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Kidney Week

Abstract: PO2378

Systemic Absorption of Vancomycin from Sternal Slurry Contributing to Vancomycin Nephrotoxicity

Session Information

Category: Trainee Case Report

  • 1800 Pharmacology (PharmacoKinetics, -Dynamics, -Genomics)

Authors

  • Li, David Yujie, Vanderbilt University, Nashville, Tennessee, United States
  • Golper, Thomas A., Vanderbilt University, Nashville, Tennessee, United States
Introduction

Vancomycin has come a long way since its start as “Mississippi mud”. It has been a valuable and safe agent in general. Adverse reactions include flushing and acute kidney injury. Clinicians are developing strategies to circumvent these problems. One strategy is the use of antibiotic slurry/paste applied to infected tissue. This has traditionally not been associated with systemic vancomycin toxicity.
We report here an incidence of vancomycin nephrotoxicity secondary to a sternal vancomycin slurry that required dialysis.

Case Description

A 62-year-old 91 kg man with Marfan’s Syndrome and total aortic arch replacement presented with mediastinal abscess and recurrent sternal osteomyelitis. Exam revealed a fluctuant sternal lump and a trans-thoracic echo revealed a circumferential fluid collection around the aortic graft. He underwent a “redo” sternotomy, exploration and drainage. Plasma creatinine concentration (Pcr) on admission was 0.76 mg/dL, his known baseline. He received one dose of 1250 mg IV vancomycin prior to the operation. Intra-operatively 4 grams of vancomycin paste was applied to his sternum. That evening he received cefepime 2g IV and vancomycin 1250 mg IV (see figure), both scheduled to be repeated every 12 hours. Pcr and vancomycin troughs are detailed in the figure. On POD2 serum vancomycin trough was 42 mg/L. Intravenous vancomycin was discontinued after he had received 5 doses each of 1250 mg. By POD3 his Pcr had risen to 5.29 mg/dL, urine output dropped to 125 mL/day and the Nephrology Service was consulted. On POD4 the serum vancomycin was 48 mg/L and Pcr 6.45mg/dL. He was emergently dialyzed. After 5 rounds of dialysis, serum vancomycin concentration lowered to 8 mg/L and Pcr to 2.77 mg/dL. Urine output improved to 1200 mL/day. He was discharged on POD14 on daptomycin and ceftriaxone. On POD21 at follow-up, serum vancomycin was undetectable and Pcr was 1.08 mg/DL.

Discussion

There can be substantial unaccounted systemic absorption from vancomycin paste. The POD4 4 AM serum level was 48 mg/dL and he was dialyzed 14 hours later under operating conditions such that the level should be reduced by at least one-third. The post dialysis level was 47 mg/dL, so by conservative estimation his predialysis level was about 70 mg/L, suggesting that there was a substantial contribution of vancomycin to the serum level in that 17-hour interval from sternal slurry.