidney, suspected sepsis, and acute renal insufficiency, venovenous hemodiafiltration with a high-flux membrane was successfully used to treat a 10-fold overdose of vancomycin (115). 

A 17-year-old anuric woman with end-stage renal insufficiency received a massive overdose of vancomycin (40 mg/kg/day for 8 days) and was treated three times with high-flux hemodiafUtration with a polysulfone membrane (134). The vancomycin concentration fell from 101 to 17 mg/1 at the end of the procedure. There were no adverse effects of either vancomycin or hemodiafUtration. 

Urinary tract In a retrospective matched-cohort study, 38 and 76 patients with MRSA bacteremia received co-trimoxazole or vancomycin respectively there was renal insufficiency in 28-29% [120 ]. 

Urinary tract Treatment with tenofovir in combination with prolonged administration of vancomycin caused renal insufficiency in two HIV-positive patients [93 ]. 

Skin Several cases of skin reactions after vancomycin have been reported. In an 82-year-old woman with chronic renal insufficiency oral vancomycin 250 mg qds caused a pruritic rash similar to red man syndrome the rash abated after vancomycin withdrawal and treatment with antihistamines [96 ]. 

Yamazaki S, Nakamura H, Yamagata S, Miura G, Hattori N, Shinozaki K, Sadahiro T, Toyoda A, Nakasa H, Ariyoshi N, Oda S, Harigaya K, Kitada M. Unexpected serum level of vancomycin after oral administration in a patient with severe colitis and renal insufficiency. Int J Clin Pharmacol Ther 2009 47(11) 701-6. 

Renal insufficiency, usually reversible, is common after the procedure and commonly related to the use of nephrotoxic drugs such as ciclosporin, tacrolimus, vancomycin or amphotericin B. In a minority of instances dialysis may be required. Microangiopathic hemolysis and thrombocytopenia secondary to ciclosporin or tacrolimus may further... 

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