Vancomycin Dosing Guidelines 2020 Update: Key Elements for Implementation

Highlights of Significant Changes in the New Vancomycin Therapeutic Monitoring Guidelines

In a nutshell:

Previous 2009 guidelines recommended the use of trough monitoring of target 15-20 mg/L as a surrogate marker of AUC/MIC of 400 mg*h/L to simplify therapy management. But this came at the cost of increased nephrotoxicity and Acute Kidney Injuries.

Trough-based dosing is no longer recommended, and an AUC/MIC-guided dosing with a target of 400-600 mg*h/L is recommended for most invasive MRSA infections in adults and pediatrics.

When empirically using AUC/MIC-guided dosing, assume MIC of 1 mg/L based on broth micro dilution methods.

Loading doses for patients who are critically ill, on renal replacement therapy, or receiving continuous infusion therapy should be based on actual body weight.

Introduction to the New Vancomycin Therapeutic Monitoring Guidelines¹

Since the 2009 Vancomycin consensus guideline for vancomycin was published, many publications evaluated the clinical safety and efficacy of trough-based dosing. In 2020, the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Pediatric Infectious Diseases Society (PIDS), and the Society of Infectious Diseases Pharmacists (SIDP) revised their 2009 recommendations and published their new consensus on the optimization of vancomycin dosing and monitoring for serious MRSA infections such as bacteremia, sepsis, infective endocarditis, pneumonia, osteomyelitis, and meningitis. These changes arise from 15-20 mg/L trough-based dosing leading to vancomycin-induced nephrotoxicity (VIN) and Acute Kidney Injuries (AKI).

Some key elements of the revised 2020 Vancomycin dosing guidelines include: the transition from a trough-based to an AUC-based dosing target, ‍the utilization of Bayesian Dosing to accurately calculate daily AUC values with non-steady-state levels, an AUC/MIC target of 400-600 for serious invasive MRSA infections.

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‍Bayesian-based precision dosing platforms are essential tools to facilitate the implementation of AUC/MIC-based vancomycin dosing guidelines and optimize clinical practice. PrecisePK is a Bayesian dosing software that has been shown to predict the future vancomycin AUC most accurately in critically ill patients, who are at increased risks of treatment failure due to altered antimicrobial pharmacokinetics2, according to a recently published peer-reviewed study3. Since 1986, we have worked with several renowned institutions such as UC San Diego, UC San Francisco, Sharp Healthcare, etc.

Why target AUC/MIC versus Trough-based dosing for Vancomycin?

• AUC/MIC is the best predictor of vancomycin activity against methicillin-susceptible S.aureus (MSSA), methicillin-resistant S.aureus (MRSA), and glycopeptide-intermediate S.aureus (GISA), according to an in vivo cidal and pharmacokinetic/pharmacodynamic (PK/PD) parameter study in neutropenic-mouse thigh infection models conducted by Ebert and colleagues in 1987...

Continue reading the guidelines here.