Abstract
Objective:A pharmacist and physician collaborative practice intervention to improve the initial dosing of vancomycin was implemented with the goal of decreasing the number of subtherapeutic first troughs and increasing the number of therapeutic troughs.Methods:Using the best available evidence, a nomogram was created to determine the initial vancomycin dose. The nomogram utilized actual bodyweight and glomerular filtration rate (eGFR) estimated with the MDRD4 equation. The dose was based on the 2009 ASHP/IDSA/SIDP guidelines, which recommended 15–20 mg/kg every 8–12 hours. Providers ordered “vancomycin IV dosed per pharmacy”.Results:The pre- (n = 75) and post-intervention (n = 108) cohorts had similar age, gender distribution, weight, and eGFR. The median total daily vancomycin dose was similar in pre- and post-intervention groups (2000 mg), although the median first trough was higher following the intervention (13.0 vs. 14.8 mcg/ml, p = 0.03). Following the intervention, the proportion of first troughs under 10 mcg/ml decreased (32% to 13%, p = 0.003), while the proportion of troughs in the 10 – 20 mcg/ml therapeutic range increased (50.7% vs. 69.4%, p= 0.01). There was no difference in the proportion of troughs over 20 mcg/ml (17.3% vs. 17.6%, p= 0.96).Conclusions:A multi-disciplinary intervention utilizing a nomogram-based pharmacy collaborative practice model significantly improves the proportion of therapeutic initial vancomycin troughs and decreases the number of subtherapeutic troughs by half.
Highlights
Vancomycin is a glycopeptide antibiotic with activity against a variety of Gram-positive organisms, including methicillin-resistant Staphylococcus aureus (MRSA)
There is a dearth of high-quality data on optimal dosing strategies for vancomycin, in 2009 the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), and the Society of Infectious Diseases Pharmacists (SIDP) released joint consensus recommendations based on the best available evidence [1]
Since vancomycin clearance is strongly tied to renal function [3], dosing every 8 hours was prescribed for patients with very high estimated glomerular filtration rate
Summary
Vancomycin is a glycopeptide antibiotic with activity against a variety of Gram-positive organisms, including methicillin-resistant Staphylococcus aureus (MRSA). It is commonly used as part of an empiric broad-spectrum antimicrobial regimen in critically ill patients. Vancomycin must be given intravenously when used for systemic infections, with dose adjustment for body weight and renal function [1]. There is a dearth of high-quality data on optimal dosing strategies for vancomycin, in 2009 the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), and the Society of Infectious Diseases Pharmacists (SIDP) released joint consensus recommendations based on the best available evidence [1]. The expert panel recommended monitoring of steady-state vancomycin troughs with a goal level above 10 mcg/ml to avoid development of resistance.
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