Severe Vancomycin Intoxication in an Infant Not Needing Dialysis: A Case Report and Literature Review

Vancomycin nephrotoxicity is a major clinical concern. We report the case of an infant with severe vancomycin intoxication. A literature review was conducted due to the paucity of reported pediatric cases. An infant was treated for suspected meningitis based on cerebrospinal fluid (CSF) cell count and was empirically started on intravenous ceftriaxone and vancomycin while awaiting the results of culture and meningitis/encephalitis polymerase chain reaction (PCR) tests. Day 2 vancomycin trough level was within the target range; however, the repeat day 4 levels were beyond the upper limit of measurement at >400 µg/mL and associated with acute kidney injury (AKI). Vancomycin was immediately discontinued. The child was treated with intravenous hydration and furosemide and did not require dialysis. The short-term kidney function outcome was reassuring. We identified 23 pediatric cases from 1992 to 2021 with high vancomycin serum levels. Vancomycin level ranges between 32-427 µg/mL. Toxic vancomycin serum levels >400 µg/mL were reported in only two patients. Nephrotoxicity developed in 73.9% of cases. Hemodialysis is the most common management intervention while some patients received watchful management. Kidney function impairment is transient in most reported cases, even in those who received no intervention. However, long-term data are lacking. An intervention is not indicated for all cases of vancomycin intoxication, regardless of serum level. However, in cases of severe nephrotoxicity resistant to medical measures or pre-existing kidney dysfunction, kidney replacement therapy (KRT) is needed to manage severe AKI and speed-up vancomycin clearance.