Feasibility of vancomycin AUC₂₄ monitoring using peak and trough concentrations in pediatric patients: a prospective...

Vancomycin remains a key medication in treating infections in pediatric patients, particularly those caused by methicillin-resistant Staphylococcus aureus (MRSA). Conventional trough-based monitoring has shown limited accuracy in predicting therapeutic exposure and nephrotoxicity. Recent guidelines recommend area under the concentration-time curve (AUC)-based monitoring, but pediatric evidence remains scarce. Our objective is to assess the feasibility of vancomycin AUC₂₄ monitoring using peak-trough concentrations in routine pediatric clinical practice and examine its correlation with the trough levels.

We conducted a prospective, multicenter study in 70 pediatric inpatients receiving vancomycin at two tertiary hospitals in Riyadh, Saudi Arabia. Vancomycin AUC₂₄ was calculated using first-order pharmacokinetics from peak and trough levels. AUC₂₄ was compared with the trough concentrations and dosing regimens.

Implementation of AUC₂₄-based monitoring was feasible in routine pediatric workflow. Pharmacists successfully calculated AUC₂₄ using the Sanford Guide mobile app, with minimal training required for nurses on sampling. The correlation between the trough levels and AUC₂₄ was strong (ρ = 0.789, p < 0.001), but the trough values did not consistently predict target attainment (AUC₂₄ 400 μg h/mL-600 μg h/mL). At trough concentrations of 10 μg/mL-15 μg/mL, only approximately half of the patients achieved the target AUC₂₄ range (400 μg h/mL-600 μg h/mL), whereas at troughs of 15 μg/mL-20 μg/mL, nearly half of the patients exceeded the safe exposure thresholds, underscoring the limitations of trough-based monitoring.

AUC₂₄ estimation from peak and trough samples was feasible in routine pediatric workflow, providing more accurate exposure assessment than trough-guided monitoring. Implementation may improve efficacy and minimize nephrotoxicity.