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Hussain K, Ikram R, Ambreen G, Salat MS. Pharmacist-directed vancomycin therapeutic drug monitoring in pediatric patients: a collaborative-practice model. J Pharm Policy Pract 2021; 14:100. [PMID: 34847951 PMCID: PMC8630891 DOI: 10.1186/s40545-021-00383-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022] Open
Abstract
Background Therapeutic drug monitoring (TDM) of Vancomycin (VCM) is required to prevent inappropriate dosage-associated bacterial resistance, therapeutic failure, and toxicities in pediatrics. Anecdotal experience and studies show that many healthcare institutions confront barriers while implementing TDM services, this study aimed to assess a pharmacist-directed VCM–TDM service for optimizing patient care in our institution. Materials and methods Patients aged 1 month–18 years who received intravenous VCM were included in this quasi-experimental study. The pre-implementation phase (March–June 2018) consisted of retrospective assessment of pediatric patients, the interventional phase (July 2018 to February 2020) included educational programs and the post-implementation phase (March–June 2020) evaluated the participants based on pharmacist-directed VCM–TDM services as a collaborative-practice model including clinical and inpatient pharmacists to provide 24/7 TDM services. Outcomes of the study included the mean difference in the number of optimal (i) prescribed initial VCM doses (primary) (ii) dosage adjustments and (iii) VCM-sampling time (secondary). After ethical approval, data were collected retrospectively. Results A hundred patients were there in each phase. The number of cases who were correctly prescribed initial VCM doses was significantly higher in the post-implementation phase, mean difference of 0.22, [95% CI (0.142–0.0.358), p < 0.0001]. Patients who had correct dosage adjustments in the post-implementation phase also had higher statistical significance, mean difference of 0.29, [95% CI (0.152–0.423), p < 0.05]. More correct practices of VCM-levels timing were observed in the post-implementation phase, mean difference of 0.15, [95% CI (− 0.053–0.264), p = 0.079]. Conclusion This study showed the significant role of pharmacist-directed TDM services to optimize the correct prescribing of initial VCM doses and dose adjustments.
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Affiliation(s)
- Kashif Hussain
- Department of Pharmacy, Aga Khan University Hospital, Aga Khan University Hospital, Stadium Road (Main Pharmacy), P.O Box 3500, Karachi, 74800, Pakistan.
| | - Rahila Ikram
- Department of Pharmacology - Faculty of Pharmacy and Pharmaceutical Sciences, University of Karachi, Karachi, Pakistan
| | - Gul Ambreen
- Department of Pharmacy, Aga Khan University Hospital, Aga Khan University Hospital, Stadium Road (Main Pharmacy), P.O Box 3500, Karachi, 74800, Pakistan
| | - Muhammad Sohail Salat
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
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Mishra V, Chouinard M, Keiser J, Wagner B, Yen MS, Banas C, Dow A. Automating Vancomycin Monitoring to Improve Patient Safety. Jt Comm J Qual Patient Saf 2019; 45:757-762. [PMID: 31526711 DOI: 10.1016/j.jcjq.2019.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 05/25/2019] [Accepted: 07/02/2019] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Intravenous vancomycin is a frequently used antibiotic and a common cause of medication-related harm because of its narrow therapeutic range. Improving monitoring of drug levels with automation in the electronic health record (EHR) may decrease this harm. METHODS After examining the existing state of vancomycin ordering, administration, and monitoring, an automated process was created in the EHR that, on initiation of a new vancomycin order, automatically ordered a vancomycin trough level 30 minutes before the fourth dose. In addition, a nursing alert was integrated into the bar coding medication administration process that, if no trough level had been drawn by the time of the administration of the fourth dose, prompted the nurse to draw a trough level. Data from a three-month, post-implementation period was compared to data from a preceding three-month period. RESULTS The frequency of trough levels drawn between the third and fourth dose increased from 58.6% to 75.8% (p < 0.01). However, the percentage of trough levels drawn within one hour of the fourth dose remained unchanged, possibly because nursing staff waited for the result of the level prior to administering the next dose of vancomycin. A minority of patients in both groups had trough levels that were in range (difference between groups, p = 0.46). CONCLUSION Automation of vancomycin monitoring was associated with improvement in the frequency of monitoring and only delayed medication dosing by six minutes. Because vancomycin is high risk, this type of process should be broadly implemented, and outcomes should be assessed to identify unexpected outcomes and necessary further refinements.
