As a hospital pharmacist, you will see a shift toward monitoring vancomycin using AUC/MIC calculations instead of trough levels. Clinical pharmacists normally aim for troughs of 15 to 20 mg/L for serious MRSA infections, to increase the likelihood of AUC/MIC over 400. But it turns out these troughs can overshoot AUC/MIC goals and are linked to more nephrotoxicity.
Now Infectious Diseases Society of America (IDSA) and others recommend using vancomycin AUC/MIC monitoring for most serious MRSA infections, such as bloodstream or pneumonia and aiming for 400 to 600 mg*hr/L (mcg*hr/mL) in adults. This seems to be the sweet spot to maintain efficacy while minimizing acute kidney injury. Many patients can achieve an AUC/MIC in this range even with troughs below 15 mg/L. But it’s too soon to say what the best goal is for CNS infections, coagulase-negative Staph or other non-MRSA organisms or less severe infections, such as a skin abscess.
Expect many hospitals to determine goals in these instances. For example, for less severe infections, some hospitals may use AUC/MIC goals, while others may continue with lower troughs of 10 to 15 mg/L. Don’t be surprised if pharmacists now order two POST-dose levels. They’ll use those levels to calculate an AUC and then determine whether dose adjustments are needed.
REFERENCES
-
Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Wong-Beringer A, Rotschafer JC, Rodvold KA, Maples HD, Lomaestro BM. 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. Available at: https://academic.oup.com/ajhp/article/77/11/835/5810200
Heil EL, Claeys KC, Mynatt RP, Hopkins TL, Brade K, Watt I, Rybak MJ, Pogue JM. Making the change to area under the curve-based vancomycin dosing. Am J Health Syst Pharm. 2018 Dec 15;75(24):1986-1995. Available at: https://academic.oup.com/ajhp/article-abstract/75/24/1986/5248543?redirectedFrom=fulltext
Finch NA, Zasowski EJ, Murray KP, Mynatt RP, Zhao JJ, Yost R, Pogue JM, Rybak MJ. A Quasi-Experiment To Study the Impact of Vancomycin Area under the Concentration-Time Curve-Guided Dosing on Vancomycin-Associated Nephrotoxicity. Antimicrob Agents Chemother. 2017 Nov 22;61(12):e01293-17. Available at: https://journals.asm.org/doi/10.1128/AAC.01293-17?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed