Vancomycin dosing nomograms as a tool to improve antibiotic use: a scoping review

Authors

  • Gabriela Felix Teixeira Postgraduate Program in Administration and Management of Pharmaceutical Assistance, Fluminense Federal University, Rio de Janeiro, RJ, Brazil , Fluminense Federal University image/svg+xml
  • Marília Berlofa Visacri Department of Pharmacy, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, SP, Brazil , University of São Paulo image/svg+xml
  • Fernando Luiz Lopes Cardoso Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, RJ, Brazil , Federal University of Rio de Janeiro image/svg+xml
  • Sabrina Calil-Elias Postgraduate Program in Administration and Management of Pharmaceutical Assistance, Fluminense Federal University, Rio de Janeiro, RJ, Brazil , Department of Pharmacy and Pharmaceutical Administration, Faculty of Pharmacy, Fluminense Federal University, Niterói, Brazil , Fluminense Federal University, Niterói, Brazil
  • Tácio de Mendonça Lima Postgraduate Program in Administration and Management of Pharmaceutical Assistance, Fluminense Federal University, Rio de Janeiro, RJ, Brazil , Department of Pharmacy and Pharmaceutical Administration, Faculty of Pharmacy, Fluminense Federal University, Niterói, Brazil , Fluminense Federal University image/svg+xml

DOI:

https://doi.org/10.1590/s2175-97902025e24593

Keywords:

Vancomycin, Methicillin-resistant, Staphylococcus aureus, Drug Utilization, Dosing nomogram, Antibiotic stewardship

Abstract

This scoping review aimed to summarize studies that developed vancomycin dosing nomograms. A search was performed in MEDLINE, Embase, Scopus, LILACS, and Google Scholar for studies published from January 2009 until January 2014. Two authors performed the study selection and data extraction. Disagreements were resolved by the third author. Forty-three studies were included. Most of them were conducted in the U.S. (48.8%), developed for the adult population (81.4%), specifically for critically ill patients (39.7%), used population data as a method to create the nomogram (67.5%), considered the serum trough concentration as the pharmacodynamic target for developing the dosing nomogram (83.7%), chose intermittent infusion (76.8%) and recommended loading doses administration in their dosing nomogram (65.1%). Twenty-eight studies evaluated the dosing nomogram; 19 (67.8%) achieved optimal vancomycin serum levels. However, most studies were observational designs, with small sample sizes and few nomograms developed based on AUC guided dosing. Moreover, data on the clinical and microbiological outcomes of the patients enrolled in the studies are lacking. Vancomycin dosing nomograms were shown to be a valuable tool to guide the achievement of the PK/PD target, mainly in Middle-Income Countries. More robust methods for the development and evaluation of vancomycin dosing nomograms should be applied and associated with vancomycin TDM.

Downloads

Download data is not yet available.

References

Ables M, Welch RW, Walley B. Development and Assessment of Vancomycin Dosing Utilizing AUC/MIC Protocol in Patients With End-Stage Renal Disease (ESRD) on Intermittent Hemodialysis (IHD). J Pharm Pract. 2023;16:8971900231198927. doi: 10.1177/08971900231198927

Álvarez R, López Cortés LE, Molina J, Cisneros JM, Pachón J. Optimizing the Clinical Use of Vancomycin. Antimicrob Agents Chemother. 2016;(5)60:2601-2609. doi: 10.1128/aac.03147-14

Agência Nacional de Vigilância Sanitária (Anvisa). Gerenciamento de antimicrobianos em serviços de saúde; Resultados da Avaliação Nacional dos programas de gerenciamento de antimicrobianos em Hospitais. 2022. [cited 2024 Out 16]. Available from: https://www.gov.br/anvisa/pt-br/assuntos/servicosdesaude/prevencao-e-controle-de-infeccao-e-resistenciamicrobiana/gerenciamento-do-uso-de-antimicrobianosem-servicos-de-saude

Baptista JP, Roberts JA, Sousa E, Freitas R, Deveza N, Pimentel J. Decreasing the time to achieve therapeutic vancomycin concentrations in critically ill patients: developing and testing of a dosing nomogram. Crit Care. 2014;18(6):654. doi: 10.1186/s13054-014-0654-2

