Vancomycin Dosing and Monitoring for Adults
Full update November 2022
This FAQ addresses common questions about vancomycin dosing and monitoring, including use of target AUC vs target trough, and differences among pharmacokinetic dosing methods.
Question |
Answer/Pertinent Information |
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What are the target vancomycin levels for documented (or suspected) serious MRSA infections? |
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Why is AUC/MIC monitoring now recommended instead of trough levels for serious MRSA infections? |
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How should vancomycin be initially dosed for serious MRSA infections? |
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How should vancomycin be monitored? |
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What are differences between using Bayesian software and doing manual pharmacokinetic calculations when monitoring vancomycin? |
Consideration |
Manual Pharmacokinetic Calculations1 |
Bayesian Software (e.g., DoseMeRX, PrecisePK)1 |
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Cost |
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When can levels be checked? |
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How many levels are needed? |
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Other considerations |
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What do you need to know about MICs? |
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How are patient specific AUC/MICs calculated using first-order kinetic equations? |
Definitions used in calculations:2 AUCinf= AUC during infusion; AUCelim = AUC during elimination; C1 = measured peak; C2 = measured trough; Cmax = true peak; Cmin = true trough; t1 = time C1 was drawn; t2 = time C2 was drawn; tau = dosing interval; tinf = infusion duration; ∆t = the time between the end of the infusion and the level being drawn Formulas (for use assuming steady state levels):2
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Are online vancomycin dosing calculators accurate? |
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How should doses be adjusted to achieve AUC/MIC goals? |
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What are special dosing/monitoring considerations in patients who are obese? |
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What are special dosing/monitoring considerations in patients with acute kidney injury? |
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What are special dosing/monitoring considerations in patients receiving kidney replacement therapy? |
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How should vancomycin be dosed/monitored in patients with MRSA meningitis? |
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How should vancomycin be dosed/monitored in patients with less severe MRSA infections or in infections caused by other organisms? |
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How should patients be dosed/monitored who are discharged on vancomycin? |
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Abbreviations: AKI = acute kidney injury; AUC = area under the serum drug concentration-versus-time curve; BMD = broth microdilution; MIC = minimum inhibitory concentration; MRSA = methicillin-resistant Staphylococcus aureus; Vd = volume of distribution.
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
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B |
Inconsistent or limited-quality patient-oriented evidence.* |
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C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. https://www.aafp.org/pubs/afp/issues/2004/0201/p548.html.]
References
- Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2020 May 19;77(11):835-864.
- ClinCalc. Vancomycin calculator. https://clincalc.com/Vancomycin/?example. (Accessed October 8, 2022).
- Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2009 Jan 1;66(1):82-98. Erratum in: Am J Health Syst Pharm. 2009 May 15;66(10):887.
- Heil EL, Claeys KC, Mynatt RP, et al. Making the change to area under the curve-based vancomycin dosing. Am J Health Syst Pharm. 2018 Dec 15;75(24):1986-1995.
- Lodise TP, Rosenkranz SL, Finnemeyer M, et al. The Emperor's New Clothes: PRospective Observational Evaluation of the Association Between Initial VancomycIn Exposure and Failure Rates Among ADult HospitalizEd Patients With Methicillin-resistant Staphylococcus aureus Bloodstream Infections (PROVIDE). Clin Infect Dis. 2020 Apr 10;70(8):1536-1545.
- Karakonstantis S, Kalemaki D. Evaluation and management of Staphylococcus aureus bacteriuria: an updated review. Infection. 2018 Jun;46(3):293-301.
- Berry T, Bennett N. 2019 ASHP competency assessment module: vancomycin dosing and monitoring. http://elearning.ashp.org/Files/Org/c52850f8e2e14ca8b14b32c98105999d/site/2019_ASHP_Competency_Assessment_Module_-_frontmatter.pdf. (Accessed October 27, 2022).
- Stanford Health Care. SHC vancomycin dosing guide. March 2022. https://med.stanford.edu/bugsanddrugs/guidebook/_jcr_content/main.html. (Accessed October 8, 2022).
- Agency for Healthcare Research and Quality. Discharged with IV antibiotics: when issues arise, who manages complications? February 2020. https://psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications. (Accessed October 8, 2022).
- Fewel N. Vancomycin area under the curves estimated with pharmacokinetic equations using trough-only data. J Clin Pharm Ther. 2021 Oct;46(5):1426-1432.
- Suzuki A, Hamada Y, Ikeda H, et al. Comparison of trough concentration and area under the curve of vancomycin associated with the incidence of nephrotoxicity and predictors of a high trough level. J Infect Chemother. 2021 Mar;27(3):455-460.
- Belz SN, Seabury RW, Steele JM, et al. Accuracy of 4 Free Online Dosing Calculators in Predicting the Vancomycin Area Under the Concentration-Time Curve Calculated Using a 2-Point Pharmacokinetic Approach. Ann Pharmacother. 2022 Aug 18:10600280221117256. doi: 10.1177/10600280221117256.
- Nix DE, Davis LE, Matthias KR. The relationship of vancomycin 24-hour AUC and trough concentration. Am J Health Syst Pharm. 2022 Mar 21;79(7):534-539.
- Abdelmessih E, Patel N, Vekaria J, et al. Vancomycin area under the curve versus trough only guided dosing and the risk of acute kidney injury: Systematic review and meta-analysis. Pharmacotherapy. 2022 Sep;42(9):741-753.
- Neely MN, Kato L, Youn G, Kraler et al. Prospective Trial on the Use of Trough Concentration versus Area under the Curve To Determine Therapeutic Vancomycin Dosing. Antimicrob Agents Chemother. 2018 Jan 25;62(2):e02042-17. doi: 10.1128/AAC.02042-17.
- Lodise TP, Drusano G. Vancomycin Area Under the Curve-Guided Dosing and Monitoring for Adult and Pediatric Patients With Suspected or Documented Serious Methicillin-Resistant Staphylococcus aureus Infections: Putting the Safety of Our Patients First. Clin Infect Dis. 2021 May 4;72(9):1497-1501.
- Jorgensen SCJ, Spellberg B, Shorr AF, Wright WF. Should Therapeutic Drug Monitoring Based on the Vancomycin Area Under the Concentration-Time Curve Be Standard for Serious Methicillin-Resistant Staphylococcus aureus Infections? - No. Clin Infect Dis. 2021 May 4;72(9):1502-1506.
- Olney KB, Wallace KL, Mynatt RP, et al. Comparison of Bayesian-derived and first-order analytic equations for calculation of vancomycin area under the curve. Pharmacotherapy. 2022 Apr;42(4):284-291.
Cite this document as follows: Clinical Resource, Vancomycin Dosing and Monitoring for Adults. Hospital Pharmacist’s Letter/Pharmacy Technician’s Letter. November 2022. [381121]
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