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 Socie

DOI 10.1093/ajhp/zxaa036 Michael J. Rybak, PharmD, MPH, PhD, FCCP, FIDP, FIDSA, Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, School of Medicine, Wayne State University, Detroit, MI, and Detroit Receiving Hospital, Detroit, MI Jennifer Le, PharmD, MAS, FIDSA, FCCP, FCSHP, BCPS-AQ ID, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA Thomas P. Lodise, PharmD, PhD, Albany College of Pharmacy and Health Sciences, Albany, NY, and Albany Medical Center Hospital, Albany, NY Donald P. Levine, MD, FACP, FIDSA, School of Medicine, Wayne State University, Detroit, MI, and Detroit Receiving Hospital, Detroit, MI John S. Bradley, MD, JSB, FIDSA, FAAP, FPIDS, Department of Pediatrics, Division of Infectious Diseases, University of California at San Diego, La Jolla, CA, and Rady Children’s Hospital San Diego, San Diego, CA Catherine Liu, MD, FIDSA, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, and Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA Bruce A. Mueller, PharmD, FCCP, FASN, FNKF, University of Michigan College of Pharmacy, Ann Arbor, MI Manjunath P. Pai, PharmD, FCCP, University of Michigan College of Pharmacy, Ann Arbor, MI Annie Wong-Beringer, PharmD, FCCP, FIDSA, University of Southern California School of Pharmacy, Los Angeles, CA John C. Rotschafer, PharmD, FCCP, University of Minnesota College of Pharmacy, Minneapolis, MN Keith A. Rodvold, PharmD, FCCP, FIDSA, University of Illinois College of Pharmacy, Chicago, IL Holly D. Maples, PharmD, University of Arkansas for Medical Sciences College of Pharmacy & Arkansas Children’s Hospital, Little Rock, AR Benjamin M. Lomaestro, PharmD, Albany Medical Center Hospital, Albany, NY The first consensus guideline for therapeutic monitoring of vancomycin in adult patients was published in 2009. A committee representing 3 organizations (the American Society for HealthSystem Pharmacists [ASHP], Infectious Diseases Society of America [IDSA], and Society for Infectious Diseases Pharmacists [SIDP]) searched and reviewed all relevant peer-reviewed data on vancomycin as it related to in vitro and in vivo pharmacokinetic and pharmacodynamic (PK/PD) characteristics, including information on clinical efficacy, toxicity, and vancomycin resistance in relation to serum drug concentration and monitoring. The data were summarized, and specific dosing and monitoring recommendations were made. The primary recommendations consisted of eliminating routine monitoring of serum peak concentrations, emphasizing a ratio of area under the curve over 24 hours to minimum inhibitory concentration (AUC/MIC) of ≥400 as the primary PK/ PD predictor of vancomycin activity, and promoting serum trough concentrations of 15 to 20 mg/L as a surrogate marker for the optimal vancomycin AUC/MIC if the MIC was ≤1 mg/L in patients with normal renal function. The guideline also recommended, albeit with limited data support, that actual body weight be used to determine the vancomycin dosage and loading doses for severe infections in patients who were seriously ill. Since those recommendations were generated, a number of publications have evaluated the impact of the 2009 guidelines on clinical efficacy and toxicity in patients receiving vancomycin for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections. It should be noted, however, that when the recommendations were originally published, there were important issues not addressed and gaps in knowledge that could not be covered adequately because of insufficient data. In fact, adequate data were not available to make recommendations in the original guideline for specific dosing and monitoring for pediatric patients outside of the neonatal age group; specific recommendations for vancomycin dosage adjustment and monitoring in the morbidly obese patient population and patients with renal failure, including specific dialysis dosage adjustments; recommendations for the use of prolonged or continuous infusion (CI) vancomycin therapy; and safety data on the use of dosages that exceed 3 g per day. In addition, there were minimal to no data on the safety and efficacy of targeted trough concentrations of 15 to 20 mg/L. This consensus revision evaluates the current scientific data and controversies associated with vancomycin dosing and serum concentration monitoring for serious MRSA infections (including but not limited to bacteremia, sepsis, infective endocarditis, pneumonia, osteomyelitis, and meningitis) and provides new recommendations based on recent available evidence. Due to a lack of data to guide appropriate targets, the development of this guideline excluded evaluation of vancomycin for methicillin-susceptible S. aureus (MSSA) strains, coagulasenegative staphylococci, and other pathogens; thus, the extrapolation of 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 applyparastyle “fig//caption/p[1]” parastyle “FigCapt”