Batchelder N, Lutheran CF, Frens J. Evaluation of a modified vancomycin nomogram for obese adults. Eur J Clin Pharmacol. 2020;76(3):403-408. doi: 10.1007/s00228-019-02811-0

Bowers RD, Cooper AA, Wente CL, Wilson DT, Johnson SW, Drew RH. Evaluation of a vancomycin dosing nomogram in obese patients weighing at least 100 kilograms. Pharm Pract (Granada). 2018;16(3):1204. doi: 10.18549/pharmpract.2018.03.1204

Bradley N, Lee Y, Sadeia M. Assessment of the Implementation of AUC Dosing and Monitoring Practices With Vancomycin at Hospitals Across the United States. J Pharm Pract. 2022;35(6):864-869. doi: 10.1177/08971900211012395.

Carland JE, Stocker SL, Baysari MT, Li C, Själin J, Moran MA, et al. Are vancomycin dosing guidelines followed? A mixed methods study of vancomycin prescribing practices. Br J Clin Pharmacol. 2021;87(11):4221-4229. doi: 10.1111/bcp.14834.

Crass RL, Dunn R, Hong J, Krop LC, Pai MP. Dosing vancomycin in the super obese: less is more. J Antimicrob Chemother. 2018;73(11):3081-3086. doi: 10.1093/jac/dky310

Crew P, Heintz SJ, Heintz BH. Vancomycin dosing and monitoring for patients with end-stage renal disease receiving intermittent hemodialysis. Am J Health Syst Pharm. 2015;72(21):1856-64. doi: 10.2146/ajhp150051.

Daylami AA, Sridharan K, Qader AM. Vancomycin nomograms in children admitted to an intensive care unit. Drugs Ther Perspect. 2020;36:166–72. doi: 10.1007/s40267-020-00708-y

Denetclaw TH, Yu MK, Moua M, Dowling TC, Steinke D. Performance of a divided-load intravenous vancomycin dosing strategy for obese patients. Ann Pharmacother. 2015;49(8):861-8. doi: 10.1177/1060028015586423

Devabhakthuni S, Gonzales JP, Tata AL, Shah P, Offurum AI, Gulati M. Evaluation of Vancomycin Dosing and Monitoring in Adult Medicine Patients. Hospital Pharmacy. 2012;47(6):451-459. doi: 10.1310/hpj4706-451

Elyasi S, Khalili H. Vancomycin dosing nomograms targeting high serum trough levels in different populations: pros and cons. Eur J Clin Pharmacol. 2016;72(7):777-788. doi: 10.1007/s00228-016-2063-8

Flannery AH, Bissell BD, Bastin MT, Morris PE, Neyra JA. Continuous Versus Intermittent Infusion of Vancomycin and the Risk of Acute Kidney Injury in Critically Ill Adults: A Systematic Review and Meta-Analysis. Crit Care Med. 2020;48(6):912-918. doi: 10.1097/ccm.0000000000004326

Frazee E, Rule AD, Lieske JC, Kashani KB, Barreto JN, Virk A, et al. Cystatin C-Guided Vancomycin Dosing in Critically Ill Patients: A Quality Improvement Project. Am J Kidney Dis. 2017;69(5):658-666. doi: 10.1053/j.ajkd.2016.11.016

Golenia BS, Levine AR, Moawad IM, Yeh DD, Arpino PA. Evaluation of a vancomycin dosing nomogram based on the Modification of Diet in Renal Disease equation in intensive care unit patients. J Crit Care. 2013;28(5):710-6. doi: 10.1016/j.jcrc.2013.01.004

Goti V, Chaturvedula A, Fossler MJ, Mok S, Jacob JT. Hospitalized Patients With and Without Hemodialysis Have Markedly Different Vancomycin Pharmacokinetics: A Population Pharmacokinetic Model-Based Analysis. Ther Drug Monit. 2018;40(2):212-221. doi: 10.1097/ftd.0000000000000490

Ho E, Gleeson S, Roberts S, Bondesio K, Salmon A. Vancomycin use for haemodialysis patients-Development of a new dosing protocol. Nephrology (Carlton). 2023;28(4):227-233. doi: 10.1111/nep.14144

