Background: Recent reports have demonstrated that vancomycin (VAN) may lead to an increase in acute kidney injury (AKI) when combined with anti-pseudomonal beta-lactams. This study compared the incidence of AKI associated with VAN plus piperacillin-tazobactam (TZP) or cefepime (FEP).
Methods: This was a retrospective, matched cohort study at an academic medical center between September 2010 and September 2014 including adult patients receiving TZP-VAN or FEP-VAN for at least 48 hours and without severe chronic or structural kidney disease, dialysis, pregnancy, cystic fibrosis, or hospital transfer. The primary outcome was difference in AKI incidence between TZP-VAN and FEP-VAN, evaluated using RIFLE criteria. Patients were matched based on: age, sex, severity of illness, baseline creatinine clearance, hypotension, number of nephrotoxicity risk factors, and IV contrast exposure.
Key Results: 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 compared to 12.6% in FEP-VAN(p<0.001). After matching, 1,633 patients receiving TZP-VAN and 578 patients receiving FEP-VAN were evaluated. The AKI incidence remained higher in patients receiving TZP-VAN compared to FEP-VAN (21.4% vs. 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 compared to FEP-VAN (95% CI 1.64-2.94) in logistic regression.
Conclusions: AKI was significantly more common in patients receiving vancomycin in combination with piperacillin-tazobactam than cefepime. This finding reinforces the need for judicious use of combination empiric antimicrobial therapy.
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