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Should Vancomycin Use in Dialysis Patients Be Restricted?

The royal dominion of Nephrology has been invaded by the government again. This time, the feds are telling nephrologists how they ought to use (and not use) vancomycin, the antibiotic ideally suited for the treatment of many gram-positive infections in patients on renal replacement therapy. The Centers for Disease Control and Prevention (CDC) through its Hospital Infection Control Practices and Advisory Committee (HICPAC) has singled out nephrologists with two of its recommendations for prudent vancomycin use (1). Under the heading “Situations in which the use of vancomycin should be discouraged,” one reads: ‘‘Routine prophylaxis for patients on continuous ambulatory peritoneal dialysis or hemodialysis” and “Treatment (chosen for dosing convenience) of infections caused by beta-lactam-sensitive gram-positive microorganisms in patients who have renal failure.” Although the response of the dialysis community to these recommendations has neither been tabulated nor formalized, the expression “Where do they get off?” has figured prominently in local discussions. Physicians who haven’t encountered vancomycin-resistant enterococci (VRE) are especially puzzled and dismayed. Indeed, to understand the HICPAC recommendations regarding vancomycin use, it is necessary to appreciate the recent emergence of VRE and the threat that they pose to the health of the nation (2, 3). Accordingly, this editorial will provide a brief review of the enterococci and the rise of VRE before tackling the wisdom of applying the HICPAC guidelines for vancomycin use in dialysis patients. Enterococci-gram-positive, facultatively anaerobic bacteria-are well known to most nephrologists as constituents of the normal human flora, especially of the colon, which occasionally cause intraabdominal infections, urinary tract infections or endocarditis. This traditional understanding of enterococci, however, has undergone several changes in the past decade. First, there has been a name change. Though long classified with the Group D streptococci, DNA homology studies in the 1980s indicated that the enterococci differed substantially from other streptococci (4). Consequently, they were assigned to a new genus. There are two major species in this genus: Enterococcus faecalis, which