Pharmacist and Physician Collaborative Practice Model Improves Vancomycin Dosing in an Intensive Care Unit (original) (raw)
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The Canadian Journal of Hospital Pharmacy, 2012
Background: Recent guidelines recommend a vancomycin trough (predose) level between 15 and 20 mg/L in the treatment of invasive gram-positive infections, but most initial dosing nomograms are designed to achieve lower targets (5-15 mg/L). Clinicians need guidance about appropriate initial dosing to achieve the higher target. Objective: To develop and validate a high-target vancomycin dosing nomogram to achieve trough levels of 15-20 mg/L. Methods: A retrospective study was conducted at 2 teaching hospitals, St Paul's Hospital and Vancouver General Hospital in Vancouver, British Columbia. Patients who were treated with vancomycin between January 2008 and June 2010 and who had achieved a trough level of 14.5-20.5 mg/L were identified. Demographic and clinical data were collected. Multiple linear regression was used to develop a vancomycin dosing nomogram for each hospital site. An integrated nomogram was constructed by merging the data from the 2 hospitals. A unique set of patients at each institution was used for validating their respective nomograms and a pooled group of patients for validating the integrated nomogram. Predictive success was evaluated, and a nomogram was deemed significantly different from another nomogram if p < 0.05 via " 2 testing. Results: Data from 78 patients at one hospital and 91 patients at the other were used in developing the respective institutional nomograms. For each hospital's data set, both age and initial serum creatinine were significantly associated with the predicted dosing interval (p < 0.001). Validation in a total of 105 test patients showed that the integrated nomogram had a predictive success rate of 56%. Conclusions: A novel vancomycin dosing nomogram was developed and validated at 2 Canadian teaching hospitals. This integrated nomogram is a tool that clinicians can use in selecting appropriate initial vancomycin regimens on the basis of age and serum creatinine, to achieve high-target levels of 15-20 mg/L. The nomogram should not replace clinical judgment for patients with unstable and/or reduced renal function.
Pharmacotherapy, 2011
Study Objective. To assess and validate the effectiveness of a newly constructed vancomycin dosing nomogram in achieving target trough serum concentrations of 15-20 mg/L. Design. Prospective multicenter study. Setting. Five tertiary care teaching hospitals. Patients. A total of 200 adults who required vancomycin dosages targeted to attain recommended trough vancomycin serum concentrations of 15-20 mg/L. Intervention. The new nomogram, which based dosing on weight and renal function, was used to calculate patients' initial vancomycin dosages. Serum trough concentrations were measured before the fourth or fifth dose, and dosages were adjusted as needed. Measurements and Main Results. Median patient age was 56 years (interquartile range [IQR] 49-65 yrs), median weight was 71.2 kg (IQR 63-85 kg)
Vancomycin administration: the impact of multidisciplinary interventions
Journal of Clinical Pathology, 2007
Background: The clinical microbiology team observed that patients were not receiving all prescribed doses of vancomycin. Ward staff was confused about ordering and interpreting vancomycin therapeutic drug monitoring (TDM) levels. Aim: To audit the incidence of vancomycin dose omission. To implement a series of interventions to improve vancomycin dose administration, and to repeat the audit process to assess these interventions. Methods: Three prospective audits were conducted to assess the impact of vancomycin TDM on administration of vancomycin. After the first audit, a number of changes in the TDM process were undertaken. After review of the second audit, a senior pharmacist coordinated ward-based pharmacists in assisting staff to interpret levels, and TDM interpretative charts were designed for drug charts. Following the third audit, feedback to hospital management and a plan for ongoing education were undertaken. Results: There was a significant reduction in the number of vancomycin doses held inappropriately in the third (10% (78/782) of prescribed doses) when compared to the first audit (16% (161/1007) of doses) (p,0.01). Of doses that were held inappropriately, there was a significant decrease in doses held for no apparent reason in audit 3 (16% (27/170) of prescribed doses) when compared to audit 1 (25% (69/282) of doses) (p,0.05). Conclusions: The interventions resulted in a 37.5% reduction in inappropriately held vancomycin doses over a one-year period; 10% of doses are still being held inappropriately. This study highlights the difficulties in identifying barriers to change and changing healthcare worker behaviour.
