From the Guidelines
Vancomycin is not contraindicated in patients with liver disease. Vancomycin is primarily eliminated by the kidneys, with approximately 80-90% of the drug excreted unchanged in urine, making renal function the primary concern when dosing this antibiotic [ 1 ]. No dose adjustment is needed for patients with hepatic impairment alone. However, if a patient has both liver disease and kidney dysfunction, dose adjustments would be necessary based on the degree of renal impairment. For patients with normal kidney function but liver disease, standard vancomycin dosing can be used, typically 15-20 mg/kg (actual body weight) every 8-12 hours for adults, with target trough concentrations of 10-15 mg/L for most infections or 15-20 mg/L for serious infections like endocarditis, osteomyelitis, or meningitis. Some key points to consider when using vancomycin in patients with liver disease include:
- Monitoring for potential drug interactions if the patient is receiving multiple medications
- Therapeutic drug monitoring to ensure appropriate levels and minimize toxicity, especially in critically ill patients where drug clearance may be altered [ 1 ]
- Being aware that liver disease itself doesn't significantly affect vancomycin metabolism, but patients should still be monitored for signs of toxicity or adverse effects [ 1 ] It's also important to note that the value of vancomycin serum concentration data is controversial in the published literature [ 1 ], and toxicity does not appear to be related to serum levels of vancomycin [ 1 ]. However, therapeutic drug monitoring is still recommended to ensure appropriate levels and minimize toxicity.
From the Research
Vancomycin Contraindication in Liver Disease
- Vancomycin is not absolutely contraindicated in patients with liver disease, but its use requires careful consideration and monitoring of liver function indicators 2, 3, 4, 5.
- Studies have shown that vancomycin can cause abnormal liver function indicators, such as elevated aspartate aminotransferase, alanine aminotransferase, alpha fetoprotein, and jaundice, in some patients with liver disease 2.
- The incidence of liver injury associated with vancomycin is generally considered low, but it can still occur, and liver function should be monitored during vancomycin treatment 2, 4.
- Patients with moderate-to-severe liver disease may be at higher risk of vancomycin-induced nephrotoxicity and mortality, and the existence of chronic liver disease should be considered when monitoring toxicity from vancomycin 4.
- The pharmacokinetics of vancomycin can be affected by liver dysfunction, and the dose and schedule of vancomycin may need to be adjusted for patients with liver impairment 3, 5.
Key Findings
- A study of 4562 patients who received vancomycin found that 17 patients (0.37%) developed liver injury, with a mean time to onset of 4.53 days 2.
- Another study found that patients with moderate-to-severe liver disease had higher vancomycin trough levels and mortality rates compared to those with mild liver disease 4.
- A study of 319 hospitalized patients who received vancomycin found that increasing age, body weight, vancomycin dose and trough levels, and critically ill patients were associated with significant increases in blood urea and serum creatinine levels 6.
- The effects of liver function on vancomycin disposition have been demonstrated, with impaired liver function resulting in a longer half-life and decreased total clearance of vancomycin 5.