Predictive Performance of Bayesian Vancomycin Monitoring in the Critically Ill

Crit Care Med. 2021 Oct 1;49(10):e952-e960. doi: 10.1097/CCM.0000000000005062.


Objectives: It is recommended that therapeutic monitoring of vancomycin should be guided by 24-hour area under the curve concentration. This can be done via Bayesian models in dose-optimization software. However, before these models can be incorporated into clinical practice in the critically ill, their predictive performance needs to be evaluated. This study assesses the predictive performance of Bayesian models for vancomycin in the critically ill.

Design: Retrospective cohort study.

Setting: Single-center ICU.

Patients: Data were obtained for all patients in the ICU between 1 January, and 31 May 2020, who received IV vancomycin. The predictive performance of three Bayesian models were evaluated based on their availability in commercially available software. Predictive performance was assessed via bias and precision. Bias was measured as the mean difference between observed and predicted vancomycin concentrations. Precision was measured as the sd of bias, root mean square error, and 95% limits of agreement based on Bland-Altman plots.

Interventions: None.

Measurements and main results: A total of 466 concentrations from 188 patients were used to evaluate the three models. All models showed low bias (-1.7 to 1.8 mg/L), which was lower with a posteriori estimate (-0.7 to 1.8 mg/L). However, all three models showed low precision in terms of sd (4.7-8.8 mg/L) and root mean square error (4.8-8.9 mg/L). The models underpredicted at higher observed vancomycin concentrations (bias 0.7-3.2 mg/L for < 20 mg/L; -5.1 to -2.3 for ≥ 20 mg/L) and the Bland-Altman plots showed a great deviation between observed and predicted concentrations.

Conclusions: Bayesian models of vancomycin show not only low bias, but also low precision in the critically ill. Thus, Bayesian-guided dosing of vancomycin in this population should be used cautiously.

MeSH terms

  • Adult
  • Aged
  • Anti-Bacterial Agents / administration & dosage
  • Anti-Bacterial Agents / analysis
  • Area Under Curve
  • Bayes Theorem
  • Cohort Studies
  • Critical Illness / therapy
  • Drug Monitoring / methods
  • Drug Monitoring / standards*
  • Drug Monitoring / statistics & numerical data
  • Female
  • Humans
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • ROC Curve
  • Retrospective Studies
  • Vancomycin / administration & dosage
  • Vancomycin / analysis*


  • Anti-Bacterial Agents
  • Vancomycin