Area Under the Curve vs Trough-Based Vancomycin Monitoring in Pediatric Patients

Background: Trough-based monitoring was previously the primary way to monitor vancomycin; however, 2020 vancomycin consensus guidelines recommend area under the curve (AUC)–based monitoring as the preferred strategy. Data regarding this approach remain limited in the pediatric population. Objective: To compare the proportion of pediatric patients achieving therapeutic vancomycin serum concentrations using AUC vs trough-based monitoring and evaluate the safety and efficacy of both strategies. Methods: This is a single-center retrospective cohort study comparing trough- and Bayesian AUC-based vancomycin monitoring. Patients aged 28 days to 18 years on vancomycin with at least 2 appropriately obtained levels were included. Patients were excluded for suspected or confirmed central nervous system infection, renal dysfunction at vancomycin initiation, neonate or postmenstrual age <44 weeks, or use of continuous vancomycin. The primary outcome was the proportion of patients achieving therapeutic vancomycin serum concentrations. Secondary outcomes included proportion of patients achieving therapeutic goal by the second pharmacokinetic evaluation, time to therapeutic goal, 30- and 90-day all-cause mortality, number of dose adjustments, number of serum concentrations collected, proportion of appropriately timed serum concentrations, and incidence of acute kidney injury (AKI). Results: Eighty-six patients were included: 49 AUC and 37 trough. Overall target attainment was higher in the AUC group (95.9% vs 51.4%; P < .001). The AUC group had a lower final vancomycin dose ( P < .001), fewer dose adjustments ( P = .004), serum concentrations obtained ( P = .02), and more appropriately timed serum concentrations ( P = .02). Incidence of AKI and 30- and 90-day all-cause mortality did not differ between groups. Conclusion and Relevance: Area under the curve monitoring was associated with higher therapeutic goal attainment, lower final vancomycin doses, higher percentage of appropriately timed serum concentrations, fewer serum concentrations drawn, and fewer dosage adjustments. These findings add pediatric-specific evidence supporting 2020 guideline recommendations and indicate Bayesian area under the curve monitoring is a feasible, resource-efficient strategy in this population.