2025 Southeastern Residency Conference

Title: Incidence of AKI Before and After Implementation of a Pharmacy-Driven Intravenous Acyclovir Protocol 

Authors: Eryn Meegan, Will Anderson, Dustin Ziegler, Kishan Patel

Objective: To assess the occurrence of AKI rates before and after implementing a pharmacy-driven intravenous acyclovir protocol aimed at optimizing dosing and intravenous hydration

Self-Assessment Question: True or False - Pharmacy involvement resulted in increased IV fluids ordered alongside IV acyclovir

Background: Acyclovir, a nucleoside analogue antiviral, is a well-recognized cause of drug-induced acute kidney injury (AKI) through crystal nephropathy, which results from intratubular obstruction due to crystalline precipitation in distal tubular lumens. In order to mitigate the risk of acyclovir-induced nephrotoxicity, the Cone Health Pharmacy and Therapeutics Committee approved and implemented a pharmacy-driven intravenous acyclovir protocol in May 2022. With this protocol, the pharmacy team aimed to improve patient safety by providing tailored dosing recommendations and ensuring appropriate fluid administration. The purpose of this study was to evaluate the effect of implementing this pharmacy-driven protocol on AKI rates. 

Methods: This institutional review board-approved, retrospective cohort study evaluated the implementation of a pharmacy-driven protocol to reduce the risk of AKIs in patients on intravenous acyclovir. This study was conducted within Cone Health, a single hospital system, between April 2020 to August 2024. Patients were included if they were 18 years or older and received at least 24 hours of intravenous acyclovir within the pre-consult implementation period of April 2020 to April 2022 or the post-consult implementation period of August 2022 to August 2024. Patients were excluded if they had end-stage renal disease, presented with an AKI, if baseline renal function was unknown, or if serum creatinine was not trended throughout the duration of acyclovir treatment. The primary endpoint was the incidence of AKI as defined by the 2012 KDIGO guidelines: an increase in serum creatinine by greater than or equal to 0.3 mg/dL within 48 hours, or an increase in serum creatinine to greater than or equal to 1.5 times baseline within the prior 7 days. The secondary endpoint evaluates the protocol's effectiveness in preventing AKI by assessing duration of intravenous fluid administration ordered per protocol. Fisher's exact test and descriptive statistics were used to analyze the data as appropriate.  

Results: Of the 120 patient charts reviewed, 31 met inclusion criteria (11 in the pre-implementation period and 20 in the post-implementation period). Baseline characteristics were similar between the two groups. Notably, more patients in the post-implementation group were on concomitant nephrotoxic agents compared to the pre-implementation group (13 patients vs. 8 patients). Median duration of acyclovir therapy increased from 2.4 days (IQR 1.7–4.0) in the pre-implementation group to 3.3 days (IQR 2.5–4.9) in the post-implementation group. The rate of AKI was 18% before implementation and increased to 25% after implementation, though this difference did not reach statistical significance (P = 0.38). Intravenous fluids were ordered for all patients (100%) compared to 82% pre-implementation, though this difference was not statistically significant (P = 0.12). The median duration of IV fluid administration significantly increased from 0.8 days (IQR 0.3–2.4) to 3.5 days (IQR 2.9–6.4) post-implementation (P = 0.0006). The rate of appropriate acyclovir dosing remained consistent between groups (91% vs 90%, P = 0.93). Similarly, the frequency of under-dosing was low and comparable (9% vs 10%, P = 0.99), and no patients in either group were over-dosed.

Conclusion: Implementation of a pharmacy-driven intravenous acyclovir protocol led to a significant increase in the duration of IV fluid administration. While the incidence of AKI was numerically higher in the post-implementation group, this difference was not statistically significant. Dosing accuracy remained high across both groups, with minimal under-dosing and no cases of overdosing observed. These findings suggest that the protocol successfully enhanced supportive care practices without compromising dosing safety, though further evaluation in a larger cohort may be warranted to better assess its impact on AKI prevention.