AUC-Based Monitoring of Vancomycin: Closing the Therapeutic Window.

Abstract

Therapeutic drug monitoring for vancomycin is in the midst of a paradigm shift from targeting trough concentrations to area under the concentration–time curve (AUC)2. The 2009 consensus review of vancomycin therapeutic drug monitoring recommended targeting trough concentrations of 15–20 mg/L to “improve tissue penetration, increase probability of obtaining optimal target serum concentrations, and improve clinical outcomes” (1). This was a level IIIB recommendation based almost entirely on expert opinion, as previous studies had demonstrated that troughs were not associated with efficacy (2). However, studies had demonstrated that trough concentrations, especially those ≥15 mg/L, were a reliable marker of increased risk of vancomycin-associated nephrotoxicity (2, 3). Conversely, AUC values and AUC/minimum inhibitory concentration (MIC) ratios had been associated with clinical efficacy (4), but no definitive upper threshold for nephrotoxicity had been established. This discordance between guideline recommendations and current literature caused a clinical dilemma, as it was known that trough concentrations have …