A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community hospital developed methicillin-resistant staphylococcus aureus (MRSA) bacteremia and endophthalmitis originating from her port. Vancomycin 1.25 grams intravenously twice daily was initiated, and the patient was transferred to a large academic medical center for ophthalmologic consultation and further treatment. Vancomycin was continued upon transfer until she was found to have a rapidly rising serum creatinine (Scr). The initial Scr was 0.4 mg/dL at the community hospital; it had increased to 0.8 mg/dL on admission to the receiving facility and was apparently interpreted as "normal," since it still fell within "normal" range. The patient was recognized to be in acute renal failure when her creatinine reached 1.09 mg/dL the day after transfer. Notably, the vancomycin trough at this time was 64 mg/L. The vancomycin blood level had not been checked previously throughout her treatment.
As a result of her renal failure, the patient rapidly developed non-anion gap metabolic acidosis and, 5 days after transfer, required urgent dialysis for volume overload and worsening acid-base status. Urine and blood studies failed to identify a clear cause of her renal failure. At present, the patient continues to be anuric and dialysis dependent, and she will likely leave the hospital receiving palliative chemotherapy and a 6-week course of vancomycin. She has a new tunneled catheter for ongoing dialysis treatments.
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