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Malaeb DN, Fahs IM, Salameh P, Hallit S, Saad M, Bourji J, Hallit R. Assessment of vancomycin utilization among Lebanese hospitals. Saudi Med J 2019; 40:152-157. [PMID: 30723860 PMCID: PMC6402470 DOI: 10.15537/smj.2019.2.23872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objectives: To assess the appropriateness of vancomycin dosing and monitoring at Lebanese hospitals. Methods: This was a multicenter retrospective study conducted at 3 Lebanese hospitals between January and March 2018. Patients 18 years of age and older treated with vancomycin for a systemic infection or prophylaxis were eligible for study enrollment. Consistency with the Infectious Diseases Society of America guidelines was evaluated to determine whether the dose of vancomycin was appropriate, as well as for the time of trough measurement, and the target concentration obtained. Results: From a total of 120 patients who met the inclusion criteria, only 11 (12%) were given the appropriate maintenance dose of vancomycin with respect to actual body weight. The trough levels were monitored for 67 (55.8%) patients, with 20 (29.9%) of these patients achieving appropriate therapeutic trough levels of 15-20 mg/l. The trough concentration time measurement before the fourth dose was only carried out in 28 (41.8%) of the 67 patients. Conclusion: This study reveals a gap between the appropriate utilization of vancomycin with respect to the international guidelines in the studied Lebanese hospitals. It highlights the need for dosing and monitoring protocols suitable for vancomycin utilization in these hospitals.
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Affiliation(s)
- Diana N Malaeb
- Department of Clinical Practice, Lebanese International University, Mouseitbah, Lebanon. E-mail.
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Alhameed AF, Khansa SA, Hasan H, Ismail S, Aseeri M. Bridging the Gap between Theory and Practice; the Active Role of Inpatient Pharmacists in Therapeutic Drug Monitoring. PHARMACY 2019; 7:pharmacy7010020. [PMID: 30781607 PMCID: PMC6473576 DOI: 10.3390/pharmacy7010020] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 11/16/2022] Open
Abstract
Many hospitals face barriers in the implementation of TDM services, this study aimed to evaluate a pharmacist-led TDM service to optimize patients' outcomes. Adult patients who were administered vancomycin, gentamicin, or amikacin were included. The pre-phase included a retrospective assessment of patients and the intervention phase consisted of an educational program. The post-phase assessed patients based on TDM services provided by inpatient pharmacists on a 24-h, 7-day basis for 3 months. The primary outcome was to assess the mean difference in proportion of correct initial doses of prescribing orders. Secondary outcomes included assessing the mean differences in proportions of correct dose adjustments and correct drug sampling time. Seventy-five patients in each phase were eligible. Patients who received optimal initial dosing in the post-phase showed a higher statistical significance, mean difference of 0.31, [95% CI (0.181⁻0.4438), p < 0.0001]. Patients in the post-phase received more optimal dose adjustments, mean difference of 0.1, [95% CI (-0.560⁻0.260), p = 0.2113]. Drug levels were ordered more correctly in the post-phase, mean difference of 0.03, [95% CI (-0.129⁻0.189), p = 0.7110]. This study demonstrated the important role of TDM services led by pharmacists in optimizing the initial dosing for these antibiotics.
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Affiliation(s)
- Abrar F Alhameed
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, 21423 Jeddah, Saudi Arabia.
- Pharmaceutical Care Services, Prince Mohammed Bin Abdulaziz Hospital, MNGHA, 42221 Madinah, Saudi Arabia.
| | - Sara Al Khansa
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, 21423 Jeddah, Saudi Arabia.
