O'Hara Nathan N, Carullo Jessica, Joshi Manjari, Banoub Mary, Claeys Kimberly C, Sprague Sheila, Slobogean Gerard P, O'Toole Robert V
Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA.
Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA.
Bone Jt Open. 2022 Apr;3(4):284-290. doi: 10.1302/2633-1462.34.BJO-2022-0009.R1.
There is increasing evidence to support the use of topical antibiotics to prevent surgical site infections. Although previous research suggests a minimal nephrotoxic risk with a single dose of vancomycin powder, fracture patients often require multiple procedures and receive additional doses of topical antibiotics. We aimed to determine if cumulative doses of intrawound vancomycin or tobramycin powder for infection prophylaxis increased the risk of drug-induced acute kidney injury (AKI) among fracture patients.
This cohort study was a secondary analysis of single-centre Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT) trial data. We included patients with a surgically treated appendicular fracture. The primary outcome was drug-induced AKI. The odds of AKI per gram of vancomycin or tobramycin powder were calculated using Bayesian regression models, which adjusted for measured confounders and accounted for the interactive effects of vancomycin and tobramycin.
Of the 782 included patients (mean age 48 years (SD 20); 59% male), 83% (n = 648) received at least one vancomycin dose (cumulative range 1 to 12 g). Overall, 45% of the sample received at least one tobramycin dose (cumulative range 1.2 to 9.6 g). Drug-induced AKI occurred in ten patients (1.2%). No association was found between the cumulative dose of vancomycin and drug-induced AKI (odds ratio (OR) 1.08 (95% credible interval (CrI) 0.52 to 2.14)). Additional doses of tobramycin were associated with a three-fold increase in the adjusted odds of drug-induced AKI (OR 3.66 (95% CrI 1.71 to 8.49)). Specifically, the risk of drug-induced AKI rose substantially after 4.8 g of tobramycin powder (7.5% (95% CrI 1.0 to 35.3)).
Cumulative doses of vancomycin were not associated with an increased risk of drug-induced AKI among fracture patients. While the risk of drug-induced AKI remains less than 4% with three or fewer 1.2 g tobramycin doses, the estimated risk increases substantially to 8% after four cumulative doses. Level of evidence: Therapeutic Level III Cite this article: 2022;3(4):284-290.
越来越多的证据支持使用局部用抗生素预防手术部位感染。尽管先前的研究表明单剂量万古霉素粉末的肾毒性风险极小，但骨折患者通常需要进行多次手术并接受额外剂量的局部用抗生素。我们旨在确定伤口内使用万古霉素或妥布霉素粉末的累积剂量用于预防感染是否会增加骨折患者发生药物性急性肾损伤（AKI）的风险。
这项队列研究是对单中心评估骨科创伤术前抗菌皮肤溶液的随机试验项目（PREP-IT）试验数据的二次分析。我们纳入了接受手术治疗的四肢骨折患者。主要结局是药物性AKI。使用贝叶斯回归模型计算每克万古霉素或妥布霉素粉末导致AKI的几率，该模型对测量的混杂因素进行了调整，并考虑了万古霉素和妥布霉素的交互作用。
在纳入的782例患者中（平均年龄48岁（标准差20）；59%为男性），83%（n = 648）接受了至少一剂万古霉素（累积剂量范围为1至12克）。总体而言，45%的样本接受了至少一剂妥布霉素（累积剂量范围为1.2至9.6克）。10例患者（1.2%）发生了药物性AKI。未发现万古霉素累积剂量与药物性AKI之间存在关联（优势比（OR）为1.08（95%可信区间（CrI）为0.52至2.14））。额外剂量的妥布霉素与药物性AKI调整后的几率增加三倍相关（OR为3.66（95% CrI为1.71至8.49））。具体而言，在使用4.8克妥布霉素粉末后，药物性AKI的风险大幅上升（7.5%（95% CrI为1.0至35.3））。
骨折患者中万古霉素的累积剂量与药物性AKI风险增加无关。虽然使用三剂或更少的1.2克妥布霉素时，药物性AKI的风险仍低于4%，但累积四剂后估计风险大幅增加至8%。证据级别：治疗性III级 引用本文：2022；3(4):284-290。
