Vancomycin Pharmacokinetics in Obese Patients: Insights from Bayesian Modeling

Optimal vancomycin dosing in obese patients remains challenging due to altered pharmacokinetics and the variable relationship between trough concentrations and therapeutic exposure.

To evaluate the pharmacokinetics of vancomycin and the attainment of therapeutic targets in obese patients using Bayesian software analysis.

This retrospective cohort study included adult inpatients (≥ 18 years) from six hospitals within the Legacy Health System (Oregon, USA) who received intravenous vancomycin for ≥ 48 h and had a steady-state level measured between August 2024 and March 2025. Patients on renal replacement therapy, with acute kidney injury, pregnancy, or ECMO were excluded. Vancomycin pharmacokinetic parameters were estimated using PrecisePK Bayesian software, and patients were categorized by body mass index (BMI): normal weight (n = 106), obese class 1 (n = 112), and obese class 2 or higher (n = 102).

A total of 320 patients were included. Mean vancomycin clearance increased with BMI (4.32 ± 2.27 L/h in normal weight vs. 4.82 ± 2.82 L/h in obese class 2+; p < 0.05), and the volume of distribution was significantly greater in obese groups (56.3 ± 14.6 L vs. 70.5 ± 18.9 L; p < 0.05). Therapeutic AUC_0-24 values (400-600 mg h/L) were achieved in approximately half of patients across all BMI categories (52-60%; p = 0.73). Trough concentrations were higher in obese class 1 patients than in normal-weight patients (14.0 ± 4.69 mg/L vs. 12.0 ± 5.11 mg/L; p = 0.008) and correlated only moderately with AUC (r = 0.59), with greater variability in more obese patients.

Obesity significantly influences vancomycin clearance and distribution but does not affect the likelihood of achieving target AUC_0-24 values. Trough concentrations are unreliable predictors of exposure in obese patients, underscoring the need for AUC-guided Bayesian dosing to optimize efficacy and minimize toxicity.