Bruce Dalton's PPC 2020 Presentation on Vancomycin Therapeutic Drug Monitoring with or without Area under the Curve (AUC! Not Just the Sound of an Angry Scot) Now Available on CSHP's Members Only Webinar Website

Presenter: Bruce Dalton is a Clinical Pharmacist and Clinical Practice Leader in Calgary where he has been a specialist in Infectious Diseases and Antimicrobial Stewardship since 2004.

Summary: Vancomycin is an important antibiotic for treatment of Gram positive infections. An update to the US clinical practice guidelines for dosing and monitoring of this drug is due to be published and a draft version (not peer reviewed) is available online. A major change of practice is a strong recommendation in the draft of the new guidelines to perform therapeutic drug monitoring (TDM) area using under the curve (AUC) to minimum inhibitory ratio instead of trough levels. Even before the guideline update there has been strong advocacy for this change. A considerable volume of study and literature on AUC TDM now exists. However, there are potential downsides to this practice in terms of possible increases in number of levels drawn, increased resources and education requirements. The guideline draft may have overlooked some important considerations in the available published literature. These may include inconsistent results in retrospective clinical studies, modest prediction value, heterogeneity and difficulties in application. Furthermore, there has been demonstration of very high correlation between AUC and trough in some human studies, suggesting that there is little to be gained from AUC TDM. A recently published a systematic review (November 2019) by clinician/researchers in Calgary will be reviewed. Clinicians trying to decide if and/or when to switch to AUC TDM of vancomycin may benefit from a critical, evidence-based review of the topic. Opportunities to improve the quality of trough based monitoring and research gaps will be discussed.

Goal: Assess the appropriateness of TDM methods for vancomycin for your own institution with awareness of the quality of the evidence


  • Describe the TDM practice changes suggested by the 2019/20 US vancomycin TDM guidelines
  • Review pharmacodynamic/pharmacokinetic concepts and how they apply to TDM and the practice changes suggested
  • Assess the study designs, study quality and results of studies cited as supporting the practice changes for vancomycin TDM
  • Describe the advantages and disadvantages of the practice change suggested by the new guidelines.

Access the presentation here.
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