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Background and Objectives <p>Therapeutic drug monitoring (TDM) of vancomycin, ideally based on the ratio of the daily area under the curve to the minimal inhibitory concentration at steady state (AUC<sub>24,SS</sub>/MIC), is hindered by sampling limitations in neonates, so trough concentration (<i>C</i><sub>trough</sub>) is often used as a surrogate. This virtual TDM study aimed to evaluate the performance of Bayesian model-informed precision dosing (MIPD) for vancomycin in neonates.</p> Methods <p>Reference pharmacokinetic (PK) parameters and drug concentrations were simulated in NONMEM for 1000 virtual neonates using a published population PK model. Four TDM strategies were compared based on the percentage of patients achieving an AUC<sub>24,SS</sub>/MIC between 360 and 540 h. Strategy 1 maintained the initial regimen unchanged; strategy 2 adjusted doses using a standard rule of three to target a <i>C</i><sub>trough</sub> of 10–15 mg/L; strategies 3 and 4 used the MIPD software Tucuxi with a steady-state <i>C</i><sub>trough</sub> and two concentrations after the first dose, respectively, for Bayesian dosage optimization. Individual dosages were adjusted following each strategy, recalculating AUC<sub>24,SS</sub> to determine the percentage of target attainment. Iterative adjustments were performed by resampling <i>C</i><sub>trough</sub>. A sub-study evaluated optimal sampling time by comparing Tucuxi-estimated AUC<sub>24,SS</sub> with the reference value.</p> Results <p>Less than 49% of patients reached the target with strategy 1, leading to frequent vancomycin overexposure. Strategy 2 enabled over 75% of patients to achieve AUC<sub>24,SS</sub>/MIC between 360 and 540&#xa0;h with every-8-h regimens, but only 31% with longer dosing intervals. Strategies 3 and 4 allowed over 74% of patients to reach the target after one TDM cycle and 100% after four cycles, regardless of the initial dosing regimen. A single sample sufficed for accurate AUC<sub>24,SS</sub> prediction.</p> Conclusion <p>This virtual TDM study indicates that Bayesian MIPD optimizes vancomycin exposure in neonates, while simplifying the sampling strategy. This approach deserves to be integrated and validated in routine neonatal care.</p>

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Evaluating Bayesian Vancomycin Dosage Adjustment in Neonates: A Simulation-Based Virtual TDM Study

  • 期刊论文

  • 发表日期：

    2026年5月2日

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  • Anne Ravix,
  • Yann Thoma,
  • Annie Cathignol,
  • Paul Thoueille,
  • Catia Marzolini,
  • Eric Giannoni,
  • Thierry Buclin,
  • Chantal Csajka,
  • Kim Dao,
  • Monia Guidi

摘要

Background and Objectives

Therapeutic drug monitoring (TDM) of vancomycin, ideally based on the ratio of the daily area under the curve to the minimal inhibitory concentration at steady state (AUC24,SS/MIC), is hindered by sampling limitations in neonates, so trough concentration (Ctrough) is often used as a surrogate. This virtual TDM study aimed to evaluate the performance of Bayesian model-informed precision dosing (MIPD) for vancomycin in neonates.

Methods

Reference pharmacokinetic (PK) parameters and drug concentrations were simulated in NONMEM for 1000 virtual neonates using a published population PK model. Four TDM strategies were compared based on the percentage of patients achieving an AUC24,SS/MIC between 360 and 540 h. Strategy 1 maintained the initial regimen unchanged; strategy 2 adjusted doses using a standard rule of three to target a Ctrough of 10–15 mg/L; strategies 3 and 4 used the MIPD software Tucuxi with a steady-state Ctrough and two concentrations after the first dose, respectively, for Bayesian dosage optimization. Individual dosages were adjusted following each strategy, recalculating AUC24,SS to determine the percentage of target attainment. Iterative adjustments were performed by resampling Ctrough. A sub-study evaluated optimal sampling time by comparing Tucuxi-estimated AUC24,SS with the reference value.

Results

Less than 49% of patients reached the target with strategy 1, leading to frequent vancomycin overexposure. Strategy 2 enabled over 75% of patients to achieve AUC24,SS/MIC between 360 and 540 h with every-8-h regimens, but only 31% with longer dosing intervals. Strategies 3 and 4 allowed over 74% of patients to reach the target after one TDM cycle and 100% after four cycles, regardless of the initial dosing regimen. A single sample sufficed for accurate AUC24,SS prediction.

Conclusion

This virtual TDM study indicates that Bayesian MIPD optimizes vancomycin exposure in neonates, while simplifying the sampling strategy. This approach deserves to be integrated and validated in routine neonatal care.