up bright and early to hear @IDpharmresearch, Dr. Jennifer Le, and Dr. Tom Lodise to go through the new #vancomycin guidelines at #ASHP19 
@IDpharmresearch AUC/MIC is the PK/PD target for all lipoglycopeptides, including newer agents #ASHP19
@IDpharmresearch first PK/PD model demonstrating AUC/MIC is the best relationship for #vancomycin presented at ICAAC in 1987 (!!)
@IDpharmresearch human data looking at eradication of S. aureus in pneumonia, AUC >/= 400 associated with increased odds of clinical success #ASHP19
@IDpharmresearch what about the MIC? automated susceptibility machines have a LOT of variability. per @IDpharmresearch, Vitek-2 has 20-30% variability in either direction. MicroScan overcalls MICs of 2 by ~75%. Phoenix undercalls MICs of 2 by ~75%. MICs tend to be slightly higher by Etest #ashp19
@IDpharmresearch per SENTRY surveillance data, 95% of S. aureus isolates have #vancomycin MIC of 1 ncbi.nlm.nih.gov/pubmed/30895214 #ASHP19
@IDpharmresearch data by Tom Lodise and colleagues demonstrate #vancomycin nephrotoxicity is associated with increased doses ( >/=4 grams/day) and prolonged exposures. Troughs >/= 15 also associated with nephrotoxicity #ASHP19
@IDpharmresearch 472 samples in 227 unique patients from the DMC demonstrate how poorly troughs predict AUC. @DosingMatters and colleagues published this poor correlation as well; troughs >/=15 way overshoot AUC goals ncbi.nlm.nih.gov/pubmed/24910345 #ASHP19
@IDpharmresearch @DosingMatters but there's hope! AUC monitoring associated with reduced nephrotoxicity #ASHP19 ncbi.nlm.nih.gov/pubmed/28923869
@IDpharmresearch @DosingMatters but careful, AUC dosing has a toxicity ceiling too ncbi.nlm.nih.gov/pubmed/29084753 #ASHP19
@IDpharmresearch @DosingMatters this is true for pediatrics, too! ncbi.nlm.nih.gov/pubmed/26582878 #ASHP19
@IDpharmresearch @DosingMatters best global outcome if AUC/MIC exposure is 400-515 per PROVIDE study ncbi.nlm.nih.gov/pubmed/31157370 #ASHP19
@IDpharmresearch @DosingMatters sneak peak of #vancomycin guideline recs! coming soon to @AJHPOfficial @ASHPOfficial #ASHP19 remember these data are for S. aureus infections only. AUC24h of 400-600 recommended, you can assume the MIC is 1
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial time for peds!! Dr. Jennifer Le discusses #vancomycin dosing and monitoring for efficacy and safety in pediatrics-- spoiler alert, two levels necessary in this patient population #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial PSA: a child is NOT the same as a small adult when it comes to pharmacokinetics. one size does not fit all. we cannot have a standard pediatric dose. #ASHP19 #vancomycin
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial literature recommendations for empiric #vancomycin dosing strategies for different pediatric patient populations #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial note: weight in pediatric studies often allometric scaling of weight, which better reflects BSA and metabolic state #vancomycin #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial we want to use the minimum effective dose of #vancomycin for safety. best way to dose is bayesian-derived. preferably 2 levels. #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial last but not least, Dr. Tom Lodise with #vancomycin dosing special considerations: loading doses, dosing in obesity, use of continuous infusions, and renal replacement therapy #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial first question-- which weight do you use for determining #vancomycin loading dose? maintenance dose? most of audience is using actual or adjusted weight. guidelines will recommend actual body weight with loading doses not to exceed 3g #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial empiric maintenance doses for most obese patients usually do not exceed 4,500 mg/day, depending on renal function #vancomycin #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial assumption for weight-based dosing is that key PK parameters (Cl, VD) change proportionately with weight (linear relationship) #vancomycin #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial however, data indicated that it is not entirely accurate to describe #vancomycin VD as being proportional to body weight, particularly among obese patients. how to account for this? guidelines recommend lower mg/kg for loading dose and cap at 3000mg #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial #vancomycin maintenance dosing in obesity: what is the optimal weight to use in the cockgroft-gault equation? very controversial in obese patients. recommend to use population estimates of vanco CL from literature to estimate total daily maintenance dose #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial #Vancomycin continuous infusions may be reasonable alternative to conventional intermittent dosing when AUC target cannot be achieved. LD of 15-20 mg/kg, followed by maintenance of CI 30-40mg/kg up to 60mg/kg, to achieve target steady state concentration of 20-25mg/L #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial risk of developing nephrotoxicity with #vancomycin continuous infusion appears to be similar or lower compared to intermittent dosing #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial summary of #vancomycin continuous infusion versus intermittent infusion published literature #ASHP19
@IDpharmresearch @DosingMatters @AJHPOfficial @ASHPOfficial draft recommendations for #vancomycin dosing in intermittent hemodialysis and continuous renal replacement therapy #ASHP19
