1,2,3 for AUC Implementing the 2020 Vancomycin Dosing Guidelines - - PowerPoint PPT Presentation

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1,2,3 for AUC Implementing the 2020 Vancomycin Dosing Guidelines - - PowerPoint PPT Presentation

Feb 19, 2023 255 likes •444 views

1,2,3 for AUC Implementing the 2020 Vancomycin Dosing Guidelines Angharad Ratliff, PharmD Greg Michaud, PharmD Katie Presser, PharmD Nick Smith, PharmD Objectives Discuss the rationale for implementing AUC dosing with vancomycin

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SLIDE 1

1,2,3 for AUC

Implementing the 2020 Vancomycin Dosing Guidelines

Angharad Ratliff, PharmD Greg Michaud, PharmD Katie Presser, PharmD Nick Smith, PharmD

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SLIDE 2

Objectives

  • Discuss the rationale for implementing AUC dosing with vancomycin
  • Identify successful practices for transitioning from trough-based to AUC-

based vancomycin dosing protocols

  • Discuss common barriers and identify potential solutions for

implementation

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SLIDE 3

Overview

  • Background – Why AUC dosing?
  • How do I do this? Calculation tools
  • When do I do this? Indications, MRSA vs non-MRSA infections, Special

Populations, OPAT

  • Who else is involved?
  • Lab
  • Nursing
  • Pharmacy education
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SLIDE 4
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SLIDE 5

Introducing the Panelists

  • Angharad – Alaska Regional Hospital
  • Greg – MatSu Regional Medical Center
  • Katie – Alaska Native Medical Center
  • Nick – Providence Alaska Medical Center
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SLIDE 6

Background: Why AUC?

2009 Guidelines

  • AUC/MIC ≥ 400
  • Trough of 15-20 mg/L as a surrogate
  • Actual body weight for determining dosage
  • Loading doses for severe infections
  • Knowledge Gaps:
  • Pediatrics
  • Morbidly obese patients
  • Renal failure
  • Prolonged or continuous infusion
  • Safety data for dosages > 3 g/day
  • Safety and efficacy of targeted troughs 15-20mg/L

2020 Guidelines

  • AUC/MIC 400-600
  • AUC/MIC < 400 – encourages emergence of resistance
  • Assume MIC of 1
  • Vancomycin-associated AKI –
  • Increased with AUC > 650
  • Vancomycin monitoring
  • Patients at high risk for nephrotoxicity
  • Patients with unstable renal function
  • Patients receiving prolonged courses of therapy ( > 3-5

days)

  • Frequent or daily monitoring for unstable patients
  • Weekly monitoring for stable patients
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SLIDE 7

Methods of Calculating AUC

  • Bayesian calculators
  • Well-developed vancomycin population PK model + individual patient’s observed drug concentration
  • Does not require steady state conditions
  • Allows for trough-only sampling in select populations
  • Limited information in special populations – obese, critically ill, pediatric, patients with unstable renal

function

  • First order PK analytic equations
  • 2 steady state serum concentrations
  • Lacks adaptive ability of Bayesian calculations
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SLIDE 8

AUC Calculators

  • Prov Excel calculator
  • Precise PK
  • Vancopk.com
  • InsightRx
  • Integration into EMR
  • Turner, et al. Pharmacotherapy 2018
  • Review of APK, BestDose, DoseMe, InsightRx, PrecisePK
  • Considerations: integration into EMR, $$$, training required, adaptability
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SLIDE 9

AUC Dosing Based Upon Indication?

  • Guidelines – serious MRSA infections only
  • Serious infections = bacteremia, sepsis, infective endocarditis, pneumonia,
  • steomyelitis, meningitis
  • Easier implementation across the board?
  • Increased workload on nursing/lab/pharmacy
  • Methods to decrease workload?
  • Which indications?
  • Differentiating MRSA from non-MRSA infections
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SLIDE 10

Special Patient Populations

  • Obesity
  • Increased risk of vancomycin-induced nephrotoxicity
  • Vd increase not reliably associated with weight increase
  • Loading dose (20-25mg/kg) recommended in patients with serious infections
  • 3gm dose cap
  • Max daily vancomycin doses of 4.5 gm/day
  • 2 level analysis
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SLIDE 11

Special Patient Populations

  • Renal Failure
  • Intermittent HD: pre-dialysis HD levels between 15-20mg/L achieves AUC 400-600
  • Loading doses based upon actual body weight and if dose is to be administered

intradialytically or post-dialysis

  • Benefits of administering dose in dialysis vs. after dialysis
  • Continuous renal replacement therapy (CRRT)
  • Loading dose of 20-25 mg/kg actual body weight
  • Initial maintenance dose: 7.5 – 10mg/kg q12h
  • Serum concentration monitoring with 2 levels within 24 hours
  • Dose based upon levels?
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SLIDE 12
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SLIDE 13

Long-term Therapy/Transition to Outpatient

  • Surrogate trough monitoring
  • When to use trough-only?
  • Continuous infusion?
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Nursing Considerations

  • Nurses can be your make or break for AUC dosing
  • Explaining the “WHY” is essential
  • Plans for nursing education
  • Concerns from nursing
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SLIDE 15

Pharmacist Education

  • Gaps in education
  • Competency assessments
  • On-hire
  • On-going
  • One-on-one meetings vs. group training sessions
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Lab Considerations

  • Labeling concerns:
  • Education on moving from single level to 2 level analysis
  • Terminology for lab orders: peak/trough, 2 randoms, AUC 1/AUC2
  • Make sure you are looking at critical levels
  • MIC concerns:
  • CLSI allows for variability +/- 1 dilution
  • E test method consistently higher MICs
  • True rates of MIC of 2 much lower than previously reported
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SLIDE 17

Open Forum

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