Vancomycin as a First-Line Treatment
The large majority of infections in dialysis patients are cause by gram-positive organisms such at Staphylococcus aureus (S. aureus). Vancomycin is often used to treat a fever of unknown in dialysis patients because it is has an excellent ability to kill gram-positive bacteria and it is very convenient to give during dialysis.
- Gram positive bacteria have a cell wall that appears blue or violet under a microscope after being stained with a special dye (Gram stain).
- Vancomycin can be easily given intravenously at the end of each dialysis treatment and no further treatment is usually necessary until the next dialysis.
Vancomycin Resistant Bacteria
Concern about the increasing incidence of vancomycin-resistant organisms has dampened kidney doctor’s enthusiasm for indiscriminate use of vancomycin in dialysis patients. In fact, because of the risk for antibiotic resistance, the Centers for Disease Control (CDC) recommends not using vancomycin for gram-positive bacteria that are sensitive to other antibiotics out of convenience.
- Gram-positive bacteria are frequently sensitive to standard antibiotics such as the penicillins or cephalosporins.
- Vancomycin-resistant enterococcus or VRE is an example of a highly-resistant bacteria that is difficult to treat and becoming more common among dialysis patients.
Cefazolin As a First-Line Treatment
For many infections, using cefazolin (marketed as Ancef®) is a good alternative to using vancomycin until the blood culture results are back. When it comes to most pathogens encountered in the hemodialysis population, it has bacteria killing properties similar to vancomycin. Also, like vancomycin, it can be given in-center three times a week.- Because gram-positive infections are usually not immediately life threatening, it often preferable to initiate treatment with cefazolin instead of vancomycin until cultures results are returned.
- Research studies suggests that cefazolin given after dialysis appears to be a safe and effective as an initial treatment for hemodialysis-related infections.
Vancyomycin should still be used as a first-line treatment for life-threatening infections or when bacteria high-resistant to standard antiobiotics are suspected.
Sources:
Fogel et al. “Cefazolin in chronic hemodialysis patients: a safe, effective alternative to vancomycin”. Am J Kidney Dis. 1998 Sep;32(3):401-9. 16 Mar. 2007.
Stryjewski et al. “Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysis-dependent patients with methicillin-susceptible Staphylococcus aureus bacteremia.” Clin Infect Dis. 2007 Jan 15;44(2):190-6. 16 Mar. 2007.