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Evaluation of a trough-only extrapolated area under the curve vancomycin dosing method on clinical outcomes

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Abstract

Background Vancomycin dosing strategies targeting trough concentrations of 15–20 mg/L are no longer supported due to lack of efficacy evidence and increased risk of nephrotoxicity. Area-under-the-curve (AUC24) nomograms have demonstrated adequate attainment of AUC24 goals ≥ 400 mg h/L with more conservative troughs (10–15 mg/L). Objective The purpose of this study is to clinically validate a vancomycin AUC24 dosing nomogram compared to conventional dosing methods with regards to therapeutic failure and rates of acute kidney injury. Setting This study was conducted at a tertiary, community, teaching hospital in the United States. Method This retrospective, cohort study compared the rates of therapeutic failures between AUC24-extrapolated dosing and conventional dosing methods. Main outcome measure Primary outcome was treatment failure, defined as all-cause mortality within 30 days, persistent positive methicillin-resistant Staphylococcus aureus blood culture, or clinical failure. Rates of acute kidney injury in non-dialysis patients was a secondary endpoint. Results There were 96 participants in the extrapolated-AUC24 cohort and 60 participants in the conventional cohort. Baseline characteristics were similar between cohorts. Failure rates were 11.5% (11/96) in the extrapolated-AUC24 group compared to 18.3% (11/60) in the conventional group (p = 0.245). Reasons for failure were 6 deaths and 5 clinical failures in the extrapolated-AUC24 cohort and 10 deaths and 1 clinical failure in the conventional group. Acute kidney injury rates were 2.7% (2/73) and 16.4% (9/55) in the extrapolated-AUC24 and conventional cohorts, respectively (p = 0.009). Conclusion Extrapolated-AUC24 dosing was associated with less nephrotoxicity without an increase in treatment failures for bloodstream infections compared to conventional dosing. Further investigation is warranted to determine the relationship between extrapolated-AUC24 dosing and clinical failures.

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Acknowledgements

The authors would like to acknowledge David Jones for his assistance with obtaining the list of patients to review for eligibility in study enrollment.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Department of Pharmacy, Johnson City Medical Center, 400 North State of Franklin Road, Johnson City, TN, USA

    Jacob Lines & Paul Lewis

  2. East Tennessee State University Physicians Infectious Diseases Clinic, Johnson City, TN, USA

    Jacob Lines

  3. Department of Pharmacy Practice, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA

    Jessica Burchette

  4. Department of Infectious, Inflammatory and Immunologic Diseases, East Tennessee State University Quillen College of Medicine, Johnson City, TN, 37614, USA

    Susan M. Kullab

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  1. Jacob Lines
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Correspondence to Paul Lewis.

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Lines, J., Burchette, J., Kullab, S.M. et al. Evaluation of a trough-only extrapolated area under the curve vancomycin dosing method on clinical outcomes. Int J Clin Pharm 43, 263–269 (2021). https://doi.org/10.1007/s11096-020-01157-3

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  • DOI: https://doi.org/10.1007/s11096-020-01157-3

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