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New 2020 Vancomycin Dosing Guidelines: What Pharmacists Need to Know

Megan N. Freeland, PharmD
August 18, 2020

By now you’ve likely heard about the new vancomycin dosing guidelines that were published earlier this year. Perhaps you’ve even read through them yourself.

But sometimes a quick refresher comes in handy, especially when it comes to new guidelines or best practices that represent a significant change from what you’re used to. 

This article starts with a bird’s eye view of the recommendations in the 2020 vancomycin dosing guidelines. Afterwards, we’ll dive into the details, discussing the changes that are most relevant to pharmacists and pharmacy partners, including updates on vanco dosing in special populations.

(If you need a brief crash course on vancomycin pharmacokinetics before we begin, have a look here.)

Prefer the video version of this article? Watch here.

Recommendations from the 2020 Vancomycin Dosing Guidelines: A Quick Summary

Let’s take a look at the major recommendations from the new guidelines:

  • Trough-based monitoring (aiming for a trough target 15-20 mg/L) is no longer recommended for patients with serious MRSA infections.
  • Instead, use AUC-based vancomycin dosing and monitoring, either with first-order PK equations or with Bayesian dosing software programs (preferred option).
  • The AUC/MIC ratio is the new recommended efficacy target. Health professionals should aim for a ratio of 400-600, assuming a vancomycin MICBMD of 1 mg/L.
  • Patients receiving vancomycin for invasive MRSA infections should receive vancomycin monitoring regularly. (Once weekly might be enough for hemodynamically stable patients, but hemodynamically unstable patients may benefit from daily monitoring.)

Remember that these suggestions don’t necessarily apply to patients with noninvasive MRSA infections or non-MRSA infections.

Vancomycin Dosing Best Practices: Trough Levels vs. AUC

According to a survey of hospital pharmacies, more than three-quarters of hospital pharmacists and pharmacy directors report issues with under- or overdosing vancomycin, which can increase the risk of insufficient clinical efficacy or adverse events like nephrotoxicity and acute kidney injury (AKI).

The shift from trough-based dosing to AUC-based dosing was largely designed to improve outcomes for patients receiving vancomycin therapy. With AUC-guided dosing and monitoring, you’re able to maximize the therapeutic efficacy of the vancomycin regimen, while minimizing the risk of AKI. 

For an in-depth look at the two options, read The Complete Guide to Vancomycin Dosing in 2020 for Hospital Pharmacists.

Why Bayesian Dosing is Now Preferred

Let’s face it—vancomycin dosing can be time-consuming for pharmacists. And now that the new guidelines recommend shifting to AUC-guided dosing, which may be less familiar to you, you might be wondering how you and your pharmacy team could realistically accomplish this. 

That’s where Bayesian-guided dosing comes in.

If you recall from the guideline highlights, you’ve got two options for AUC-guided dosing: first-order PK equations or Bayesian dosing. There are a few perks that make Bayesian dosing the preferred option.

Bayesian Dosing is Faster

Most Bayesian dosing software options can be integrated into your institution’s existing electronic health record (EHR) system. EHR-integrated dosing software makes for a faster, more efficient AUC dosing and therapeutic monitoring process.

Bayesian Dosing Allows for More Flexibility

With trough-based monitoring, samples should only be taken once steady state is reached, which means you have to wait until the patient has had 3-4 doses before drawing a level. The samples you need for Bayesian-guided dosing and monitoring can be taken at any time, including before steady state is reached.

Bayesian Dosing Requires Less Sampling

Speaking of sampling, Bayesian dosing only requires one vancomycin level in many cases—a trough level or a “random level.” This advantage does have two important caveats, however:

  1. While it’s possible to achieve accurate AUC estimation with only one level, using two levels typically increases the accuracy of the AUC estimate.
  2. You may need to use two levels for AUC estimation in special populations, such as obese or critically ill patients. 

