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Jensen JUS, Hein L, Lundgren B, Bestle MH, Mohr T, Andersen MH, Thornberg KJ, Løken J, Steensen M, Fox Z, Tousi H, Søe-Jensen P, Lauritsen AØ, Strange DG, Reiter N, Thormar K, Fjeldborg PC, Larsen KM, Drenck NE, Johansen ME, Nielsen LR, Østergaard C, Kjær J, Grarup J, Lundgren JD. Kidney failure related to broad-spectrum antibiotics in critically ill patients: secondary end point results from a 1200 patient randomised trial. BMJ Open 2012; 2:e000635. [PMID: 22411933 PMCID: PMC3307126 DOI: 10.1136/bmjopen-2011-000635] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To explore whether a strategy of more intensive antibiotic therapy leads to emergence or prolongation of renal failure in intensive care patients. DESIGN Secondary analysis from a randomised antibiotic strategy trial (the Procalcitonin And Survival Study). The randomised arms were conserved from the primary trial for the main analysis. SETTING Nine mixed surgical/medical intensive care units across Denmark. PARTICIPANTS 1200 adult intensive care patients, 18+ years, expected to stay +24 h. EXCLUSION CRITERIA bilirubin >40 mg/dl, triglycerides >1000 mg/dl, increased risk from blood sampling, pregnant/breast feeding and psychiatric patients. INTERVENTIONS Patients were randomised to guideline-based therapy ('standard-exposure' arm) or to guideline-based therapy supplemented with antibiotic escalation whenever procalcitonin increased on daily measurements ('high-exposure' arm). MAIN OUTCOME MEASURES Primary end point: estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2). Secondary end points: (1) delta eGFR after starting/stopping a drug and (2) RIFLE criterion Risk 'R', Injury 'I' and Failure 'F'. Analysis was by intention to treat. RESULTS 28-day mortality was 31.8% and comparable (Jensen et al, Crit Care Med 2011). A total of 3672/7634 (48.1%) study days during follow-up in the high-exposure versus 3016/6949 (43.4%) in the 'standard-exposure arm were spent with eGFR <60 ml/min/1.73 m(2), p<0.001. In a multiple effects model, 3 piperacillin/tazobactam was identified as causing the lowest rate of renal recovery of all antibiotics used: 1.0 ml/min/1.73 m(2)/24 h while exposed to this drug (95% CI 0.7 to 1.3 ml/min/1.73 m(2)/24 h) vs meropenem: 2.9 ml/min/1.73 m(2)/24 h (2.5 to 3.3 ml/min/1.73 m(2)/24 h)); after discontinuing piperacillin/tazobactam, the renal recovery rate increased: 2.7 ml/min/1.73 m(2)/24 h (2.3 to 3.1 ml/min/1.73 m(2) /24 h)). eGFR <60 ml/min/1.73 m(2) in the two groups at entry and at last day of follow-up was 57% versus 55% and 41% versus 39%, respectively. CONCLUSIONS Piperacillin/tazobactam was identified as a cause of delayed renal recovery in critically ill patients. This nephrotoxicity was not observed when using other beta-lactam antibiotics. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00271752.
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Affiliation(s)
- Jens-Ulrik Stæhr Jensen
- Copenhagen HIV Programme, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lars Hein
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Glostrup, Glostrup, Denmark
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Hillerød, Hillerød, Denmark
| | - Bettina Lundgren
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Diagnostic Centre at Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten Heiberg Bestle
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Hillerød, Hillerød, Denmark
| | - Thomas Mohr
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Gentofte, Gentofte, Denmark
| | - Mads Holmen Andersen
- Department of Anesthesia and Intensive Care, Aarhus University Hospital in Skejby, Aarhus, Denmark
| | - Klaus Julius Thornberg
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Gentofte, Gentofte, Denmark
| | - Jesper Løken
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Morten Steensen
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Zoë Fox
- Copenhagen HIV Programme, University of Copenhagen, Copenhagen, Denmark
- Royal Free Hospital, School of Medicine, London, UK
| | - Hamid Tousi
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Peter Søe-Jensen
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Anne Øberg Lauritsen
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - Ditte Gry Strange
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - Nanna Reiter
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Roskilde, Denmark
| | - Katrin Thormar
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Gentofte, Gentofte, Denmark
| | - Paul Christian Fjeldborg
- Department of Anesthesia and Intensive Care, Aarhus University Hospital in Skejby, Aarhus, Denmark
| | - Kim Michael Larsen
- Department of Anesthesia and Intensive Care, Aarhus University Hospital in Skejby, Aarhus, Denmark
| | - Niels-Erik Drenck
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Roskilde, Denmark
| | | | - Lene Ryom Nielsen
- Copenhagen HIV Programme, University of Copenhagen, Copenhagen, Denmark
| | - Christian Østergaard
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Clinical Microbiology, Copenhagen University Hospital, Herlev, Denmark
| | - Jesper Kjær
- Copenhagen HIV Programme, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Grarup
- Copenhagen HIV Programme, University of Copenhagen, Copenhagen, Denmark
| | - Jens D Lundgren
- Copenhagen HIV Programme, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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