Treatment

Updated Consensus Guidelines for Vancomycin Monitoring Released

The American Society of Health-Systems Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists have released new guidelines for dosing and monitoring of vancomycin for patients with serious methicillin-resistant Staphylococcus aureus infections.

The guidelines serve as an update to the groups’ 2009 recommendations and were created in response to new evidence suggesting that trough monitoring could be associated with nephrotoxicity among this population.

“Despite more than 61 years of clinical use of vancomycin, knowledge gaps regarding the most appropriate approach for optimizing therapy and minimizing toxicity still exist,” the authors wrote.

“The previous consensus guidelines in 2009 recommended the use of trough monitoring (target 15–20 mg/L) as a surrogate marker of the area under the curve over 24 hours to minimum inhibitory concentration ratio (AUC/MIC)(target 400 mg*hour/L) for ease of managing therapy and simplifying dose adjustments and monitoring…However, since the implementation of these recommendations, there have been numerous reports of increased nephrotoxicity in adults and pediatrics when trough level monitoring using these targets has been applied.”

Among the recommendations:

  • Individualized target AUC-MICBMD ratio of 400 to 600 should be advocated for in patients with suspected or definitive serious MRSA infections (A-II recommendation).
  • Trough-only monitoring is no longer recommended in patients with serious MRSA infections (A-II recommendation).
  • In adults, doses of 15 to 20 mg/kg (based on actual body weight) administered every 8–12 hours as an intermittent infusion are recommended for most patients with normal renal function when assuming MICBMD of 1 mg/L (A-II recommendation).
  • The recommended initial dosage for children with normal renal function is 60–80 mg/kg/day, divided every 6 to 8 hours, for children ages 3 months and older (A-II) recommendation.

—Michael Potts

Reference:

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. Clin Infec Dis. 2020;71(6):1361-1364. https://doi.org/10.1093/cid/ciaa303