Updates on Vanco Dosing in Special Populations

Historically, vanco dosing and monitoring have been trickier in special populations, considering that you have to account for factors like body weight and kidney function. The 2020 vanco dosing guidelines offer recommendations on how to proceed with AUC-based vancomycin dosing and monitoring in obesity, renal disease, and pediatrics.

Vancomycin Dosing in Obesity

Vanco loading doses are informed by the volume of distribution (Vd), and empiric maintenance doses depend on clearance. Both of these patient-specific measures are impacted by obesity.

As it turns out, Vd may not increase proportionately with actual body weight. So per the guidelines, if a loading dose is clinically appropriate, you should use an actual body weight-based dose of 20-25 mg/kg, but cap the dose at 3000 mg.

Since empiric maintenance doses depend on vancomycin clearance, which typically doesn’t exceed a certain level in obese patients, it’s also recommended to stay below 4500 mg/day.

A targeted maintenance dose initially benefits from two levels—a peak level taken one hour after the end of the infusion, and a trough level—to establish an accurate AUC estimate. After the first estimation is complete, you can employ Bayesian dosing with one level for future estimates. 

Vancomycin Dosing in Renal Disease

Patients getting hemodialysis may be dosed according to their actual body weight, but the weight-based dose will depend on dialyzer permeability and timing of vancomycin dosing.

Vancomycin dosing for patients receiving hemodialysis

Weight-based dosing offers a helpful starting point, but the consensus guideline team encourages use of serum concentration monitoring for more accurate dosing.

Like the general population, patients with renal disease should also have an AUC target of 400-600, which can typically be achieved by keeping predialysis vancomycin concentrations between 15 and 20 mg/L. It’s recommended to take the samples before dialysis and not during or within two hours after a hemodialysis treatment.

Vancomycin Dosing in Pediatrics

Here’s where the guidelines land on vancomycin dosing in pediatric populations:

AUC target: The AUC target in pediatrics is the same as the target in adults, but it may be wise to use the more conservative goal of 400 since there’s not as much data to support the higher end of the range.

Loading dose: There’s no firm recommendation on loading doses in pediatric patients due to a lack of evidence.

Maintenance dose:

  • Children 3 months to <12 years old: 60-80 mg/kg/day in divided doses every 6 hours
  • Children 12 years or older: 60-70 mg/kg/day in divided doses every 6-8 hours
  • Maximum empiric daily dose: 3600 mg, although most children won’t need more than 3000 mg/day

Monitoring: AUC-guided monitoring is recommended and may begin as early as 24-48 hours into vancomycin therapy. If using Bayesian-guided AUC estimation, a one-level sampling strategy may be used.

How to Implement the New 2020 Vancomycin Dosing Guidelines in 3 Simple Steps

Pharmacy departments around the country are preparing to make the transition to AUC-guided dosing using Bayesian software. Here’s an approach your institution can take to align its vancomycin procedures with the new vancomycin dosing best practices.

Step 1: Familiarize your pharmacy colleagues or team with the new 2020 vancomycin dosing guidelines.

Now that you have a solid grasp on the new vanco dosing and monitoring guidelines, you’ll need to get the rest of your pharmacy colleagues on board, for example, fellow clinical pharmacists or the pharmacy director. 

You’re welcome to share our 2020 Vancomycin Dosing Guidelines white paper with your colleagues.

Step 2: Research Bayesian dosing software solutions.

In order to reap the full benefits of AUC-guided dosing and monitoring, you’ll want to adopt the Bayesian dosing and monitoring approach. We recommend finding a Bayesian dosing platform that gives you the most value for your pharmacy department’s budget. 

Step 3: Request a free trial of our Bayesian dosing platform, InsightRX Nova.

If you can, try out the dosing platform before you make a decision. Get a sense of how the software can support your alignment with the new vanco guidelines.

We’re excited to offer you the opportunity to test drive our Bayesian dosing platform, InsightRX Nova. That way, you can explore its custom dosing functionality and patient-specific AUC estimations for yourself.


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