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Vancomycin Levels: Have the 2020 Vanco Guidelines Changed the Way we Draw Levels?

Megan N. Freeland, PharmD
December 8, 2020

Drawing vancomycin levels is a standard and common practice in many, if not most, hospitals and health systems. Many of your patients are receiving vancomycin to treat infections, so clinical staff are in close communication about serum vancomycin concentrations, patient kidney function, and dosing changes.

With the publication of the 2020 vancomycin dosing guidelines, it’s worth highlighting any significant changes to vancomycin level targets and the frequency of drawing them (separately from considerations on improving accuracy and reducing nephrotoxicity).

The Previous Approach: Targeting Vancomycin Trough Levels

In the past, you’ve probably taken a trough-based approach to vanco levels. Perhaps your institution still follows this recommendation.

For serious methicillin-resistant Staphylococcus aureus (MRSA) infections, the 2009 recommendation was to aim for serum trough levels between 15 and 20 mg/L. This recommendation was based on the idea that serum trough levels would serve as surrogate markers for a vancomycin area under the curve (AUC) of at least 400 mg*h/L.

Due to the need for precisely timed levels, nursing and phlebotomy staff could spend a considerable amount of time and energy drawing (and sometimes re-drawing) levels from patients on vancomycin.

What the New Guidelines Say About Vancomycin Levels

The new vanco guidelines have shifted the way we think about vancomycin levels and therapeutic drug monitoring. We’ve published a complete guide that walks you through the most important components of the new guidelines, but here’s a quick overview of what the guidelines state about vancomycin levels, specifically.

  • For patients with serious MRSA infections, trough-based monitoring (aiming for a trough target 15-20 mg/L) is no longer recommended.
  • The AUC/MIC ratio is the new recommended efficacy marker, with a target range of 400-600, assuming a vancomycin MICBMD of 1 mg/L.
  • Using Bayesian dosing software programs to facilitate AUC-based vancomycin dosing and monitoring is now recommended. InsightRX Nova is an example of one such dosing software solution.
  • For patients receiving a continuous infusion of vancomycin, a goal serum concentration of 20-25 mg/L has been suggested.

A major benefit of Bayesian dosing software, beyond improved accuracy and patient safety, is the ability to obtain a patient-specific vancomycin dosing regimen that only requires one serum level to be drawn. This level could be a trough level or a random level. Best of all, nursing and phlebotomy staff don’t have to wait hours for a patient to reach steady-state after initiating vanco to draw the level. 

Drawing two levels is still an option with Bayesian dosing software and will help to improve the accuracy of the AUC estimate even more. In certain populations like critically ill patients, drawing two levels will be necessary. But for most patients, Bayesian dosing offers increased sampling flexibility. 

Is there a reliable online vancomycin calculator that meets the new vanco guideline recommendations?

If you’re like other clinicians, you’ve gone to Google once or twice in search of a free vancomycin calculator. You may be wondering whether you can still use an online calculator, even when AUC-guided dosing is now recommended.

The guideline team specifically recommends using a Bayesian precision dosing tool to accurately and safely dose vancomycin according to precise AUC estimates. When possible, it’s recommended and preferred to use dosing software like InsightRX Nova to accomplish this.

If you choose to use an online vancomycin calculator, please understand that this is not a substitute for precision dosing software.

To get a feel for how InsightRX would work for your institution, request a free trial.

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