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**9** 

*1Section of Nephrology 2Department of Medicine 3VA Medical Center* 

*Oklahoma City, OK* 

 *USA* 

*University of Oklahoma Health Sciences Center* 

**Vancomycin-Induced Nephrotoxicity** 

*University of Oklahoma Medical Center and VA Medical Center* 

1Ahmad Bilal\*1,2, Omar Abu-Romeh\*1,2, Talla A. Rousan2 and Kai Lau1,2,3

Nephrotoxicity associated with vancomycin administration has been a topic of debate for over five decades (Tables 1 & 2). Vancomycin is a glycopeptide antibiotic excreted by the kidney and has been used extensively, especially for methicillin-resistant staphylococcus aureus (MRSA) and for many strains of pathogenic staphylococcus epidermis. The nephrotoxic potential of vancomycin is neither fully appreciated nor well characterized. Previously, most reports of acute kidney injury (AKI) associated with vancomycin had blamed the acute renal failure (ARF) on early, relatively impure formulations of vancomycin (impurities popularly known as Mississippi mud). This conventional belief and the ensuing ambiguity if not controversy in the literature about its nephrotoxic potential have led to common notion that it is rather innocuous. Its popularity as an inexpensive and effective anti-staph medication and its widespread use had contributed to the increased incidence of AKI. But the impurity theory

no longer holds because the modern purified preparations are devoid of additives.

\* Both authors contributed equally to the work in this Chapter)

The incidence of vancomycin (Van)-induced AKI (Van-AKI) has been on the rise due to (1) the staphylococcal epidemic, (2) the increasing incidence of health-care associated pneumonia (HCAP) and osteomyelitis (due to mounting use of prosthetic hard-wares and more ready diagnosis by routine MRI and CT scans), and (3) wider acceptance and practice of protracted vancomycin administration as outpatient or in nursing homes, where unfortunately physician involvement and toxicity monitoring are inherently less vigorous. This issue is further compounded by the poor recognition and/or delayed diagnosis due to (1) the outdated notion that vancomycin is relatively benign and safe (Sorrel et al 1985, Kalil et al 2010), (2) the lack of modern guidelines in drug and creatinine monitoring, (3) the recent Infectious Disease (ID) recommendation to target trough levels of 15-20 mg/L in treating MRSA with potentially higher minimal inhibitory concentration (MIC) than the typical sensitivity range of <1 mg/L, (4) the prevailing assumption of renal tolerance based on absolute serum creatinine levels below certain rather arbitrary threshold, instead of using changes in serum creatinine or changes in estimated creatinine clearance from baseline, and

**1. Introduction** 

