Early De-Escalation of Vancomycin + Pip/Tazo May Reduce AKI Risk

Researchers sought to determine whether or not antimicrobial de-escalation significantly affects AKI rates.

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SAN DIEGO—Early de-escalation of vancomycin (VAN) plus piperacillin-tazobactam (TZP) antimicrobial therapy might reduce the risk of acute kidney injury (AKI), according to authors of a retrospective database analysis.

“Early antimicrobial de-escalation was associated with significant decreases in AKI incidence in patients receiving empiric VAN and TZP therapy,” reported W. Cliff Rutter, PharmD, MS, University of Kentucky College of Pharmacy, Lexington, KY. “Controlled studies of early antimicrobial de-escalation and AKI are warranted.”

Other recent research findings indicated that combination VAN+TZP therapy might increase AKI but “no data exists linking AKI with delayed antimicrobial de-escalation,” explained Dr. Rutter. 

Using information for patients who received VAN+TZP for ≥48 hours between July 2007 and October 2015 found in the University of Kentucky Center for Clinical and Translational Sciences Enterprise Data Trust database, the study team therefore sought to determine whether or not antimicrobial de-escalation significantly affects AKI rates. 

Data were excluded from analysis for patients who were pregnant, had a history of chronic kidney disease, or who presented with AKI outside the treatment window or at baseline. AKI was assessed with the Risk, Injury, Failure, Loss, End stage (RIFLE) criteria. De-escalation was defined as discontinuation of either or both drugs.

Patients were categorized to reflect treatment duration from baseline (initiation) to de-escalation; patients de-escalated in ≤3 days were categorized as “early,” 4–7 days being “mid-treatment,” and >7 days being “late” de-escalation.

“A total of 4,026 patients met all inclusion criteria, with 1,926 having early, 1,160 with mid-treatment, and 940 with late de-escalation,” Dr. Rutter noted. “Patients in the late de-escalation group were had higher baseline comorbidity, and were more likely to be exposed to concomitant nephrotoxins than patients in the early and mid de-escalation groups.”

AKI was more common among patients in the late group (48.0% vs. 28.1% and 16.6% for mid- and early groups, respectively; P<0.00001).

“After controlling confounders, late de-escalation had significantly higher odds of AKI occurring compared to patients who had early antimicrobial de-escalation” (adjusted odds ratio [aOR] 3.87; 95% CI: 3.16–4.75), Dr. Rutter reported. “Additionally, patients in the mid de-escalation group were more likely to experience AKI compared to those in the early group (aOR 1.88; 95% CI:1.56–2.27). 

Moreover, the authors observed a significant longer length of stay in the late de-escalation group. 

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Rutter CW, Burgess DS. Early antimicrobial de-escalation is associated with decreased acute kidney injury in patients receiving empiric combination therapy. Poster presented at IDWeek; October 4–8, 2017; San Diego, CA. IDWeek.org.