Vancomycin Advanced AUC with CrCL options

Vancomycin Monitoring (ASHP 2020)

See source below for the complete guidelines.
"In patients with suspected or definitive serious MRSA infections, an individualized target of the AUC/MIC_BMD ratio of 400 to 600 (assuming a vancomycin MIC_BMD of 1 mg/L) should be advocated to achieve clinical efficacy while improving patient safety (A-II). Doses of 15 to 20 mg/kg (based on actual body weight) administered every 8 to 12 hours as an intermittent infusion are recommended for most patients with normal renal function when assuming a MIC_BMD of 1 mg/L (A-II). In patients with normal renal function, these doses may not achieve the therapeutic AUC/MIC target when the MIC is 2 mg/L."

"In patients with suspected or definitive serious MRSA infections, an individualized target of the AUC/MIC_BMD ratio of 400 to 600 (assuming a vancomycin MIC_BMD of 1 mg/L) should be advocated to achieve clinical efficacy while improving patient safety (A-II). Doses of 15 to 20 mg/kg (based on actual body weight) administered every 8 to 12 hours as an intermittent infusion are recommended for most patients with normal renal function when assuming a MIC_BMD of 1 mg/L (A-II). In patients with normal renal function, these doses may not achieve the therapeutic AUC/MIC target when the MIC is 2 mg/L."

"Based on current national vancomycin susceptibility surveillance data, under most circumstances of empiric dosing, the vancomycin MIC should be assumed to be 1 mg/L. When the MIC_BMD is >1 mg/L, the probability of achieving an AUC/MIC target of ≥400 is low with conventional dosing; higher doses may risk unnecessary toxicity, and the decision to change therapy should be based on clinical judgment. In addition, when the MIC_BMD is <1 mg/L, we do not recommend decreasing the dose to achieve the AUC/MIC target. It is important to note the limitations in automated susceptibility testing methods, including the lack of precision and variability in MIC results depending on method used (B-II)."

"Trough-only monitoring, with a target of 15 to 20 mg/L, is no longer recommended based on efficacy and nephrotoxicity data in patients with serious infections due to MRSA (A-II). There is insufficient evidence to provide recommendations on whether trough-only or AUC-guided vancomycin monitoring should be used among patients with noninvasive MRSA or other infections."

"A vancomycin loading dose of 20 to 25 mg/kg using actual body weight, with a maximum dose of 3,000 mg, may be considered in obese adult patients with serious infections (B-II). Initial maintenance doses of vancomycin can be computed using a population PK estimate of vancomycin clearance and the target AUC in obese patients. Empiric maintenance doses for most obese patients usually do not exceed 4,500 mg/day, depending on their renal function (B-II). Early and frequent monitoring of AUC exposure is recommended for dose adjustment, especially when empiric doses exceed 4,000 mg/day (A-II). Measurement of peak and trough concentrations is recommended to improve the accuracy of vancomycin AUC estimation and maintenance dose optimization in obese patients, aligning with recommendations 2 and 5 for nonobese adults."

Source: Rybak MJ, Le J, Lodise TP, Levine DP, 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 May 19;77(11):835-864. doi: 10.1093/ajhp/zxaa036. PMID: 32191793.
    [BMD]-  MIC determined by broth  microdilution