Sanford Guide Editor Douglas Black, Pharm.D. This data is how we determined our AUC goal of 400 to 600mg.h/L for Enterococcus and other strep species. See Vancomycin Bayesian Modeling for more information. An AUC can be measured by checking a peak and trough concentration at steady state; however, this requires obtaining an additional blood sample. \\ Cp = Cp^0*e^{-kt} When the MICBMD is >1 mg/L, the probability of achieving an AUC/MIC target of 400 is low with conventional dosing; higher doses may risk unnecessary toxicity, and the decision to change therapy should be based on clinical judgment. Unfortunately, vancomycin pharmacokinetics can be more complex and requires more finesse than the simple first order elimination equations can provide. The simple first order equation above for vancomycin dosing does have limitations. All rights reserved. These calculations can be done with a calculator, paper and pencil, using an Excel spreadsheet, or via an online calculator such as the, Answers to some common questions about therapeutic vancomycin monitoring can be found at. by levels. This is to ensure the highest degree of safety and accuracy. While we strive to always be your go-to resource for a spanning array of calculation needs, please realize there are occasionally limitations to the tools we can provide. The following equations are used as part of these models: CLvanco is estimated using a linear relationship to creatinine clearance while normalizing to total body weight: CLvanco is estimated using a linear relationship to creatinine clearance: Note that this method comes from the same manuscript that published the linear relationship between Kel and CrCl (Kel=0.00083*CrCl+0.0044), sometimes called the Creighton equation. Vancomycin Calculator. Two drug levels (peak and trough) collected after a single dose (non-steady state), Two drug levels (peak and trough) collected at steady state (after at least three doses). A Look Into Free Online Vancomycin Dosing Calculators - IDStewardship AUC 24 Calculation if calculated AUC was 900 with 3g/day, a dose of 1.5g/d approximately correlates to an AUC of 450). Background: Vancomycin area under the curve/minimum inhibitory concentration (AUC/MIC) has been proposed as a therapeutic drug monitoring (TDM) target to dose vancomycin. It is time-consuming to estimate AUCs using traditional methods. This calculator is not designed for patients receiving any form of renal replacement therapy (such as intermittent hemodialysis, SLED, or CRRT). This feature can be disabled by selecting "Population Estimates" in the "Preferred modeling method" setting. Vancomycin IV | Infectious Diseases Management Program at UCSF One approach used by some facilities is the creation of spreadsheet or electronic health record integrated calculators. 5. No sign-in needed. Some of these steps are summarized below: The 2020 dosing guidelines for vancomycin dosing have made the transition from attaining a target trough to instead focusing on the AUC. Doses of 15 to 20 mg/kg (based on actual body weight) administered every 8 to 12 hours as an intermittent infusion are recommended for most patients with normal renal function when assuming a MICBMD of 1 mg/L (A-II). download a printer-friendly version of this information here, Area under the serum concentration vs. time curve for 0-24 hours (AUC, Note: traditional pediatric dosing of 45-60 mg/kg/day frequently does not achieve target AUC in term infants and older children with normal renal function. David McAuley, Pharm.D. Therapeutic Vancomycin Monitoring Using AUC How it Works Enter Values Enter starting values and click "Calculate" to determine current AUC24. This method relies on having two post-dose drug levels from the same dosing interval ideally collected at steady state. Using this information and the predictive power of Bayesian estimation, the program can use this information to provide a new dosing regimen to arrive within the goal AUC. Bayesian Analysis - Commercial Versions vs Free Options, Trough drawn early? Using a population estimate of Vd, extrapolate a peak value: Using the extrapolated peak and trough values, calculate Kel and CL. These side effects were prevalent even when kept within the trough goals of 15-20 mcg/mL for severe infections and most commonly involved AKI. There are three ways to calculate vancomycin clearance from levels (without the use of a population Vd model): 1) Two levels after the first dose, 2) a steady state peak and trough, or 3) three non-steady-state levels. AKI can be a very unfortunate finding in patients receiving vancomycin. Early and frequent monitoring of AUC exposure is recommended for dose adjustment, especially when empiric doses exceed 4,000 mg/day (A-II). A key assumption of the dual trapezoid method of calculating vancomycin AUC is that the peak and trough concentrations are obtained under steady-state conditions. Because the patient is at steady state, the trough concentration measured 30 minutes before the fourth dose will be equivalent to a trough measured 30 minutes before the fifth dose (refer to above graphic). [. $$, Convert AUC to AUC:MIC ratio over 24 hours, $$ The Sawchuk-Zaske method uses two post-dose concentrations (regardless of being at steady state) using the following approach:11. Bayesian estimation is based on Bayes Theorem. $$, Vd is the volume of distribution (in liters); dose is the vancomycin dose (in milligrams); T. Kane SP. All Rights Reserved. