Table 2

Summary of Expert Panel Recommendations for Vancomycin Therapeutic Drug Monitoring (TDM)a

VariableRecommendationLevel of Evidence and Grade of RecommendationSection of Consensus Review
Recommended TDM Parameters
Optimal monitoring parameterTrough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy.IIBTherapeutic vancomycin drug monitoring, Peak versus trough concentrations
Timing of monitoringTroughs should be obtained just prior to the next dose at steady-state conditions (just before the fourth dose).IIBTherapeutic vancomycin drug monitoring, Peak versus trough concentrations
Optimal trough concentration (see also Optimal trough concentration—complicated infections)Minimum serum vancomycin trough concentrations should always be maintained above 10 mg/L to avoid development of resistance. For a pathogen with an MIC of 1 mg/L, the minimum trough concentration would have to be at least 15 mg/L to generate the target AUC:MIC of 400.IIIBTherapeutic vancomycin drug monitoring, Optimal trough concentrations
Optimal trough concentration— complicated infections (bacteremia, endocarditis, osteomyelitis, meningitis, and hospital-acquired pneumonia caused by Staphylococcus aureus)Vancomycin serum trough concentrations of 15–20 mg/L are recommended to improve penetration, increase the probability of obtaining optimal target serum concentrations, and improve clinical outcomes.IIIBTherapeutic vancomycin drug monitoring, Optimal trough concentrations
Dosing Regimen
Dosing to achieve optimal trough concentrationsDoses of 15–20 mg/kg (as actual body weight) given every 8–12 hr are recommended for most patients with normal renal function to achieve the suggested serum concentrations when the MIC is =1 mg/L. In patients with normal renal function, the targeted AUC:MIC of >400 is not achievable with conventional dosing methods if the MIC is =2 mg/L in a patient with normal renal function.IIIBTherapeutic vancomycin drug monitoring, Optimal trough concentrations
Loading doses—complicated infectionsIn seriously ill patients, a loading dose of 25–30 mg/kg (based on actual body weight) can be used to facilitate rapid attainment of target trough serum vancomycin concentration.IIIBTherapeutic vancomycin drug monitoring, Optimal trough concentrations
Continuous vs. intermittent dosingContinuous infusion regimens are unlikely to substantially improve patient outcome when compared to intermittent dosing.IIAImpact of dosing strategies on pharmacokinetic and pharmacodynamic parameters
TDM for Vancomycin-Induced Nephrotoxicity
DefinitionA minimum of two or three consecutive documented increases in serum creatinine concentrations (defined as an increase of 0.5 mg/dL or a =50% increase from baseline, whichever is greater) after several days of vancomycin therapy.IIBVancomycin toxicity; Incidence, mechanism, and definition of nephrotoxicity
Criteria for monitoringData do not support using peak serum vancomycin concentrations to monitor for nephrotoxicity.IIBVancomycin toxicity, Role of therapeutic drug monitoring in preventing nephrotoxicity
Trough monitoring is recommended for patients receiving aggressive dosing (i.e., to achieve sustained trough levels of 15–20 mg/L) and all patients at high risk of nephrotoxicity (e.g., patients receiving concurrent nephrotoxins).IIIBVancomycin toxicity, Role of therapeutic drug monitoring in preventing nephrotoxicity
Monitoring is also recommended for patients with unstable (i.e., deteriorating or significantly improving) renal function and those receiving prolonged courses of therapy (more than three to five days).IIBVancomycin toxicity, Role of therapeutic drug monitoring in preventing nephrotoxicity
Frequency of monitoringFrequent monitoring (more than one trough before the fourth dose) for short course or lower intensity dosing (to attain target trough concentrations below 15 mg/L) is not recommended.IIBVancomycin toxicity, Role of therapeutic drug monitoring in preventing nephrotoxicity
All patients on prolonged courses of vancomycin (exceeding three to five days) should have at least one steady-state trough concentration obtained no earlier than at steady state (just before the fourth dose) and then repeated as deemed clinically appropriate.IIBVancomycin toxicity, Role of therapeutic drug monitoring in preventing nephrotoxicity
There are limited data supporting the safety of sustained trough concentrations of 15–20 mg/L. Clinical judgment should guide the frequency of trough monitoring when the target trough is in this range. Once-weekly monitoring is recommended or hemodynamically stable patients. More frequent or daily trough monitoring is advisable in patients who are hemodynamically unstable.IIIBVancomycin toxicity, Role of therapeutic drug monitoring in preventing nephrotoxicity
TDM for Vancomycin-Induced Ototoxicity
Criteria for monitoringMonitoring for ototoxicity is not recommended for patients receiving vancomycin monotherapy.IIIBVancomycin toxicity, Incidence of ototoxicity and role of therapeutic drug monitoring for prevention of vancomycin-induced hearing loss
Monitoring should be considered for patients receiving additional ototoxic agents, such as aminoglycosides.IIIBVancomycin toxicity, Incidence of ototoxicity and role of therapeutic drug monitoring for prevention of vancomycin-induced hearing loss
  • a MIC = minimum inhibitory concentration, AUC = area under the concentration-versus-time curve.