Janssen EJ, Välitalo PA, Allegaert K, de Cock RF, Simons SH, Sherwin CM, Mouton JW, van den Anker JN, Knibbe CA. Towards Rational Dosing Algorithms for Vancomycin in Neonates and Infants Based on Population Pharmacokinetic Modeling. Antimicrob Agents Chemother. 2015;60(2):1013-21. doi: 10.1128/aac.01968-15

Kim Y, Kim S, Park J, Lee H. Clinical Response and Hospital Costs of Therapeutic Drug Monitoring for Vancomycin in Elderly Patients. J Pers Med. 2022;12(2):163. doi: 10.3390/jpm12020163

Kosmisky DE, Griffiths CL, Templin MA, Norton J, Martin KE. Evaluation of a New Vancomycin Dosing Protocol in Morbidly Obese Patients. Hosp Pharm. 2015;50(9):789-97. doi: 10.1310/hpj5009-789

Kullar R, Leonard SN, Davis SL, Delgado G Jr, Pogue JM, Wahby KA, et al. Validation of the effectiveness of a vancomycin nomogram in achieving target trough concentrations of 15-20 mg/L suggested by the vancomycin consensus guidelines. Pharmacotherapy. 2011;31(5):441-8. doi: 10.1592/phco.31.5.441

Lake KD, Peterson CD. A simplified dosing method for initiating vancomycin therapy. Pharmacotherapy. 1985;5(6):340-4. doi: 10.1002/j.1875-9114.1985.tb03441.x

Lee BV, Fong G, Bolaris M, Neely M, Minejima E, Kang A, et al. Cost-benefit analysis comparing trough, two-level AUC and Bayesian AUC dosing for vancomycin. Clin Microbiol Infect. 2021;27(9):1346.e1-1346.e7. doi: 10.1016/j.cmi.2020.11.008.

Leu WJ, Liu YC, Wang HW, Chien HY, Liu HP, Lin YM. Evaluation of a vancomycin dosing nomogram in achieving high target trough concentrations in Taiwanese patients. Int J Infect Dis. 2012;16(11):e804-10. doi: 10.1016/j.ijid.2012.07.005

Levin D, Glasheen JJ, Kiser TH. Pharmacist and Physician Collaborative Practice Model Improves Vancomycin Dosing in an Intensive Care Unit. Int J Clin Med. 2016;7(10):675-684. doi: 10.4236/ijcm.2016.710073

Lewis SJ, Mueller BA. Development of a vancomycin dosing approach for critically ill patients receiving hybrid hemodialysis using Monte Carlo simulation. SAGE Open Med. 2018;6:2050312118773257. doi: 10.1177/2050312118773257

Lim AS, Foo SHW, Benjamin Seng JJ, Magdeline Ng TT, Chng HT, Han Z. Area-Under-Curve-Guided Versus Trough-Guided Monitoring of Vancomycin and Its Impact on Nephrotoxicity: A Systematic Review and Meta-Analysis. Ther Drug Monit. 2023;45(4):519-532. doi: 10.1097/FTD.0000000000001075.

Lima T de M, Elias SC, Estrela R de C, Cardoso FLL. Implementation of vancomycin dosing nomogram in an electronic prescribing system: An innovative tool in antibiotic stewardship. Braz J Pharm Sci. 2014;50(3):567-572. doi: 10.1590/S1984-82502014000300016

Luo C, Hussaini T, Lacaria K, Yeung J, Lau TT, Broady RC. Evaluation of a Once-Daily Vancomycin Regimen in an Outpatient Leukemia/Bone Marrow Transplant Clinic (OD-VANCO Study). Can J Hosp Pharm. 2014;67(4):280-5. doi: 10.4212/cjhp.v67i4.1372

Masich AM, Kalaria SN, Gonzales JP, Heil EL, Tata AL, Claeys KC, et al. Vancomycin Pharmacokinetics in Obese Patients with Sepsis or Septic Shock. Pharmacotherapy. 2020;40(3):211-220. doi: 10.1002/phar.2367

McCluggage L, Lee K, Potter T, Dugger R, Pakyz A. Implementation and evaluation of vancomycin nomogram guidelines in a computerized prescriber-order-entry system. Am J Health Syst Pharm. 2010;67(1):70-5. doi: 10.2146/ajhp080625