Journal of Pharmacy and Pharmacology
Purpose: Evaluate the implementation of a large hospital system vancomycin dosing guideline in a community hospital with pharmacist vancomycin management. Design: Single center, retrospective and prospective quality assessment study. Methods: Pharmacist-managed vancomycin therapy was evaluated pre and post-implementation of a new dosing guideline in a study population of 586 from one community hospital. Results: Of the study population, 274 patients evaluated pre-implementation were compared to 312 patients post-implementation of the large hospital-system guideline (46.8% and 53.2%, respectively). There was no significant difference in demographics between both patient populations. Days of vancomycin therapy was shorter in the post-implementation group (4.32 2.241) versus the pre-implementation group [(4.81 2.764), p = 0.018]. Days to goal trough was longer in the post-implementation group (3.51 1.622) compared to the pre-implementation group [(3.09 2.046), p = 0.054]. A post-hoc regression analysis was conducted, showing that age, days of vancomycin therapy and goal trough are predictors for 77% of cases within the post-implementation group. Conclusion: The implementation of a new vancomycin dosing guideline significantly impacted days of vancomycin therapy and days to goal trough in patients on vancomycin managed by pharmacists. Our results encourage completion of future studies utilizing the regression analysis data, which may impact the future care of patient on vancomycin managed by pharmacists.
Infectious diseases and therapy, 2017
Vancomycin remains one of our essential antibiotics after fifty years of treating serious infections such as methicillin-resistant Staphylococcus aureus. Vancomycin, unlike many other antibiotic agents, requires individualized dosing and monitoring of serum drug levels to ensure it is efficacious, to minimize toxicity, and to limit the development of antibiotic resistance. These issues have led to numerous vancomycin clinical practice guidelines being published in recent years including several key national guidelines. Significant resources are invested during the development of such guidelines; however, there is often little or no information about how such guidelines or other vancomycin practice improvement initiatives should be implemented. The aim of this systematic review is to identify and evaluate the effect of interventions using education, guideline implementation, and dissemination of educational resources that have sought to improve therapeutic drug monitoring and dosing ...
Trials, 2024
Background Vancomycin is a commonly prescribed antibiotic to treat gram-positive infections. The efficacy of vancomycin is known to be directly related to the pharmacokinetic/pharmacodynamic (PK/PD) index of the area under the concentration-time curve (AUC) divided by the minimal inhibitory concentration (MIC) of the pathogen. However, in most countries, steady-state plasma concentrations are used as a surrogate parameter of target AUC/ MIC, but this practice has some drawbacks. Hence, direct AUC-guided monitoring of vancomycin using modelinformed precision dosing (MIPD) tools has been proposed for earlier attainment of target concentrations and reducing vancomycin-related nephrotoxicity. However, solid scientific evidence for these benefits in clinical practice is still lacking. This randomized controlled trial (RCT) aims to investigate the clinical utility of MIPD dosing of vancomycin administered via continuous infusion in hospitalized adults. Methods Participants from 11 wards at two Belgian hospitals are randomly allocated to the intervention group or the standard-of-care comparator group. In the intervention group, clinical pharmacists perform dose calculations using CE-labeled MIPD software and target an AUC24h of 400 to 600 mg × h/L, whereas patients in the comparator group receive standard-of-care dosing and monitoring according to the institutional guidelines. The primary endpoint is the proportion of patients reaching the target AUC24h/MIC of 400-600 between 48 and 72 h after start of vancomycin treatment. Secondary endpoints are the proportion of patients with (worsening) acute kidney injury (AKI) during and until 48 h after stop of vancomycin treatment, the proportion of patients reaching target AUC24h/ MIC of 400-600 between 72 and 96 h after start of vancomycin treatment, and the proportion of time within the target AUC24h/MIC of 400-600. Discussion This trial will clarify the propagated benefits and provide new insights into how to optimally monitor vancomycin treatment.
