万古霉素与达托霉素治疗严重革兰氏阳性感染患者时肾毒性发生的相关因素：一项基于实践的研究。
Factors associated with development of nephrotoxicity in patients treated with vancomycin versus daptomycin for severe Gram-positive infections: A practice-based study.
作者信息
Barberan J, Mensa J, Artero A, Epelde F, Rodriguez J C, Ruiz-Morales J, Calleja J L, Guerra J M, Martínez-Gil I, Giménez M J, Granizo J J, Aguilar L
机构信息
Dr José Barberán, Internal Medicine Department, Hospital Universitario HM Montepríncipe-Universidad San Pablo CEU. Av. de Montepríncipe 25, 28660 Boadilla del Monte, Madrid, Spain.
出版信息
Rev Esp Quimioter. 2019 Feb;32(1):22-30. Epub 2019 Jan 8.
OBJECTIVE
To evaluate nephrotoxicity development in patients treated with vancomycin (VAN) and daptomycin (DAP) for proven severe Gram-positive infections in daily practice.
METHODS
A practice-based, observational, retrospective study (eight Spanish hospitals) was performed including patients ≥18 years with a baseline glomerular filtration rate (GFR)>30 mL/min and/or serum creatinine level<2 mg/dL treated with DAP or VAN for >48h. Nephrotoxicity was considered as a decrease in baseline GRF to <50 mL/min or decrease of >10 mL/min from a baseline GRF<50 mL/min. Multivariate analyses were performed to determine factors associated with 1) treatment selection, 2) nephrotoxicity development, and 3) nephrotoxicity development within each antibiotic group.
RESULTS
A total of 133 patients (62 treated with DAP, 71 with VAN) were included. Twenty-one (15.8%) developed nephrotoxicity: 4/62 (6.3%) patients with DAP and 17/71 (23.3%) with VAN (p=0.006). No differences in concomitant administration of aminoglycosides or other potential nephrotoxic drugs were found between groups. Factors associated with DAP treatment were diabetes mellitus with organ lesion (OR=7.81, 95%CI:1.39-4.35) and basal creatinine ≥0.9 mg/dL (OR=2.53, 95%CI:1.15-4.35). Factors associated with VAN treatment were stroke (OR=7.22, 95%CI:1.50-34.67), acute myocardial infarction (OR=6.59, 95%CI:1.51-28.69) and primary bacteremia (OR=5.18, 95%CI:1.03-25.99). Factors associated with nephrotoxicity (R2=0.142; p=0.001) were creatinine clearance<80 mL/min (OR=9.22, 95%CI:1.98-30.93) and VAN treatment (OR=6.07, 95%CI:1.86-19.93). Factors associated with nephrotoxicity within patients treated with VAN (R2=0.232; p=0.018) were congestive heart failure (OR=4.35, 95%CI:1.23-15.37), endocarditis (OR=7.63, 95%CI:1.02-57.31) and basal creatinine clearance<80 mL/min (OR=7.73, 95%CI:1.20-49.71).
CONCLUSIONS
Nephrotoxicity with VAN was significantly higher than with DAP despite poorer basal renal status in the DAP group.
目的
评估在日常临床实践中，接受万古霉素（VAN）和达托霉素（DAP）治疗确诊的严重革兰氏阳性菌感染患者的肾毒性发生情况。
方法
开展一项基于临床实践的观察性回顾性研究（西班牙的八家医院），纳入年龄≥18岁、基线肾小球滤过率（GFR）>30 mL/分钟和/或血清肌酐水平<2 mg/dL、接受DAP或VAN治疗超过48小时的患者。肾毒性定义为基线GFR降至<50 mL/分钟，或基线GFR<50 mL/分钟时下降>10 mL/分钟。进行多因素分析以确定与以下因素相关的因素：1）治疗选择；2）肾毒性发生；3）各抗生素组内的肾毒性发生。
结果
共纳入133例患者（62例接受DAP治疗，71例接受VAN治疗）。21例（15.8%）发生肾毒性：DAP治疗的患者中有4/62例（6.3%），VAN治疗的患者中有17/71例（23.3%）（p=0.006）。两组间在同时使用氨基糖苷类药物或其他潜在肾毒性药物方面未发现差异。与DAP治疗相关的因素为伴有器官损害的糖尿病（OR=7.81，95%CI：1.39 - 4.35）和基础肌酐≥0.9 mg/dL（OR=2.53，95%CI：1.15 - 4.35）。与VAN治疗相关的因素为中风（OR=7.22，95%CI：1.50 - 34.67）、急性心肌梗死（OR=6.59，95%CI：1.51 - 28.69）和原发性菌血症（OR=5.18，95%CI：1.03 - 25.99）。与肾毒性相关的因素（R2=0.142；p=0.001）为肌酐清除率<80 mL/分钟（OR=9.22，95%CI：1.98 - 30.93）和VAN治疗（OR=6.07，95%CI：1.86 - 19.93）。在接受VAN治疗的患者中与肾毒性相关的因素（R2=0.232；p=0.018）为充血性心力衰竭（OR=4.35，95%CI：1.23 - 15.37）、心内膜炎（OR=7.63，95%CI：1.02 - 57.31）和基础肌酐清除率<80 mL/分钟（OR=7.73，95%CI：1.20 - 49.71）。
结论
尽管DAP组患者的基础肾脏状况较差，但VAN导致的肾毒性显著高于DAP。
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