Large Vancomycin Overdose in Two Premature Infants with Minimal Toxicity

ABSTRACT

Two premature infants received 10-fold overdoses of vancomycin with resulting peak plasma concentrations > 300 μg/mL. Discontinuation of vancomycin and watchful waiting were employed, with no specific intervention to accelerate vancomycin clearance. Plasma vancomycin concentration < 40 μg/mL was attained at < 48 hours in one infant and < 72 hours in the other. Although one infant sustained a transient increase in serum creatinine to 1.4 mg/dL, no further evidence of renal, auditory, or other toxicity was detected in either infant acutely or long term. Contemporary preparations of vancomycin appear much less toxic than earlier formulations. Aggressive and invasive interventions to hasten clearance may be unnecessary following overdose in infants with normal or near-normal basal renal function, although careful surveillance for clearance and toxic effects still appear warranted.

KEYWORDS

Vancomycin - ototoxicity - nephrotoxicity - overdose - premature infant

REFERENCES

• 1 Griffith R S. Introduction to vancomycin.  Rev Infect Dis. 1981;  3(suppl) S200-S204
• 2 Brown R, Wise W. Vancomycin: a reappraisal.  BMJ. 1982;  284 1508-1509
• 3 Elting L S, Rubenstein E B, Kurtin D et al.. Mississippi mud in the 1990s: risks and outcomes of vancomycin-associated toxicity in general oncology practice.  Cancer. 1998;  83 2597-2607
• 4 Geraci J F. Vancomycin.  Mayo Clin Proc. 1977;  52 631-634
• 5 Walker R W, Heaton A. Thrombocytopenia due to vancomycin.  Lancet. 1985;  1 932
• 6 Mackett R L, Guay D R. Vancomycin-induced neutropenia.  Can Med Assoc J. 1985;  132 39-40
• 7 Wilhelm M P. Vancomycin.  Mayo Clin Proc. 1991;  66 1165-1170
• 8 Cole D R, Oliver M, Coward R A, Brown C B. Allergy, red man syndrome and vancomycin.  Lancet. 1985;  2 80
• 9 Farber B F, Moellering Jr R C. Retrospective study of the toxicity of preparations of vancomycin from 1974 to 1981.  Antimicrob Agents Chemother. 1983;  23 138-141
• 10 Woodley D W, Hall W H. Treatment of severe staphylococcal infections with vancomycin.  Ann Intern Med. 1961;  55 235-249
• 11 Bailie G R, Neal D. Vancomycin ototoxicity and nephrotoxicity: a review.  Med Toxicol Adverse Drug Exp. 1988;  3 376-386
• 12 Appel G B, Neu H C. The nephrotoxicity of antimicrobial agents.  N Engl J Med. 1977;  296 722-729
• 13 Wenzel R P. The emergence of methicillin resistant Staphylococcus aureus .  Ann Intern Med. 1982;  97 440-442
• 14 Brummett R E. Ototoxicity of vancomycin and analogues.  Otolaryngol Clin North Am. 1993;  26 821-828
• 15 Hook III E W, Johnson W D. Vancomycin therapy of bacterial endocarditis.  Am J Med. 1978;  65 411-415
• 16 Mellor J A, Kingdom J, Cafferkey M, Keane C T. Vancomycin toxicity: a prospective study.  J Antimicrob Chemother. 1985;  15 773-780
• 17 Gendeh B S, Gibb A G, Aziz N S et al.. Vancomycin administration in continuous ambulatory hemodialysis: the risk of ototoxicity.  Otolaryngol Head Neck Surg. 1998;  118 551-558
• 18 Brummett R E, Fox K E. Vancomycin- and erythromycin-induced hearing loss in humans.  Antimicrob Agents Chemother. 1989;  33 791-796
• 19 Cantu T G, Yamanaka-Yuen N A, Lietman P S. Serum vancomycin concentrations: reappraisal of their clinical value.  Clin Infect Dis. 1994;  19 1180-1182
• 20 De Hoog M, van Zanten B A, Hop W C et al.. Newborn hearing screening: tobramycin and vancomycin are not factors for hearing loss.  J Pediatr. 2003;  142 41-46
• 21 Masur H, Francioli P, Ruddy M, Murray H W. Vancomycin serum levels and toxicity in chronic hemodialysis patients with Staphylococcus aureus bacteremia.  Clin Nephrol. 1983;  20 85-88