2016
Background: Vancomycin is a glycopeptide antibiotic used to treat infections caused by Gram-positive bacteria. Irrational administration of this antibiotic may result in increased morbidity or mortality due to toxicity and the emergence of resistant organisms and also impose additional costs. Objectives: The current study aimed at evaluating the effect of pharmacist intervention on vancomycin administration, and discussing appropriate and inappropriate applications of this drug. Methods: The current study was performed on all patients receiving vancomycin intravenously in the intensive care unit (ICU) of Loghman educational Hospital in Tehran, Iran, from May to September 2015. Relevant data were collected by a pharmacist from each patient and their datasheets such as medical records, patient's history, medical orders, nursing reports, and the experimental results available in the patient's records, duration of vancomycin use, history of drug allergy, first diagnoses, type of administration, monitoring necessity, dosing regimen, and occurrence of adverse drug reaction. Patients then were followed until discharge from ICU. Results: About 82% of patients had received vancomycin without noticing their body mass index (BMI) or calcium-induced calcium release (CICR). In addition, 2.63% had inappropriate indication, and in general, the duration of therapy was somehow correct in 44.73% of patients, and 55.26% received vancomycin for more than the appropriate period. Most of the wrong administration was for postoperative prophylaxis. The appropriate duration is maximum 48 hours. But in 63.33% of the patients, it continued for more than 2-3 days. And this inappropriate usage could increase vancomycin resistance. Conclusions: Due to the increasing resistance rate to antibiotics, indication and duration of administration and dosing should be more accurate, and for each patient must be according to his/her ideal body weight (IBW).
Factors Associated With Supratherapeutic Vancomycin Trough Concentrations in a Referral Center
Open Forum Infectious Diseases, 2015
Variable Non-supratherapeutic Supratherapeutic Number of patients 4317 (66.1) 2212 (33.9) Age (years)* 50.2 (16.5) 52.4 (15.7) Age ≥ 65 years 869 (20.1) 499 (22.6) Male Gender 2581 (59.8) 1147 (51.9) Weight (kg)* 86.89 (26.9) 92.11 (28.8) Charlson Comorbidity Index^2 (1-5) 3 (1-5) Length of Stay^8 (5-16) 13 (7-25) Mortality 323 (7.5) 274 (12.4) Hypotension exposure 1214 (28.1) 829 (37.5) Transfer from outside facility 1486 (34.4) 973 (44.0) Admission type Elective 626 (14.5) 225 (11.5) Emergency 2216 (51.3) 1119 (50.6) Urgent 1100 (25.5) 713 (32.2) Trauma Center 375 (8.7) 125 (5.7) Baseline CrCl (mL/min)^104 (78-132) 92.1 (68-122) Baseline CrCl group ≥ 90 mL/min 2716 (62.9) 1139 (51.5) 60-89 mL/min 1067 (24.7) 671 (30.3) 30-59 mL/min 458 (10.6) 342 (15.5) < 30 mL/min 76 (1.8) 60 (2.7) Initial VAN trough (mg/L)^11.3 (8.2-14.9) 22 (13.1-27.8) Maximum VAN trough (mg/L)^13 (9.5-16.4) 26.6 (22.7-33.4) VAN days of therapy^5 (4-7) 7 (4-11) VAN days of therapy > 7 days 893 (20.7) 976 (44.1) Average daily VAN dose (mg/day)^, † 2125 (1667-2643) 2083 (1650-2606) Average daily VAN dose (mg/kg/day)* 26.1 (7.9) 24.7 (8.7) Average daily VAN dose < 15 mg/kg/day 230 (5.3) 174 (7.9) 15-29 mg/kg/day 2940 (68.1) 1566 (70.8) 30-44 mg/kg/day 1056 (24.5) 416 (18.8) ≥ 45 mg/kg/day 91 (2.1) 56 (2.5) Piperacillin-tazobactam exposure 2767 (64.1) 1505 (68.0) Cefepime exposure 805 (18.6) 485 (21.9) Beta-lactam exposure 3270 (75.7) 1751 (79.2
Outcome Assessment of Minimizing Vancomycin Monitoring and Dosing Adjustments
Pharmacotherapy, 1999