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. By using this website, you agree to its use of cookies. Vancomycin single level - Advanced version Vancomycin - Empiric dosing Vancomycin Empiric dosing - AUC/MIC Diseases Society and the Society of Infectious Diseases Pharmacists. AUC total Target AUC24 is 400-600 Acceptable vancomycin peaks should be <50 tpeakmeasured AUCtotal Dose Used T used tinf Used tinf used Revised Dose Calcs Initial Dose Calcs Actual Trough level Interval Used Cpeak actual Ctrough actual Vancomycin AUC24 Note: assumes vancomycin volume of distribution is constant; caution with obesity, fluid . Vd is determined using the selected Vd method (see Methods for Determining Vancomycin Volume of Distribution). $$, $$ UCSF Vancomycin AUC calculator; UCSF Vancomycin AUC calculator. They also can forecast the expected drug levels and daily AUC based on the new regimen selected. van Hal S, Paterson D, and Lodise T. Systematic review and meta-analysis of vancomycin-induced nephrotoxicity associated with dosing schedules that maintain troughs between 15 and 20 milligrams per liter. The VanLaanen Vanculator Use the following table to guide monitoring of vancomycin based on the patient's clinical status: Clinical Situation Monitoring Recommendation Patients with stable renal function (including patients with CKD and receiving CRRT) Obtain 2 vancomycin levels at steady state and calculate AUC to achieve goal AUC of 400-600 The rationale for using Bayesian dosing for non- Staphylococcus aureus infections are based on trials that showed that in Enterococcal bacteremia, achieving an AUC of greater than 400mg.h/L improved 30 day all-cause mortality. Although vancomycin historically has been classified as a concentration-dependent antibiotic, in more recent years, it has been informally classified as "exposure" or "AUC-dependent". NEW webinar: Mastering Big Data Register now , Vancomycin is a glycopeptide antibiotic with activity against methicillin-resistant Staphylococcus aureus (MRSA)as well as other clinically important gram-positive organisms.1. our study included 2065 obese or morbidly obese patients, far For users who would like to use a specific volume of distribution value (L/kg), this option can be selected. Calculating the AUC requires a bit of work. Note that this recommendation is made on the basis of expert opinion and is not supported by clinical trial data. Do Not Copy, Distribute or otherwise Disseminate without express permission. Why doesn't this calculator use a volume of distribution (Vd) of 0.7 L/kg? The distinguishing factor between zero order and first order pharmacokinetics is the ability of the elimination system to become saturated by the drug.15, When administered intravenously, vancomycin is eliminated renally with >80% of the administered drug recoverable unchanged in the urine.1, While there are other means of vancomycin elimination, renal function plays the most central role in determining how quickly a patient can remove vancomycin from the central compartment. This recommendation is of most importance when considering patients that are critically ill and need more intensive drug monitoring for a serious infection. "In patients with suspected or definitive serious MRSA infections, an individualized target of the AUC/MIC BMD ratio of 400 to 600 (assuming a vancomycin MIC BMD of 1 mg/L) should be advocated to achieve clinical efficacy while improving patient safety (A-II). Jeffres M. The whole price of vancomycin: toxicities, troughs, and time. Doses of 15 to 20 mg/kg (based on actual body weight) administered every 8 to 12 hours as an intermittent infusion are recommended for most patients with normal renal function when assuming a MICBMD of 1 mg/L (A-II). AUC Excel Calculator . Other models do exist that may have less bias and more precision (such as Goti et al. $$, $$ None of the equations used are age-specific, and no age-specific assumptions are made during any calculation. Preparing patients to discharge on vancomycin for outpatient parenteral antimicrobial therapy will present challenges if they are receiving their vancomycin through a home infusion company or are discharged to another facility that remains on a trough-only monitoring protocol. De-escalation Guide (Vancomycin) Patient Case Tutorial . REGISTER: Features: Empiric vancomycin dosing that selects a classic equations with the highest probability of success using Naive Bayesian classifiers. Vancomycin regimens can be calculated both empirically (without any prior doses) or using one or two vancomycin levels. Nursing team members must understand and be able to counsel the patient regarding why they need to draw another drug level, and the patient must be willing to submit to additional testing. Calculate the elimination rate constant (ke), Time from start of infusion to peak (T1, hours): 2. This vancomycin calculator uses pharmacokinetic population estimates, Bayesian modeling, and the Sawchuk-Zaske method to calculate a vancomycin dosing regimen for an adult patient. Implementation Resources - MAD-ID Similarly, a true trough (Cmin) can be calculated using the time elapsed between the second drug concentration (Cp) and the when the next dose is due to begin infusing. To hand calculate the AUC using first order equations, the Sawchuk-Zaske method can be used.18. Obtain approval from members of management and other key stakeholders. Bayesian modeling is a mathematically complex process that involves the following steps: When multiple vancomycin drug concentrations are available, traditional pharmacokinetic equations can be implemented to calculate patient-specific pharmacokinetic parameters. Trough drawn early? These factors contribute to increasing the complexity of estimating the concentrations of alcohol at a given time point. Vancomycin AUC Dosing Resources - MAD-ID
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