Jane E Carland1,2,3, Sophie L Stocker1,2,4, Melissa T Baysari5, Crystal Li1,6, Jacqueline Själin1,7, Maria A Moran1, Sarah Tang1,8, Indy Sandaradura9,10, Tania Elhage1,6, Timothy Gilbey11, Kenneth M Williams1,6, Deborah J E Marriott2,11, Richard O Day1,2. 1. Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia. 2. St Vincent's Clinical School, University of NSW, Kensington, NSW, Australia. 3. Department of Pharmacology, School of Medical Sciences, University of NSW, Kensington, NSW, Australia. 4. Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia. 5. Sydney School of Health Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, NSW, Australia. 6. School of Medical Sciences, University of NSW, Kensington, NSW, Australia. 7. Department of Medicine, Karolinska Institute, Stockholm, Sweden. 8. Pharmacy Department, Singapore General Hospital, Singapore, Singapore. 9. Centre for Infectious Diseases and Clinical Microbiology, Westmead Hospital, Westmead, NSW, Australia. 10. Sydney School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, NSW, Australia. 11. Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, NSW, Australia.
Abstract
AIMS: Despite the availability of international consensus guidelines, vancomycin dosing and therapeutic drug monitoring (TDM) remain suboptimal. This study aimed to assess concordance of vancomycin dosing and TDM with institutional guidelines and to identify factors taken into consideration by clinicians when prescribing vancomycin. METHODS: A retrospective audit of 163 patients receiving vancomycin therapy (≥48 hours) was undertaken. Data collected included patient characteristics, dosing history and plasma vancomycin and creatinine concentrations. Concordance of dosing and TDM with institutional guidelines was evaluated. Semi-structured interviews, including simulated prescribing scenarios, were undertaken with prescribers (n = 17) and transcripts analysed. RESULTS: Plasma vancomycin concentrations (n = 1043) were collected during 179 courses of therapy. Only 24% of courses commenced with a loading dose with 72% lower than recommended. The initial maintenance dose was concordant in 42% of courses with 34% lower than recommended. Only 14% of TDM samples were trough vancomycin concentrations. Dose was not adjusted for 60% (21/35) of subtherapeutic and 43% (18/42) of supratherapeutic trough vancomycin concentrations, respectively. Interview participants reported that patient characteristics (including renal function), vancomycin concentrations, guidelines and expert advice influenced vancomycin prescribing decisions. Despite referring to guidelines when completing simulated prescribing scenarios, only 37% of prescribing decisions aligned with guideline recommendations. CONCLUSION: Poor compliance with institutional vancomycin guidelines was observed, despite prescriber awareness of available guidelines. Multifaceted strategies to support prescriber decision-making are required to improve vancomycin dosing and monitoring.
AIMS: Despite the availability of international consensus guidelines, vancomycin dosing and therapeutic drug monitoring (TDM) remain suboptimal. This study aimed to assess concordance of vancomycin dosing and TDM with institutional guidelines and to identify factors taken into consideration by clinicians when prescribing vancomycin. METHODS: A retrospective audit of 163 patients receiving vancomycin therapy (≥48 hours) was undertaken. Data collected included patient characteristics, dosing history and plasma vancomycin and creatinine concentrations. Concordance of dosing and TDM with institutional guidelines was evaluated. Semi-structured interviews, including simulated prescribing scenarios, were undertaken with prescribers (n = 17) and transcripts analysed. RESULTS: Plasma vancomycin concentrations (n = 1043) were collected during 179 courses of therapy. Only 24% of courses commenced with a loading dose with 72% lower than recommended. The initial maintenance dose was concordant in 42% of courses with 34% lower than recommended. Only 14% of TDM samples were trough vancomycin concentrations. Dose was not adjusted for 60% (21/35) of subtherapeutic and 43% (18/42) of supratherapeutic trough vancomycin concentrations, respectively. Interview participants reported that patient characteristics (including renal function), vancomycin concentrations, guidelines and expert advice influenced vancomycin prescribing decisions. Despite referring to guidelines when completing simulated prescribing scenarios, only 37% of prescribing decisions aligned with guideline recommendations. CONCLUSION: Poor compliance with institutional vancomycin guidelines was observed, despite prescriber awareness of available guidelines. Multifaceted strategies to support prescriber decision-making are required to improve vancomycin dosing and monitoring.
Authors: Rachel Constance Yager; Natalie Taylor; Sophie Lena Stocker; Richard Osborne Day; Melissa Therese Baysari; Jane Ellen Carland Journal: BMC Health Serv Res Date: 2022-04-18 Impact factor: 2.908