Nichelle Vadakkel
North Florida/South Georgia Veterans Health System
Gainesville, Florida
Disclosure information not submitted.
Robert Ross, PharmD
Clinical Pharmacy Research Fellow
NF/SG VA Health System
Gainesville, Florida
Disclosure information not submitted.
Nora Bairagdar, PharmD
Clinical Pharmacy Specialist
North Florida/South Georgia Veterans Health System, United States
Disclosure information not submitted.
Joseph Pardo, PharmD
Clinical Pharmacy Specialist
North Florida/South Georgia Veterans Health System, United States
Disclosure information not submitted.
Nicole Maltese, PharmD
Clinical Pharmacy Specialist
North Florida/South Georgia Veterans Health System, United States
Disclosure information not submitted.
Andrew Franck, PharmD
Clinical Pharmacy Specialist
North Florida/South Georgia Veterans Health System, United States
Disclosure information not submitted.
Title: Comparison of Vancomycin Area Under the Curve versus Trough Only Monitoring in a Veteran Population
INTRODUCTION: Vancomycin therapeutic monitoring guidelines recommend area under the curve/mean inhibitory concentration (AUC) monitoring for serious methicillin-resistant Staphylococcus aureus infections due to concerns for nephrotoxicity when solely targeting high trough levels. These guidelines suggest future studies focus on the research gaps including the efficacy benefit of AUC and toxicodynamics of vancomycin in a critically ill population.
Methods: This evaluation compared patients who received intravenous (IV) vancomycin at a single Veterans Affairs Medical Center before and after a quality improvement project to transition from trough only to AUC monitoring. Patients monitored using a traditional trough-based method from May 2018 to July 2018 were compared to those monitored using AUC from February 2021 to April 2021. The primary endpoint was occurrence of acute kidney injury (AKI). Secondary endpoints included duration of therapy and proportion of patients with at least one supratherapeutic vancomycin level.
Results: 231 patients were included in this assessment (120 in the trough group, 111 in the AUC group). Baseline characteristics were compared between groups, with the AUC group having a significantly older population and a higher severity of illness. The proportion of AKI was numerically higher in the trough group compared to the AUC group (13.3% vs. 11.7%; p = 0.84), but this was not statistically significant. The trough group had a significantly shorter duration of therapy (5.38 ± 3.29 days vs. 7.18 ± 6.30 days; p < 0.01) and a numerically higher proportion of patients with at least one supratherapeutic level (34.2% vs. 23.4%; p = 0.08).
Conclusion: Although most of the endpoints did not show a significant difference between groups, there was a trend towards lower percentage of AKI and supratherapeutic levels in the AUC group. The AUC group had significantly longer duration of therapy, older population, and more severe illness, which may have had led to an increased risk of AKI. Despite this potentially higher risk, results showed a numerically lower percentage of AKI in the AUC group compared to the trough group. This could indicate AUC monitoring may have improved safety for patients receiving vancomycin, but higher powered studies may be required to evaluate these observations.