• 22 Burkhart K K, Metcalf S, Shurnas E et al.. Exchange transfusion and multidose activated charcoal following vancomycin overdose.  J Toxicol Clin Toxicol. 1992;  30 285-294
• 23 Bunchman T E, Valentini R P, Gardner J et al.. Treatment of vancomycin overdose using high-efficiency dialysis membranes.  Pediatr Nephrol. 1999;  13 773-774
• 24 Akil I Ö, Mir S. Hemodiafiltration for vancomycin overdose in a patient with end-stage renal failure.  Pediatr Nephrol. 2001;  16 1019-1021
• 25 Walczyk M H, Hill D, Arai A, Wolfson M. Acute renal failure owing to inadvertent vancomycin overdose. Vancomycin removal by continuous arteriovenous hemofiltration.  Ann Clin Lab Sci. 1988;  18 440-443
• 26 Panzarino V M, Feldstein T J, Kashtan C E. Charcoal hemoperfusion in a child with vancomycin overdose and chronic renal failure.  Pediatr Nephrol. 1998;  12 63-64
• 27 Goebel J, Ananth M, Lewy J E. Hemodiafiltration for vancomycin overdose in a neonate with end-stage renal failure.  Pediatr Nephrol. 1999;  13 423-425
• 28 Lutz H, Lenarz T, Weidauer H, Federspil P, Hoth S. Ototoxicity of vancomycin: an experimental study in guinea pigs.  ORL J Otorhinolaryngol Relat Spec. 1991;  53 273-278
• 29 Nishihara K, Shimizu T, Kotaki H et al.. Lack of effect of vancomycin and gentamicin on auditory function in guinea pigs.  Antimicrob Agents Chemother. 1996;  40 1098-1103
• 30 Tange R A, Lieviet H L, Marle J et al.. An experimental study of vancomycin-induced cochlear damage.  Arch Otorhinolaryngol. 1989;  246 67-70
• 31 Davis R R, Brummett R E, Bendrick T W, Himes D L. The ototoxic interaction of viomycin, capreomycin, and polymyxicn B with ethacrynic acid.  Acta Otolaryngol. 1982;  93 211-217
• 32 Brummett R E, Fox K E, Jacobs F et al.. Augmented gentamicin ototoxicity induced by vancomycin in guinea pigs.  Arch Otolaryngol Head Neck Surg. 1990;  116 61-64
• 33 Aronoff G R, Sloan R S, Dinwiddie Jr C B et al.. Effects of vancomycin on renal function in rats.  Antimicrob Agents Chemother. 1981;  19 306-308
• 34 Cohen E, Dadashev A, Drucker M et al.. Once-daily versus twice-daily intravenous administration of vancomycin for infections in hospitalized patients.  J Antimicrob Chemother. 2002;  49 155-160
• 35 Wood C A, Kohlhepp S J, Kohnen P W et al.. Vancomycin enhancement of experimental tobramycin nephrotoxicity.  Antimicrob Agents Chemother. 1986;  30 20-24
• 36 Goetz M B, Sayers J. Nephrotoxicity of vancomycin and aminoglycoside therapy separately and in combination.  J Antimicrob Chemother. 1993;  32 325-334
• 37 Sorrell T C, Collignon P J. A prospective study of adverse reactions associated with vancomycin therapy.  J Antimicrob Chemother. 1985;  16 235-241
• 38 Rybak M J, Albrecht L M, Boike S C, Chanresekar P H. Nephrotoxicity of vancomycin, alone and with an aminoglycoside.  J Antimicrob Chemother. 1990;  25 679-687
• 39 Goren M P, Baker Jr D K, Shenep J L. Vancomycin does not enhance amikacin-induced tubular nephrotoxicity in children.  Pediatr Infect Dis J. 1989;  8 278-282
• 40 Nakata M C. Lack of nephrotoxicity in pediatric patients receiving concurrent vancomycin and aminoglycoside therapy.  Chemotherapy. 1987;  33 302-304
• 41 Hall J W, Brown D P, Mackey-Hargadine J R. Pediatric applications of serial auditory brainstem and middle latency evoked response recordings.  Int J Pediatr Otorhinolaryngol. 1985;  9 201-218
• 42 Müller D, Hufnagel M, Suttorp M. Accidental overdose of vancomycin in preterm twins.  Pediatr Infect Dis J. 1999;  18 744-745