Mcgrady KA, Benton M, Tart S, Bowers R. Evaluation of traditional initial vancomycin dosing versus utilizing an electronic AUC/MIC dosing program. Pharm Pract (Granada). 2020;18(3):2024. doi: 10.18549/pharmpract.2020.3.2024

Medellín-Garibay SE, Romano-Moreno S, Tejedor-Prado P, Rubio-Álvaro N, Rueda-Naharro A, Blasco-Navalpotro MA, et al. Influence of Mechanical Ventilation on the Pharmacokinetics of Vancomycin Administered by Continuous Infusion in Critically Ill Patients. Antimicrob Agents Chemother. 2017;61(12):e01249-17. doi: 10.1128/aac.01249-17

Morales-Junior R, Tiguman GM, Juodinis VD, Santos ICPF, Santos SRCJ. Monitoramento terapêutico de vancomicina: como estamos no Brasil? Braz J Infect Dis. 2022;26(S1):101703. doi: 10.1016/j.bjid.2021.101707

O'Brien KA, Mok S. Evaluation of the Safety of a Vancomycin Nomogram Used to Achieve Target Trough Concentrations. Hosp Pharm. 2015;50(10):900-910. doi: 10.1310%2Fhpj5010-900

Oda K, Katanoda T, Hashiguchi Y, Kondo S, Narita Y, Iwamura K, et al. Development and evaluation of a vancomycin dosing nomogram to achieve the target area under the concentration-time curve. A retrospective study. J Infect Chemother. 2020;26(5):444-450. doi: 10.1016/j.jiac.2019.11.009

Okada A, Kariya M, Irie K, Okada Y, Hiramoto N, Hashimoto H, et al. Population Pharmacokinetics of Vancomycin in Patients Undergoing Allogeneic Hematopoietic Stem-Cell Transplantation. J Clin Pharmacol. 2018;58(9):1140-1149. doi: 10.1002/jcph.1106

Pea F, Furlanut M, Negri C, Pavan F, Crapis M, Cristini F, et al. Prospectively validated dosing nomograms for maximizing the pharmacodynamics of vancomycin administered by continuous infusion in critically ill patients. Antimicrob Agents Chemother. 2009;53(5):1863-7. doi: 10.1128/aac.01149-08

Pokorná P, Šíma M, Černá O, Slanař O. Nomogram based on actual body weight for estimation of vancomycin maintenance dose in infants. Infect Dis (Lond). 2019a;51(5):334-339. doi: 10.1080/23744235.2018.1541250

Pokorná P, Šíma M, Černá O, Allegaert K, Tibboel D, Slanař O. Actual body weight-based vancomycin dosing in neonates. J Chemother. 2019b;31(6):307-312. doi: 10.1080/1120009x.2019.1599574

Rybak M, Lomaestro B, Rotschafer JC, Moellering R Jr, Craig W, Billeter M, et al. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2009;66(1):82-98. doi: 10.2146/ajhp080434

Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, et al. 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. Am J Health Syst Pharm. 2020;77(11):835-864. doi: 10.1093/ajhp/zxaa036

Reilly AM, Ding MX, Rower JE, Kiser TH. The Effectiveness of a Vancomycin Dosing Guideline in the Neonatal Intensive Care Unit for Achieving Goal Therapeutic Trough Concentrations. J Clin Pharmacol. 2019;59(7):997-1005. doi: 10.1002/jcph.1392

Saugel B, Gramm C, Wagner JY, Messer M, Lahmer T, Meidert AS, et al. Evaluation of a dosing regimen for continuous vancomycin infusion in critically ill patients: an observational study in intensive care unit patients. J Crit Care. 2014;29(3):351-5. doi: 10.1016/j.jcrc.2013.12.007

Sin JH, Newman K, Elshaboury RH, Yeh DD, de Moya MA, Lin H. Prospective evaluation of a continuous infusion vancomycin dosing nomogram in critically ill patients undergoing continuous venovenous haemofiltration. J Antimicrob Chemother. 2018;73(1):199-203. doi: 10.1093/jac/dkx356

