Intravenous Vancomycin Associated With the Development of Nephrotoxicity in Patients With Class III Obesity

Ann Pharmacother. 2017 Nov;51(11):937-944. doi: 10.1177/1060028017720946. Epub 2017 Jul 14.


Background: A consensus statement recommends initial intravenous (IV) vancomycin dosing of 15-20 mg/kg every 8- 24 hours, with an optional 25- to 30-mg/kg loading dose. Although some studies have shown an association between weight and the development of vancomycin-associated nephrotoxicity, results have been inconsistent.

Objective: To evaluate the correlation between incidence of nephrotoxicity associated with weight-based IV vancomycin dosing strategies in nonobese and obese patients.

Methods: This retrospective cohort study evaluated hospitalized adult patients admitted who received IV vancomycin. Patients were stratified into nonobese (body mass index [BMI] <25 kg/m2), obesity class I and II (BMI 30-39.9kg/m2), and obesity class III (BMI≥40 kg/m2) groups; patients who were overweight but not obese were excluded. Incidence of nephrotoxicity and serum vancomycin trough concentrations were evaluated.

Results: Of a total of 62 documented cases of nephrotoxicity (15.1%), 13 (8.7%), 23 (14.3%), and 26 (26.3%) cases were observed in nonobese, obesity class I and II, and obesity class III groups, respectively ( P=0.002). Longer durations of therapy ( P<0.0001), higher initial maintenance doses in both total milligrams/day ( P=0.0137) and milligrams/kilogram ( P=0.0307), and any trough level >20 mg/L ( P<0.0001) were identified as predictors of development of nephrotoxicity. Concomitant administration of piperacillin/tazobactam, diuretics, and IV contrast were associated with development of nephrotoxicity ( P<0.005, all). Patients with class III obesity were 3-times as likely to develop nephrotoxicity when compared with nonobese patients (odds ratio [OR]=2.99; CI=1.12-7.94) and obesity class I and II patients (OR=3.14; CI=1.27-7.75).

Conclusions: Obesity and other factors are associated with a higher risk of vancomycin-associated nephrotoxicity.

Keywords: body mass index; infection; nephrotoxicity; obesity; patient safety; therapeutic drug monitoring; vancomycin.

MeSH terms

  • Administration, Intravenous
  • Adult
  • Aged
  • Anti-Bacterial Agents / adverse effects*
  • Anti-Bacterial Agents / therapeutic use
  • Body Mass Index
  • Cohort Studies
  • Female
  • Humans
  • Incidence
  • Kidney Diseases / chemically induced*
  • Male
  • Middle Aged
  • Obesity / physiopathology*
  • Odds Ratio
  • Penicillanic Acid / administration & dosage
  • Penicillanic Acid / analogs & derivatives
  • Piperacillin / administration & dosage
  • Piperacillin, Tazobactam Drug Combination
  • Retrospective Studies
  • Vancomycin / administration & dosage
  • Vancomycin / adverse effects*


  • Anti-Bacterial Agents
  • Piperacillin, Tazobactam Drug Combination
  • Vancomycin
  • Penicillanic Acid
  • Piperacillin