VVancomycin Area Under the Curve (AUC) Monitoring Versus Trough-Only Dosing for Nephrotoxicity Reduction

Abstract

Introduction: Trough-only vancomycin monitoring (goal 15–20 mg/L) is associated with nephrotoxicity. AUC-guided dosing (target 400–600 mg·h/L) using Bayesian software may improve safety.
Methods: Systematic review of 9 RCTs and 14 cohort studies (n=4,837) comparing AUC-guided (2 levels + Bayesian) versus trough-only monitoring in adults with MRSA infections. Primary outcome: acute kidney injury (AKI, KDIGO criteria). Secondary: treatment failure (persistent bacteremia, recurrence), vancomycin duration.
Results: AUC monitoring reduced AKI (12% vs 23%, RR 0.52, 95% CI 0.41–0.66, NNT=9). Time to therapeutic levels was similar (48h vs 52h). Treatment failure was unchanged (21% vs 24%). Median trough levels were lower in AUC group (14.2 vs 18.6 mg/L, p<0.001). In patients with baseline CKD, AUC monitoring had even greater benefit (AKI: 18% vs 38%). Bayesian software required estimated glomerular filtration rate (eGFR) input; errors in eGFR led to AUC miscalculation in 6%.
Discussion: AUC monitoring reduces nephrotoxicity by avoiding excessive troughs without sacrificing efficacy. Software learning curve is required.
Conclusion: AUC-guided vancomycin monitoring (target 400–600) significantly reduces acute kidney injury compared to trough-only monitoring.