Vancomycin Area Under the Curve Dosing and Monitoring at an Academic Medical Center: Transition Strategies and Lessons Learned

Gregory, Eric; Burgess, Donna; Cotner, Sarah; VanHoose, Jeremy; Flannery, Alexander H.; Gardner, Brian; Autry, Elizabeth; Forster, Derek; Burgess, David S.; Wallace, Katie

doi:10.1177/0897190019834369

Cited by 21 publications

(21 citation statements)

References 18 publications

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“…In September of 2017, in anticipation of vancomycin TDM guideline changes, the monitoring of vancomycin was changed from trough-based to AUC, as previously described. 7 In a retrospective cohort design, all patients admitted to the medical intensive care unit (MICU) from September 2017 to June 2019 with at least 2 vancomycin serum concentrations ordered to calculate AUC at SS and receiving more than 1 dose of intravenous vancomycin were assessed for inclusion in the study. Patients were excluded if serum concentrations were obtained after the first dose but no SS levels (therapy was discontinued before SS concentrations obtained), if the patient was receiving intermittent vancomycin dosing due to AKI or the receipt of renal replacement therapy, if they received vancomycin at an outside hospital before transfer (as first-dose vancomycin concentrations would not have been able to be obtained), or if the vancomycin concentrations were drawn incorrectly (i.e., drawn from nonflushed catheter) or laboratory error was suspected by the assessing pharmacist as determined by documented records.…”

Section: Methodsmentioning

confidence: 99%

“…Pharmacists may alter vancomycin dosages, order vancomycin levels, and order laboratory tests for monitoring, such as a basic metabolic panel for serum creatinine. In September of 2017, in anticipation of vancomycin TDM guideline changes, the monitoring of vancomycin was changed from trough‐based to AUC, as previously described 7 …”

Section: Methodsmentioning

confidence: 99%

“…As an early adopter of AUC-guided vancomycin dosing, our center has several years of experience with AUC monitoring of vancomycin in a wide variety of patient populations. 7 We developed a protocol using serum vancomycin concentrations obtained after the first dose of vancomycin to calculate patientspecific pharmacokinetic parameters used for further dosing as one approach to target precision dosing of vancomycin in high-risk patients, including the critically ill. Alternatively, empiric dosing based on population pharmacokinetic estimates was also available as a method to develop initial vancomycin regimens targeted at AUC values. The use of firstdose kinetics to guide dosing and the subsequent impact on vancomycin trough attainment has demonstrated mixed results in prior studies.…”

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confidence: 99%

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First‐Dose Vancomycin Pharmacokinetics Versus Empiric Dosing on Area‐Under‐the‐Curve Target Attainment in Critically Ill Patients

et al. 2020

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Background Early attainment of target area under the curve (AUC) to minimum inhibitory concentration (MIC) ratios have been associated with clinical success, as well as lower incidence of acute kidney injury (AKI), in patients receiving vancomycin for methicillin-resistant Staphylococcus aureus (MRSA). Critically ill patients are particularly vulnerable to poor outcomes from infection and face multiple risk factors for AKI, thus early precision dosing of vancomycin is vital in this population. We hypothesized that a personalized dosing approach, using vancomycin levels obtained after the first dose to guide further dosing, would be superior to empiric dosing in terms of AUC target attainment assessed at steady state (SS). Methods A retrospective cohort study of 66 critically ill adult patients admitted to the medical intensive care unit without AKI and receiving vancomycin with at least two SS concentrations obtained for AUC calculation was performed. Patients were separated into cohorts based on whether they had two concentrations assessed after the first dose of vancomycin and were subsequently dosed based on personalized pharmacokinetic calculations (first-dose kinetics) or whether they were empirically dosed using population estimates. The primary outcome was AUC target attainment (400-600 mg hour/L) at SS. Results Compared with patients receiving empiric dosing by population estimates, using first-dose kinetics to guide subsequent dosing resulted in significantly greater AUC target attainment at SS (58.6% first-dose vs 32.4% empiric; p=0.033). Patients dosed empirically yielded more variable AUC values across a wide range compared with the first-dose kinetics group (coefficient of variation 40.7% empiric vs 26.1% first-dose). There was no difference in AKI up to 48 hours after SS concentrations between the two dosing schemes. Conclusions A dosing strategy using two vancomycin serum concentrations after the first dose and calculating personalized pharmacokinetic parameters to guide subsequent dosing is associated with greater AUC target attainment at SS compared with empiric dosing of vancomycin in critically ill adults with relatively stable renal function. KEY WORDS vancomycin, pharmacokinetics, area under the curve, critical care, dosing, therapeutic drug monitoring.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 99%

