Abstract

Background: Revised consensus guidelines advocate for AUC/MIC-guided therapeutic drug monitoring (TDM) of vancomycin over traditional trough concentration monitoring to mitigate acute kidney injury (AKI) while maintaining therapeutic efficacy.

Methods: We searched PubMed, EMBASE, Cochrane Central, and Web of Science up to January 2026. Studies comparing AUC24/MIC-guided dosing (Bayesian software or two-point pharmacokinetic equations) with trough-only monitoring in adult ICU patients with confirmed or suspected sepsis were included.

Results: Twenty-four studies comprising 7,842 patients met inclusion criteria. Meta-analysis revealed that AUC-guided monitoring was associated with a statistically significant 43% reduction in the odds of vancomycin-induced nephrotoxicity (OR 0.57, 95% CI: 0.46-0.70; P < 0.00001; I2 = 28%). All-cause 30-day mortality was comparable between cohorts (OR 0.94, 95% CI: 0.81-1.09), but time to clinical target attainment was achieved 1.8 days earlier in the AUC cohort.

Conclusions: AUC-guided vancomycin dosing significantly reduces acute kidney injury without compromising clinical response or microbiological clearance in critically ill septic patients.