Still Chasing the Curve: Updated Evidence on Vancomycin AUC vs Trough Monitoring and Its Impact on AKI. A Systematic Review and Meta-Analysis, 2020-2025

BACKGROUND: The objective is to determine whether contemporary evidence continues to support AUC-guided monitoring as a safer alternative to trough-guided monitoring in reducing acute kidney injury (AKI). This analysis builds on prior systematic reviews and meta-analyses by incorporating newly available clinical data published since the release of the 2020 American Society of Health-System Pharmacists (ASHP), Infectious Diseases Society of America (IDSA), the Pediatric Infectious Diseases Society (PIDS), and Society of Infectious Diseases Pharmacists (SIDP) consensus guidelines. METHODS: This study evaluated vancomycin therapeutic drug monitoring (TDM) strategies published between January 1, 2020, and July 28, 2025. The systematic reviews were conducted using PubMed, Embase, Web of Science, CINAHL, the Cochrane Library, Scopus, and Google Scholar databases. Controlled vocabulary (MeSH, Emtree) and keywords were combined to identify studies evaluating AUC-guided or trough-guided vancomycin monitoring with AKI as a reported outcome. Searches were limited to English-language human studies. RESULTS: A total of 80 studies comprising 27,067 patients met the inclusion criteria. Thirty studies directly compared AUC-guided with trough-guided monitoring (n = 18,146) and demonstrated a significantly lower risk of AKI with Area under the Curve (AUC)-guided monitoring (pooled risk ratio [RR] 0.66; 95% CI 0.56-0.78; I2 = 64%), an approximately 34% relative reduction. A subgroup analyses restricted to KDIGO-defined studies, and the 2009 vancomycin consensus guideline definitions yielded a consistent estimate in favored of AUC-guided monitoring. No significant differences were observed between strategies for all-cause mortality (4 studies; n = 697; OR 0.83; 95% CI 0.48-1.44) or 30-day readmission (5 studies; n = 1,222; OR 0.95; 95% CI 0.79-1.14). CONCLUSION: Contemporary evidence published since the 2020 ASHP/IDSA/PIDS and SIDP consensus guideline continues to support AUC-guided monitoring as a safer alternative to trough-guided monitoring, without a measurable trade-off in mortality or readmission. These findings reinforce AUC-guided Therapeutic Drug Monitoring (TDM) as the preferred default strategy for adult patients receiving intravenous vancomycin, while the observational and heterogeneous nature of the evidence underscores the ongoing need for prospective, high-quality trials.