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

Abstract

Background Recent vancomycin PK/PD and toxicodynamic studies enable a reassessment of the current dosing and monitoring guideline in an attempt to further optimize the efficacy and safety of vancomycin therapy. The area‐under‐the‐curve to minimum inhibitory concentration (AUC/MIC) has been identified as the most appropriate pharmacokinetic/pharmacodynamic (PK/PD) target for vancomycin. The 2009 vancomycin consenus guidelines recommended specific trough concentrations as a surrogate marker for AUC/MIC. However, more recent toxicodynamic studies have reported an increase in nephrotoxicity associated with trough monitoring. Methods and Results This is the executive summary of the new vancomycin consensus guidelines for dosing and monitoring vancomycin therapy and was developed by the American Society of Health‐Systems Pharmacists, Infectious Diseases Society of America, Pediatric Infectious Diseases Society and the Society of Infectious Diseases Pharmacists vancomycin consensus guidelines committee. Conclusions The recommendations provided in this document are intended to assist the clinician in optimizing vancomycin for the treatment of invasive MRSA infections in adult and pediatric patients. An AUC/MIC by broth microdilution (BMD) ratio of 400 to 600 (assuming MICBMD of 1 mg/L) should be advocated as the target to achieve clinical efficacy while improving patient safety for patients with serious MRSA infections. In such cases, AUC‐guided dosing and monitoring is the most accurate and optimal way to manage vancomycin therapy.

Meta-analysis of Randomized Controlled Trials of Vancomycin for the Treatment of Patients With Gram-Positive Infections: Focus on the Study Design

“…The main characteristics of the analyzed trials are given in the supplemental online table (available at www.mayoclinicproceedings.org). The mean quality score of the included trials was 2.7, whereas the median was 2 (range, [1][2][3][4][5]. The quality of 26 trials (49%) was high (score Ն3).…”

“…In addition, its use has increased throughout the years, especially in some settings, 1 mainly because of the emergence of ␤-lactam-resistant staphylococci and enterococci. Although vancomycin has proved effective for the treatment of patients with gram-positive infections, several studies have emphasized some important disadvantages, including nephrotoxicity and other adverse reactions, 2-4 the need for continuous monitoring of its trough serum levels, 5 relatively poor pharmacokinetic properties (especially in the lungs), 6,7 data pointing toward reduced effectiveness when the minimal inhibitory concentration (MIC) of Staphylococcus aureus was higher than 1 g/mL, [8][9][10][11] and vancomycin resistance or increasing MICs. 12 However, vancomycin continues to be the treatment of choice for serious resistant gram-positive infections (including bacteremia, pneumonia, endocarditis, and complicated skin and soft tissue infections [SSTIs]) in the published guidelines of medical societies.…”

Evaluation of methods to estimate glomerular filtration rate versus actual drug clearance in patients with chronic spinal cord injury

“…Overestimation of GFR results in dosing renally cleared medications higher than recommended, and this could lead to supratherapeutic vancomycin and AG serum levels leading to adverse drug effects and/or toxicity. [5][6][7] In the nephrology arena, a more recently developed equation, the Modification of Diet in Renal Disease equation (MDRD), has been widely used to estimate GFR. [8][9] Moreover, a new equation, the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI), has been proposed to more accurately estimate GFR compared with MDRD.…”

The relationship between trough concentration of vancomycin and effect on methicillin-resistant Staphylococcus aureus in critically ill patients

“…5 Guidelines on recommended dosing of vancomycin have been published. 4,6 The ratio of the area under the serum drug concentration-versustime curve (AUC) and the minimum inhibitory concentration (MIC) are among the most useful pharmacokinetic/pharmacodynamic…”