Evaluation of Real-World Vancomycin Dosing and Attainment of Therapeutic Drug Monitoring Targets

In 2020, the Infectious Diseases Society of America (IDSA) recommended a change in vancomycin therapeutic drug monitoring from trough-based to AUC/MIC-based to optimize vancomycin's efficacy and reduce nephrotoxicity. Many hospitals have not implemented this change due to barriers such as the cost of AUC/MIC software and lack of provider familiarity. The purpose of this study was to determine the rate of AUC/MIC ratio target attainment using current trough-based vancomycin dosing practices at a city hospital. The rates of acute kidney injury (AKI) were also evaluated. Vancomycin orders were reviewed retrospectively to determine the expected AUC/MIC ratios using first-order pharmacokinetic equations over a 7-month period. Orders were excluded if they were written for a one-time dose, for individuals less than 18 years of age, or for those on hemodialysis. A total of 305 vancomycin orders were included in this review. Overall, 27.9% (85/305) of vancomycin orders attained the AUC/MIC ratio target of 400-600 mg·h/L as recommended by the guidelines. Nearly 35% (106/305) achieved AUC/MIC ratios below 400 mg·h/L and 37.4% (114/305) achieved AUC/MIC ratios above 600 mg·h/L. Orders for obese patients were significantly more likely to have below the target AUC/MIC ratios (68% vs. 23.9%, X² 48.48, p < 0.00001) and non-obese patients were significantly more likely to have above the target AUC/MIC ratios (45.7% vs. 12%, X² 27.36, p < 0.00001). The overall rate of acute kidney injury observed was 2.6%. Most vancomycin orders did not attain therapeutic drug monitoring targets, reflecting the ongoing clinical challenge of optimizing vancomycin doses and implementing new guideline recommendations.