title: Acute renal failure associated with vancomycin and β-lactams for the treatment of osteomyelitis in diabetics: piperacillin-tazobactam as compared with cefepime.
abstract: Few data are available on the nephrotoxic potential of vancomycin when combined with certain β-lactam antibiotics for the treatment of osteomyelitis (OM). A retrospective cohort study was conducted of all diabetic patients with OM treated with vancomycin plus piperacillin-tazobactam (VPT) or vancomycin plus cefepime (VC) for at least 72 h at a VA Medical Center between 1 January 2006 and 31 December 2011. All patients with a creatinine clearance (CrCl) of ≤ 40 mL/min, a blood urea nitrogen/serum creatinine (SCr) ratio of ≥ 20 : 1 or an absolute neutrophil count of <500 cells/mm(3) were excluded. The primary outcome was development of acute renal failure (ARF), defined as an increase in SCr of 0.5 mg/dL or 50% of baseline. One hundred and thirty-nine patients met the inclusion criteria; 109 in the piperacillin-tazobactam group and 30 in the cefepime group. Among patients receiving VPT, 29.3% (32/109) developed ARF, as compared with 13.3% (4/30) receiving VC (p 0.099). Among patients receiving high-dose therapy (≥ 18 g of piperacillin-tazobactam daily or ≥ 3 g of cefepime daily), 37.5% (9/24) receiving VPT and 17.6% (3/17) receiving VC developed ARF (p 0.29). A multiple logistic regression analysis identified weight and average vancomycin trough as the only significant predictors of ARF; the choice of VPT as therapy yielded an OR of 3.45 (95% CI 0.96-12.40; p 0.057). The authors were unable to detect a statistically significant difference in ARF between groups; however, the power requirement was not met. Further study with a larger patient population seems warranted.
authors.affiliation: Pharmacy Service, VA St Louis Health Care System-John Cochran Division, St Louis, MO, USA; Pharmacy Practice, St Louis College of Pharmacy, St Louis, MO, USA.
authors.forename: R P
authors.initials: RP
authors.lastname: Moenster
authors.forename: T W
authors.initials: TW
authors.lastname: Linneman
authors.forename: P M
authors.initials: PM
authors.lastname: Finnegan
authors.forename: S
authors.initials: S
authors.lastname: Hand
authors.forename: Z
authors.initials: Z
authors.lastname: Thomas
authors.forename: J R
authors.initials: JR
authors.lastname: McDonald
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced*; D000900:Anti-Bacterial Agents / Q000009:adverse effects* / Q000627:therapeutic use; D000077723:Cefepime; D002511:Cephalosporins / Q000009:adverse effects* / Q000627:therapeutic use; D015331:Cohort Studies; D048909:Diabetes Complications / Q000188:drug therapy*; D004359:Drug Therapy, Combination / Q000009:adverse effects / Q000379:methods; D006801:Humans; D015994:Incidence; D008875:Middle Aged; D010019:Osteomyelitis / Q000188:drug therapy*; D010397:Penicillanic Acid / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use; D010878:Piperacillin / Q000009:adverse effects / Q000627:therapeutic use; D000077725:Piperacillin, Tazobactam Drug Combination; D012189:Retrospective Studies; D014640:Vancomycin / Q000009:adverse effects* / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D000077725:Piperacillin, Tazobactam Drug Combination; D014640:Vancomycin; D000077723:Cefepime; D010397:Penicillanic Acid; D010878:Piperacillin
keywords: Acute renal failure; osteomyelitis; vancomycin; β-lactams