Enhancing Patient Outcomes: Vancomycin Therapeutic Drug Monitoring in Critically Ill Patients

Background: Vancomycin is essential for treating severe Gram-positive infections in adult critically ill patients, but its narrow therapeutic index requires therapeutic drug monitoring (TDM) to optimize efficacy and minimize toxicity. The debate between trough concentration (Cmin)-based dosing and area under the curve (AUC)-based dosing remains unresolved, impacting mortality, nephrotoxicity, and clinical outcomes. Aims: This meta-analysis evaluates the impact of TDM on mortality, nephrotoxicity, and clinical cure rates in adult critically ill patients receiving vancomycin. Methods: A systematic search in PubMed, Scopus, Google Scholar, ProQuest, and Cochrane Library identified nine studies assessing vancomycin TDM in adult critically ill patients. These included three studies each for mortality, nephrotoxicity, and clinical cure rates. Results: TDM significantly reduced mortality in three studies (N = 11,587 vs. 11,150; RR 0.84 [95% CI: 0.79, 0.89]). Subgroup analysis of Cmin <15 mg/L vs. Cmin >15 mg/L (N = 11,737) showed improved survival with lower trough levels (RR 0.65 [95% CI: 0.54, 0.78]). Nephrotoxicity risk (N = 156 vs. 150) showed no significant difference (RR 0.83 [95% CI: 0.48, 1.44]). Clinical cure rates (N = 22 vs. 48) comparing AUC <400 vs. >400 mg·h/L found no clear benefit (RR 1.80 [95% CI: 0.41, 7.98]). Conclusions: This meta-analysis confirms TDM significantly reduces mortality, especially with Cmin <15 mg/L, challenging high-trough strategies. However, nephrotoxicity and clinical cure rates were not significantly impacted, supporting a shift to AUC-based dosing. Further randomized trials are needed to refine vancomycin TDM protocols.