An approach to minimize monitoring of vancomycin therapy was evaluated in 120 patients, and results were compared with data from 120 patients in whom vancomycin therapy was monitored and adjusted based on serum peak and trough concentrations and traditional pharmacokinetic methods. Patients dosed by the nomogram (NM) had regimens adjusted based on actual body weight, estimated creatinine clearance, and a targeted trough concentration of 5-20 µg/ml. A single trough serum concentration was drawn only after 5 or more days of therapy. Overall, the average length of therapy was similar between groups (9.9 ± 9.4 days NM and 8.6 ± 7.2 days pharmacokinetic). The most common regimen for both groups was 1 g every 12 hours, although NM patients received significantly fewer grams/day (1.9 ± 0.7g/day) than the pharmacokinetic group (2.2 ± 1.0 g/day, p<0.04). Patients dosed by NM also had significantly fewer regimen changes (0.63 ± 0.96 vs pharmacokinetic 0.92 ± 0.97, p=0.02) as well as significantly fewer serum concentrations measured/patient (1.08 ± 1.9 vs 1.96 ± 2.0, p=0.001). In addition, serum concentrations for NM patients were drawn later in therapy (5.4 ± 2.5 vs 3.8 ± 3.4 days, p=0.004). Of patients dosed by NM guidelines, 77 had trough concentrations drawn; these data were used to validate the nomogram. Seventy-two patients (94%) had trough concentrations in the target range of 5-20 µg/ml. No differences were found between groups with respect to cure, improvement, failure, or days to eradication, or with respect to nephrotoxicity. Finally, total drug cost/patient was not different between groups. A considerable cost savings to our institution was noted for patients dosed by NM compared with pharmacokinetics ($232.5 ± 50.74 vs $403.75 ± 70.97/mo, p=0.009) based on levels saved. Caution should be applied when generalizing our results to other patient populations.
Integrated Pharmacy Research and Practice, 2015
Background: Vancomycin is the antibiotic of choice for the treatment of serious infections such as methicillin-resistant Staphylococcus aureus (MRSA). Inappropriate prescribing of vancomycin can lead to therapeutic failure, antibiotic resistance, and drug toxicity. Objective: To examine the effectiveness of pharmacist-led implementation of a clinical practice guideline for vancomycin dosing and monitoring in a teaching hospital. Methods: An observational pre-post study design was undertaken to evaluate the implementation of the vancomycin guideline. The implementation strategy principally involved education, clinical vignettes, and provision of pocket guidelines to accompany release of the guideline to the hospital Intranet. The target cohort for clinical behavioral change was junior medical officers, as they perform the majority of prescribing and monitoring of vancomycin in hospitals. Assessment measures were recorded for vancomycin prescribing, therapeutic drug monitoring, and patient outcomes. Results: Ninety-nine patients, 53 pre-and 46 post-implementation, were included in the study. Prescribing of a loading dose increased from 9% to 28% (P=0.02), and guideline adherence to starting maintenance dosing increased from 53% to 63% (P=0.32). Dose adjustment by doctors when blood concentrations were outside target increased from 53% to 71% (P=0.12), and correct timing of initial concentration measurement increased from 43% to 57% (P=0.23). Appropriately timed trough concentrations improved from 73% to 81% (P=0.08). Pre-dose (trough) concentrations in target range rose from 33% to 44% (P=0.10), while potentially toxic concentrations decreased from 32% to 21% (P=0.05) post-implementation. Infection cure rates for patients increased from 85% to 96% (P=0.11) after the guideline was implemented. Conclusion: The implementation strategy employed in this study demonstrated potential effectiveness, and should prompt additional larger studies to optimize strategies that will translate into improved clinical practice using vancomycin.