Rutter W Cliff, Cox Jessica N, Martin Craig A, Burgess Donna R, Burgess David S
University of Kentucky College of Pharmacy, Lexington, Kentucky, USA.
University of Kentucky HealthCare, Lexington, Kentucky, USA.
Antimicrob Agents Chemother. 2017 Jan 24;61(2). doi: 10.1128/AAC.02089-16. Print 2017 Feb.
Recent reports have demonstrated that vancomycin (VAN) may lead to an increase in the incidence of acute kidney injury (AKI) when it is combined with antipseudomonal beta-lactams. This study compared the incidence of AKI associated with VAN plus piperacillin-tazobactam (TZP) or cefepime (FEP). This was a retrospective, matched cohort study that was conducted at an academic medical center between September 2010 and September 2014 and that included adult patients without severe chronic or structural kidney disease, dialysis, pregnancy, cystic fibrosis, or a hospital transfer receiving TZP-VAN or FEP-VAN for at least 48 h. The primary outcome was the difference in the AKI incidence between the TZP-VAN and FEP-VAN groups, evaluated using the risk, injury, failure, loss of kidney function, and end-stage kidney disease (RIFLE) criteria. Patients in the two groups were matched on the basis of age, sex, severity of illness, baseline creatinine clearance, hypotension, number of nephrotoxicity risk factors, and intravenous contrast exposure. In total, 4,193 patients met all inclusion criteria (3,605 received TZP-VAN and 588 received FEP-VAN). The unadjusted AKI incidence was 21.4% in patients receiving TZP-VAN, whereas it was 12.6% in patients receiving FEP-VAN (P < 0.001). After the patients were matched, 1,633 patients receiving TZP-VAN and 578 patients receiving FEP-VAN were evaluated. The AKI incidence remained higher in patients receiving TZP-VAN than in those receiving FEP-VAN (21.4% versus 12.5%, P < 0.0001). This trend remained true for all classifications of the RIFLE criteria. After controlling for remaining confounders, TZP-VAN therapy was associated with 2.18 times the odds of AKI than FEP-VAN therapy (95% confidence interval, 1.64 to 2.94 times) in logistic regression. AKI was significantly more common in patients receiving vancomycin in combination with piperacillin-tazobactam than in those receiving vancomycin in combination with cefepime. This finding reinforces the need for the judicious use of combination empirical antimicrobial therapy.
近期报告显示，万古霉素（VAN）与抗假单胞菌β-内酰胺类药物联用时，可能会导致急性肾损伤（AKI）的发生率增加。本研究比较了VAN联合哌拉西林-他唑巴坦（TZP）或头孢吡肟（FEP）时AKI的发生率。这是一项回顾性匹配队列研究，于2010年9月至2014年9月在一家学术医疗中心进行，纳入的成年患者无严重慢性或结构性肾脏疾病、未接受透析、未怀孕、无囊性纤维化，也未从其他医院转入，且接受TZP-VAN或FEP-VAN治疗至少48小时。主要结局是TZP-VAN组和FEP-VAN组之间AKI发生率的差异，采用风险、损伤、衰竭、肾功能丧失和终末期肾病（RIFLE）标准进行评估。两组患者根据年龄、性别、疾病严重程度、基线肌酐清除率、低血压、肾毒性危险因素数量和静脉造影剂暴露情况进行匹配。共有4193例患者符合所有纳入标准（3605例接受TZP-VAN治疗，588例接受FEP-VAN治疗）。接受TZP-VAN治疗的患者未调整的AKI发生率为21.4%，而接受FEP-VAN治疗的患者为12.6%（P<0.001）。患者匹配后，对1633例接受TZP-VAN治疗的患者和578例接受FEP-VAN治疗的患者进行了评估。接受TZP-VAN治疗的患者AKI发生率仍高于接受FEP-VAN治疗的患者（21.4%对12.5%，P<0.0001）。RIFLE标准的所有分类均呈现这一趋势。在控制了其余混杂因素后，在逻辑回归中，TZP-VAN治疗与AKI的比值比是FEP-VAN治疗的2.18倍（95%置信区间为1.64至2.94倍）。接受万古霉素联合哌拉西林-他唑巴坦治疗的患者中AKI明显比接受万古霉素联合头孢吡肟治疗的患者更常见。这一发现强化了审慎使用联合经验性抗菌治疗的必要性。