- Pharmaceutical Care Services, King Khalid Hospital, MNGHA, 21589 Jeddah, Saudi Arabia.
| | - Hani Hasan
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, 21423 Jeddah, Saudi Arabia.
- Pharmaceutical Care Services, King Khalid Hospital, MNGHA, 21589 Jeddah, Saudi Arabia.
| | - Sherine Ismail
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, 21423 Jeddah, Saudi Arabia.
- Pharmaceutical Care Services, King Khalid Hospital, MNGHA, 21589 Jeddah, Saudi Arabia.
| | - Mohammed Aseeri
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, 21423 Jeddah, Saudi Arabia.
- Pharmaceutical Care Services, King Khalid Hospital, MNGHA, 21589 Jeddah, Saudi Arabia.
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Phillips CJ, Wisdom AJ, McKinnon RA, Woodman RJ, Gordon DL. Interventions targeting the prescribing and monitoring of vancomycin for hospitalized patients: a systematic review with meta-analysis. Infect Drug Resist 2018; 11:2081-2094. [PMID: 30464551 PMCID: PMC6219104 DOI: 10.2147/idr.s176519] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Vancomycin prescribing requires individualized dosing and monitoring to ensure efficacy, limit toxicity, and minimize resistance. Although there are nationally endorsed guidelines from several countries addressing the complexities of vancomycin dosing and monitoring, there is limited consideration of how to implement these recommendations effectively. Methods We conducted a systematic search of multiple databases to identify relevant comparative studies describing the impact of interventions of educational meetings, implementation of guidelines, and dissemination of educational material on vancomycin dosing, monitoring, and nephrotoxicity. Effect size was assessed using ORs and pooled data analyzed using forest plots to provide overall effect measures. Results Six studies were included. All studies included educational meetings. Two studies used implementation of guidance, educational meetings, and dissemination of educational materials, one used guidance and educational meetings, one educational meetings and dissemination of educational materials, and two used educational meetings solely. Effect sizes for individual studies were more likely to be significant for multifaceted interventions. In meta-analysis, the overall effect of interventions on outcome measures of vancomycin dosing was OR 2.50 (95% CI 1.29–4.84); P< 0.01. A higher proportion of sampling at steady-state concentration was seen following intervention (OR 1.95, 95% CI 1.26–3.02; P<0.01). Interventions had no effect on appropriate timing of trough sample (OR 2.02, 95% CI 0.72–5.72; P=0.18), attaining target concentration in patients (OR 1.50, 95% CI 0.49–4.63; P=0.48, or nephrotoxicity (OR 0.75, 95% CI 0.42–1.34; P=0.33). Conclusion Multifaceted interventions are effective overall in improving the complex task of dosing vancomycin, as well as some vancomycin-monitoring outcome measures. However, the resulting impact of these interventions on efficacy and toxicity requires further investigation. These findings may be helpful to those charged with designing implementation strategies for vancomycin guidelines or complex prescribing processes in hospitals.