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First‐Dose Vancomycin Pharmacokinetics Versus Empiric Dosing on Area‐Under‐the‐Curve Target Attainment in Critically Ill Patients

et al. 2020

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“…The implementation strategy largely reflected those outlined from tertiary care centers. 5,6 First, key personnel from the laboratory department met to discuss this practice change and to add vancomycin peaks to the ordering menu. A critical value was set at 40 mcg/ml.…”

Section: Methodsmentioning

confidence: 99%

“…There are strategies from tertiary care centers that drive this practice change in the medical literature. 5,6 However, it is important to reproduce these implementation practices in small, rural facilities that may face unique challenges with limited resources and may be slower to implement consensus guidelines. 7,8 As this is a major practice change, it is imperative to evaluate the extent of transition and identify areas of needed improvement.…”

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confidence: 99%

Gap Analysis for the Conversion to Area Under the Curve Vancomycin Monitoring in a Small Rural Hospital

Cole¹

2020

Federal Practitioner

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Consensus guidelines for vancomycin monitoring now recommend area under the curve (AUC) calculations for optimal vancomycin efficacy and safety. This will be a major practice change for many facilities. Implementation guidance is available but has not been reported in smaller, primary care hospitals. The objective of this study was to measure the uptake of AUC monitoring implementation in a rural facility. Methods: This is a gap analysis evaluating the appropriateness of vancomycin levels tests after the April 1, 2019 transition. All vancomycin levels between April 2019 and June 2019 after the go-live date were included with no exclusions in a retrospective chart review. The primary outcome was the proportion of levels in the appropriate time frame: peaks 1 to 2 hours after infusion with troughs at least 1 half-life after initial dose and prior to the next dose. Secondary outcomes included reasons identified for inappropriate levels and the proportion of AUC 24 calculations within therapeutic range (400-600 mg.h/L). Descriptive statistics were used to measure the scope and outcomes of this transition. Results: The transition was effective with 97% of cases utilizing AUC-based methods. There were 65 vancomycin levels in the 3-month study period with 86% deemed appropriate. Of the 9 inappropriate levels, 4 had to be repeated for accurate monitoring. There were 28 two-level couplets used for AUC 24 calculations, 17 (61%) fell within therapeutic range. Conclusion: Implementation strategies for the AUC transition described in tertiary medical centers can be successfully utilized in primary facilities.

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“How to” guide for pharmacist‐led implementation of beta‐lactam therapeutic drug monitoring in the critically ill

Ausman

Moreland‐Head

Saleh

et al. 2023

J Am Coll Clin Pharm

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Beta‐lactam therapeutic drug monitoring (TDM) can improve precision dosing and clinical outcomes in critically ill patients, but has not been implemented widely in the United States. Mayo Clinic recently implemented a beta‐lactam TDM program. This single‐center experience forms the basis of the manuscript which outlines practical considerations involved with beta‐lactam TDM implementation, including the pharmacist's role as a leader. Our implementation effort focused on three primary domains. First, we aimed to ensure a supportive organizational infrastructure. Early leadership engagement by the pharmacist‐led core team facilitated advocacy for the clinical need, allocation of resources, and assay development. Second, core clinical workflows were developed that addressed the preferred patient population for use, desirable pharmacokinetic and pharmacodynamic targets, and the preferred sampling strategy. Clinical tools to guide pharmacists in interpreting the results (e.g., pharmacokinetics calculator) and documenting decisions were developed. Third, stakeholders were offered repeated exposure to evidence and expertise to facilitate understanding and application of the new practice. This act of ‘individual internalization’ seems to be uniquely important to beta‐lactam TDM implementation compared with the implementation of other antimicrobial TDM programs. Educational strategies and supportive materials that were developed were focused on providing substantive and varied information tailored to the stakeholders' role in the process. For pharmacists, this included both clinical and operational considerations. A continuous improvement plan to support management of the process was instituted to address necessary updates and changes that inevitably emerged. In summary, the described approach to implementation of a pharmacist‐led beta‐lactam TDM program could be used as a roadmap to aid other institutions that aim to develop such a program.

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Vancomycin Area Under the Curve Dosing and Monitoring at an Academic Medical Center: Transition Strategies and Lessons Learned

Cited by 21 publications

References 18 publications

First‐Dose Vancomycin Pharmacokinetics Versus Empiric Dosing on Area‐Under‐the‐Curve Target Attainment in Critically Ill Patients

First‐Dose Vancomycin Pharmacokinetics Versus Empiric Dosing on Area‐Under‐the‐Curve Target Attainment in Critically Ill Patients

Gap Analysis for the Conversion to Area Under the Curve Vancomycin Monitoring in a Small Rural Hospital

“How to” guide for pharmacist‐led implementation of beta‐lactam therapeutic drug monitoring in the critically ill

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