Silva MP, Luz LD, Soares TC, Dantas ES, Teixeira GF, Lima CR, et al. Desenvolvimento de um nomograma de doses de vancomicina para pacientes pediátricos: uma estratégia para o uso racional de antimicrobianos. Rev Amaz Cien Farma. 2021;2(1):3-8. doi: 10.17648/2675-5572.racf.v2n1.1

Smit C, Goulooze SC, Brüggemann RJM, Sherwin CM, Knibbe CAJ. Dosing Recommendations for Vancomycin in Children and Adolescents with Varying Levels of Obesity and Renal Dysfunction: a Population Pharmacokinetic Study in 1892 Children Aged 1-18 Years. AAPS J. 2021;23(3):53. doi: 10.1208/s12248-021-00577-x

Spadaro S, Berselli A, Fogagnolo A, Capuzzo M, Ragazzi R, Marangoni E, et al. Evaluation of a protocol for vancomycin administration in critically patients with and without kidney dysfunction. BMC Anesthesiol. 2015;15:95. doi: 10.1186%2Fs12871-015-0065-1

Tang Z, Guan J, Li J, Yu Y, Qian M, Cao J, et al. Determination of vancomycin exposure target and individualised dosing recommendations for neonates: model-informed precision dosing. Int J Antimicrob Agents. 2021;57(3):106300. doi: 10.1016/j.ijantimicag.2021.106300

Thalakada R, Legal M, Lau TT, Luey T, Batterink J, Ensom MH. Development and validation of a novel vancomycin dosing nomogram for achieving high-target trough levels at 2 canadian teaching hospitals. Can J Hosp Pharm. 2012;65(3):180-7. doi: 10.4212/cjhp.v65i3.1140

Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467-473. doi: 10.7326/m18-0850

van Maarseveen EM, Bouma A, Touw DJ, Neef C, van Zanten AR. Design and prospective validation of a dosing instrument for continuous infusion of vancomycin: a within-population approach. Eur J Clin Pharmacol. 2014;70(11):1353-9. doi: 10.1007/s00228-014-1742-6

Wesner AR, Brackbill ML, Coyle LL, Kidd RS. Prospective trial of a novel nomogram to achieve updated vancomycin trough concentrations. Interdiscip Perspect Infect Dis. 2013;2013:839456. doi: 10.1155/2013/839456

Williams P, Beall G, Cotta MO, Roberts JA. Antimicrobial dosing in critical care: A pragmatic adult dosing nomogram. Int J Antimicrob Agents. 2020;55(2):105837. doi: 10.1016/j.ijantimicag.2019.10.018

Wong S, Reuter SE, Jones GR, Stocker SL. Review and evaluation of vancomycin dosing guidelines for obese individuals. Expert Opin Drug Metab Toxicol. 2022;18(5):323-335. doi: 10.1080/17425255.2022.2098106

Yoon S, Park KR, Lee S, Song SH, Park WB, Jang IJ, et al. Assessment of Appropriateness of an Initial Dosing Regimen of Vancomycin and Development of a New Dosing Nomogram. Basic Clin Pharmacol Toxicol. 2018;122(2):233-238. doi: 10.1111/bcpt.12873

Zhang G, Zhang N, Xu J, Yang T, Yin H, Cai Y. Efficacy and safety of vancomycin for the treatment of Staphylococcus aureus bacteraemia: a systematic review and meta-analysis. Int J Antimicrob Agents. 2023;62(4):106946. doi: 10.1016/j.ijantimicag.2023.106946.

Zelenitsky SA, Ariano RE, McCrae ML, Vercaigne LM. Initial vancomycin dosing protocol to achieve therapeutic serum concentrations in patients undergoing hemodialysis. Clin Infect Dis. 2012;55(4):527-33. doi: 10.1093/cid/cis458

Downloads

Published

2025-11-10

Data Availability Statement

Not informed.

Issue

Vol. 61 (2025)

Section

Article

License

Copyright (c) 2025 Brazilian Journal of Pharmaceutical Sciences

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

All content of the journal, except where identified, is licensed under a Creative Commons attribution-type BY.

The on-line journal has open and free access.

How to Cite

Vancomycin dosing nomograms as a tool to improve antibiotic use: a scoping review. (2025). Brazilian Journal of Pharmaceutical Sciences, 61, e24593. https://doi.org/10.1590/s2175-97902025e24593