Introduction: Vancomycin is effective against gram-positive bacteria including staphylococcus aureus which are resistant to methicillin. Vancomycin has a narrow therapeutic range and is associated with adverse drug reactions related to iv infusion, nephrotoxicity and ototoxicity. Drug therapeutic level monitoring of this ambiguous drug is important, as a low therapeutic level will not be effective against multidrug-resistant bacteria and a higher drug level may lead to adverse drug reactions mainly renal damage. Hence therapeutic drug monitoring (TDM) of vancomycin becomes very crucial. Objective: To discuss the TDM of vancomycin guidelines. Discussion: This guideline includes indications of TDM, vancomycin target AUC/MIC (Area Under Curve over 24 hours/Minimum Inhibitory Concentration) ratio should be 400–600 mg/hour. In case of a MIC value of >1 mg/L, the guideline recommends changing the therapy. In critically ill patient loading dose can be considered. When conventional intermittent infusion fails to reach adequate therapeutic drug level continuous infusion of vancomycin is recommended. Children above the age of 3 months with suspected MRSA sepsis should receive vancomycin 60–80 mg/kg/day (should not increase >3600 mg/day) in three to four divided doses, considering they have normal renal function. Vancomycin dose should not increase >100 mg/kg/day which is more likely to surpass the threshold level. In the case of obese patients and patients on dialysis therapeutic monitoring and changing the dosage according to that is more important. Conclusion: Vancomycin has a narrow therapeutic index. Low therapeutic levels can lead to treatment failure, and a higher level can lead to adverse effects. This article stresses the need for therapeutic monitoring of vancomycin, especially in children who are critically ill, who have compromised renal function, and those receiving other renal toxic drugs.
Gardete S, Tomasz A. Mechanisms of vancomycin resistance in Staphylococcus aureus. J Clin Invest 2014;124(7):2836–2840. DOI: 10.1172/JCI68834
Carreno JJ, Kenney RM, Lomaestro B. Vancomycin-associated renal dysfunction: where are we now? Pharmacotherapy 2014;34(12): 1259–1268. DOI: 10.1002/phar.1488
“Goodman and Gilman's THE PHARMACOLOGICAL BASIS OF THERAPEUTICS”. THIRTEENTH EDITION, Laurence L. Brunton, et al. Volume 1. p. 1059.
Duffull SB, Begg EJ. Vancomycin toxicity: what is the evidence for dose dependency? Adverse Drug React Toxicol Rev 1994;13(2):103–114. PMID: 7918897.
Rybak M, Lomaestro B, Rotschafer JC, et al. 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. Am J Health Syst Pharm 2009;66(1):82–98. DOI: 10.2146/ajhp080434
Kishk OA, Lardieri AB, Heil EL, et al. Vancomycin AUC/MIC and corresponding troughs in a pediatric population. J Pediatr Pharmacol Ther 2017;22(1):41–47. DOI: 10.5863/1551-6776-22.1.41
Eyler RF, Shvets K. Clinical pharmacology of antibiotics. Clin J Am Soc Nephrol 2019;14(7):1080–1090. DOI: 10.2215/CJN.08140718
Ye ZK, Tang HL, Zhai SD. Benefits of therapeutic drug monitoring of vancomycin: a systematic review and meta-analysis. PloS One 2013;8(10):e77169. DOI: 10.1371/journal.pone.0077169
Tsutsuura M, Moriyama H, Kojima N, et al. The monitoring of vancomycin: a systematic review and meta-analyses of area under the concentration-time curve-guided dosing and trough-guided dosing. BMC Infect Dis 2021;21(1):153. DOI: 10.1186/s12879-021-05858-6
Al-Maqbali JS, Shukri ZA, Sabahi NA, et al. Vancomycin therapeutic drug monitoring (TDM) and its association with clinical outcomes: a retrospective cohort. J Infect Public Health 2022;15(5):589–593. DOI: 10.1016/j.jiph.2022.04.007
Aljefri DM, Avedissian SN, Rhodes NJ, et al. Vancomycin area under the curve and acute kidney injury: a meta-analysis. Clin Infect Dis 2019;69(11):1881–1887. DOI: 10.1093/cid/ciz051
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. Am J Health Syst Pharm 2020;77(11):835–864. DOI: 10.1093/ajhp/zxaa036
Matsumoto K, Oda K, Shoji K, et al. Clinical practice guidelines for therapeutic drug monitoring of vancomycin in the framework of model-informed precision dosing: a consensus review by the Japanese Society of Chemotherapy and the Japanese Society of Therapeutic Drug Monitoring. Pharmaceutics 2022;14(3):489. DOI: 10.3390/pharmaceutics14030489
Elyasi S, Khalili H, Dashti-Khavidaki S, et al. Vancomycin-induced nephrotoxicity: mechanism, incidence, risk factors and special populations. A literature review. Eur J Clin Pharmacol 2012;68(9):1243–1255. DOI: 10.1007/s00228-012-1259-9
Crass RL, Dunn R, Hong J, et al. Dosing vancomycin in the super obese: less is more. J Antimicrob Chemother 2018;73(11):3081–3086. DOI: 10.1093/jac/dky310
Schmelzer TM, Christmas AB, Norton HJ, et al. Vancomycin intermittent dosing versus continuous infusion for treatment of ventilator-associated pneumonia in trauma patients. Am Surg 2013;79(11):1185–1190. DOI: 10.1177/000313481307901123
Tafelski S, Nachtigall I, Troeger U, et al. Observational clinical study on the effects of different dosing regimens on vancomycin target levels in critically ill patients: continuous versus intermittent application. J Infect Public Health 2015;8(4):355–363. DOI: 10.1016/j.jiph.2015.01.011
Hutschala D, Kinstner C, Skhirdladze K, et al. Influence of vancomycin on renal function in critically ill patients after cardiac surgery: continuous versus intermittent infusion. Anesthesiology 2009;111(2):356–365. DOI: 10.1097/ALN.0b013e3181a97272