Relationships between creatinine increase and mortality rates in patients given vancomycin in 76 hospitals: The increasing role of infectious disease pharmacists.

PURPOSE: Vancomycin is a commonly used antimicrobial with the potential for renal toxicity. We evaluated vancomycin duration, changes in renal function after vancomycin initiation ("post-vancomycin" renal function changes), and associated mortality risk among hospitalized patients. METHODS: We analyzed data from 76 hospitals and excluded patients with a baseline serum creatinine concentration (SCr) of >3.35 mg/dL. We estimated mortality risk relative to vancomycin duration and the magnitude of post-vancomycin SCr change, controlling for demographics, baseline SCr, underlying diseases, clinical acuity, and comorbidities. RESULTS: Among 128,993 adult inpatients treated with vancomycin, 49.0% did not experience SCr elevation. Among the remaining patients, 26.0%, 11.4%, 8.8% and 4.8% experienced increases in post-vancomycin SCr of 1% to 20%, 21% to 40%, 41% to 100%, and greater than 100%, respectively. Compared to mortality risk among patients with a vancomycin therapy duration between 4 and 5 days (the lowest-mortality group), longer vancomycin therapy duration was not independently associated with higher mortality risk after adjusting for confounders. In contrast, there was a graded relationship between post-vancomycin SCr elevation and mortality. Multivariable adjusted mortality odds ratios ranged from 1.60 to 13.66, corresponding to SCr increases of 10% and greater than 200%, respectively. CONCLUSION: Half of patients given vancomycin did not experience SCr elevation and had the lowest mortality, suggesting that vancomycin can be used safely if renal function is stabilized. In the large study cohort, vancomycin duration itself was not an independent predictor of mortality. Post-vancomycin SCr elevation appeared to be a driver of in-hospital mortality. Even a 10% post-vancomycin SCr increase was associated with an increased mortality risk. This finding stresses the importance of closely monitoring renal function and may support the value of pharmacokinetic dosing.

Variability in intravenous medication practices: implications for medication safety.

BACKGROUND: Infusion devices can be programmed with individual hospitals' "best practice" rules for intravenous (i.v.) drug administration, and alerts can be provided if dosages fall outside pre-established limits. High variation levelsare common in medical care but can increase safety risk if the variation is unnecessary. METHODS: The i.v. best practice data sets of drugs from 100 hospitals using one manufacturer's infusion devices were compared to assess the number of drug names used and thevariation in concentrations, dose units, dose limits, and administration practices. RESULTS: The 100 hospitals showed an average of 64 drugs per data set and an average of 113 different drug/concentration 4 combinations. On average, each hospital had designated 6 profiles or unique patient care areas; there were 4 different names per drug across the hospitals (for example, amiodarone had 45 different names). High levels of variation in concentrations were ubiquitous. Overall, 60% of medications had more than one continuous dosage unit (range, 1-9). Variation was also noted in bolus dosing; 59 (50%) of 119 drugs had more than one unit (range, 1-4). Dose limits also varied substantially but were difficult to assess since the limits typically varied withthe indication. CONCLUSIONS: Substantial unnecessary variation in i.v. medication practicesis likely associated with increased risk of harm. Standardization has the potential to substantially improve i.v. medication safety.