Vancomycin nephrotoxicity

Now that we are giving higher doses to get around the problem of MRSA treatment failure this issue is surfacing. Is it a real problem? The evidence suggests it is, but there are confounders. The topic is reviewed in a recent issue of the American Journal of Medicine:

Recent studies suggest that increased rates of nephrotoxicity are associated with aggressive vancomycin dosing. These increased rates are confounded by concomitant nephrotoxins, renal insufficiency, or changing hemodynamics. These studies also have demonstrated that vancomycin's nephrotoxicity risk is minimal in patients without risk factors for nephrotoxicity. Clinicians unwilling to dose vancomycin in accordance with clinical practice guidelines should use an alternative agent because inadequate dosing increases the likelihood of selecting heteroresistant methicillin-resistant S. aureus isolates.