Cardiac surgery, Acute kidney injury, Antibiotic prophylaxis, Vancomycin I read with great interest the article by Reineke et al.  about adding vancomycin to perioperative prophylaxis in high-risk cardiac surgery patients to possibly decrease deep sternal wound infections. The study included 1493 patients who were deemed to be at high risk for deep sternal wound infections, and of these, 639 patients received vancomycin in addition to routine cefuroxime prophylaxis. The study reported a significant reduction in deep sternal wound infections in high-risk cardiac surgery patients in whom vancomycin was added to standard cephalosporin antibiotic prophylaxis. Although patients seemed to benefit from a reduced risk of serious wound infections in this study, this needs to be carefully weighed against the well-known risk of vancomycin-associated nephrotoxicity . Acute kidney injury after cardiac surgery is associated with increased morbidity and mortality [3–5]. Teicoplanin may be less nephrotoxic than vancomycin, but has been shown to increase the risk of acute kidney injury, particularly in women and patients with impaired renal function, when used as prophylaxis in cardiac surgery . In the article by Reineke et al. , there was no difference in peak postoperative creatinine or the need for postoperative dialysis between patients who received vancomycin in addition to cefuroxime and those who received only cefuroxime. However, the peak postoperative creatinine and the need for postoperative dialysis are not sensitive measures of renal injury. Prior studies have shown that even minor increases in the postoperative serum creatinine level following coronary artery bypass surgery is associated with long-term all-cause mortality and cardiovascular outcomes independent of preoperative renal function . Therefore, it would be valuable if the authors were able to investigate the incidence of acute kidney injury preferably using the Acute Kidney Injury Network (AKIN) or the Kidney Disease: Improving Global Outcomes (KDIGO) definitions. It is possible that the reduction in the rate of serious wound infections observed in this study led to an increased incidence of acute kidney injury. Fortunately, this question could be addressed if the authors would perform additional analyses. Before a general recommendation to use vancomycin as additional prophylaxis in high-risk patients undergoing cardiac surgery can be made, the complete safety profile of such a strategy must be explored. The article by Reineke et al.  could hopefully provide better evidence in this area, and additional analyses of the collected data have the potential to further inform clinical practice and improve patient care. Conflict of interest: none declared. REFERENCES  Reineke S , Carrel TP , Eigenmann V , Gahl B , Fuehrer U , Seidl C et al. Adding vancomycin to perioperative prophylaxis decreases deep sternal wound infections in high-risk cardiac surgery patients . Eur J Cardiothorac Surg 2018 ; 53 : 428 – 34 . Google Scholar CrossRef Search ADS  Filippone EJ , Kraft WK , Farber JL. The nephrotoxicity of vancomycin . Clin Pharmacol Ther 2017 ; 102 : 459 – 69 . Google Scholar CrossRef Search ADS PubMed  Liotta M , Olsson D , Sartipy U , Holzmann MJ. Minimal changes in postoperative creatinine values and early and late mortality and cardiovascular events after coronary artery bypass grafting . Am J Cardiol 2014 ; 113 : 70 – 5 . Google Scholar CrossRef Search ADS PubMed  Olsson D , Sartipy U , Braunschweig F , Holzmann MJ. Acute kidney injury following coronary artery bypass surgery and long-term risk of heart failure . Circ Heart Fail 2013 ; 6 : 83 – 90 . Google Scholar CrossRef Search ADS PubMed  Ryden L , Sartipy U , Evans M , Holzmann MJ. Acute kidney injury after coronary artery bypass grafting and long-term risk of end-stage renal disease . Circulation 2014 ; 130 : 2005 – 11 . Google Scholar CrossRef Search ADS PubMed  Olsson DP , Holzmann MJ , Sartipy U. Antibiotic prophylaxis by teicoplanin and risk of acute kidney injury in cardiac surgery . J Cardiothorac Vasc Anesth 2015 ; 29 : 626 – 31 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
European Journal of Cardio-Thoracic Surgery – Oxford University Press
Published: Jan 2, 2018
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