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Affiliation(s)
- Cameron J Phillips
- SA Pharmacy, Flinders Medical Centre, Bedford Park, Adelaide, SA 5042, Australia, .,College of Medicine and Public Health, Flinders University, Adelaide, SA 5000, Australia, .,School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA 5000, Australia, .,Infectious Diseases and Immunity, Department of Medicine, Imperial College, London W12 0NN, UK,
| | - Alice J Wisdom
- SA Pharmacy, Lyell McEwin Hospital, Elizabeth Vale, Adelaide, SA 5112, Australia
| | - Ross A McKinnon
- College of Medicine and Public Health, Flinders University, Adelaide, SA 5000, Australia, .,School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA 5000, Australia, .,Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, SA 5000, Australia
| | - Richard J Woodman
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, Adelaide, SA 5000, Australia
| | - David L Gordon
- College of Medicine and Public Health, Flinders University, Adelaide, SA 5000, Australia, .,SA Pathology, Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Bedford Park, Adelaide, SA 5042, Australia.,Division of Medicine, Flinders Medical Centre, Bedford Park, Adelaide, SA 5042, Australia
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6
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The effectiveness of information technology to improve antimicrobial prescribing in hospitals: A systematic review and meta-analysis. Int J Med Inform 2016; 92:15-34. [DOI: 10.1016/j.ijmedinf.2016.04.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/06/2016] [Accepted: 04/17/2016] [Indexed: 12/19/2022]
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Cardile AP, Tan C, Lustik MB, Stratton AN, Madar CS, Elegino J, Hsue G. Optimization of time to initial vancomycin target trough improves clinical outcomes. SPRINGERPLUS 2015. [PMID: 26203410 PMCID: PMC4506278 DOI: 10.1186/s40064-015-1146-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Outcomes data for the efficacy of interventions designed to decrease the time to initial target vancomycin troughs are sparse. OBJECTIVE A vancomycin therapeutic drug monitoring (TDM) program was initiated to reduce the time to initial target troughs and to examine the impact on clinical outcomes. METHODS Single-center, pre- and post-intervention observational study in a 250 bed teaching facility. Adult inpatients treated with physician-guided, vancomycin therapy (historical control, CTRL) were compared to high trough, pharmacist-guided vancomycin therapy (TDM). Nephrotoxicity analyses were conducted to the ensure safety of the TDM. Clinical outcome analysis was limited to patients with normal renal function and culture-confirmed gram positive infections and a pre-defined MRSA subset. RESULTS 340 patients met initial inclusion criteria for the nephrotoxicity analysis (TDM, n = 173; CTRL, n = 167). Acute kidney injury occurrence was similar between the CTRL (n = 20) and TDM (n = 23) groups (p = 0.7). Further exclusions yielded 145 patients with gram positive infections for clinical outcomes evaluation (TDM, n = 66; CTRL, n = 75). The time to initial target trough was shorter in the TDM group (3 vs. 5 days, p < 0.001). Patients in the TDM group discharged from the hospital more rapidly, 7 vs. 14 days (Hazards Ratio (HR), 1.41; 95% Confidence Interval [CI] 1.08-1.83; p = 0.01), reached clinical stability faster, 4 vs. 8 days (HR, 1.51; 95% CI 1.08-2.11; p = 0.02), and had shorter courses of vancomycin, 4 vs. 7 days (HR, 1.5; 95% CI 1.15-1.95; p = 0.003). In the MRSA infection subset (TDM, n = 36; CTRL, n = 35), patients in the TDM group discharged from the hospital more rapidly, 7 vs. 16 days (HR, 1.89; 95% CI 1.08-3.3; p = 0.03), reached clinical stability faster, 4 vs. 6 days (HR, 2.69; 95% CI 1.27-5.7; p = 0.01), and had shorter courses of vancomycin, 5 vs. 8 days (HR, 2.52; 95% CI 1.38-4.6; p = 0.003). Attaining initial target troughs in <5 days versus ≥5 days was associated with improved clinical outcomes. All cause in-hospital mortality, and vancomycin treatment failure occurred at comparable rates between groups. CONCLUSIONS Interventions designed to decrease the time to reach initial target vancomycin troughs can improve clinical outcomes in gram positive infections, and in particular MRSA infections.
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Affiliation(s)
- Anthony P Cardile
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Christopher Tan
- Department of Pharmacy, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Michael B Lustik
- Department of Clinical Investigation, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Amy N Stratton
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Cristian S Madar
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Jun Elegino
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
| | - Günther Hsue
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA ; Department of Infectious Diseases, Tripler Army Medical Center, 1 Jarrett White Roadm, Honolulu, HI 96859 USA
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8
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Marquis KA, DeGrado JR, Labonville S, Kubiak DW, Szumita PM. Evaluation of a Pharmacist-Directed Vancomycin Dosing and Monitoring Pilot Program at a Tertiary Academic Medical Center. Ann Pharmacother 2015; 49:1009-14. [PMID: 25991831 DOI: 10.1177/1060028015587900] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Consensus guidelines recommend vancomycin doses of 15 to 20 mg/kg every 8 to 12 hours in patients with normal renal function. OBJECTIVE To evaluate the effect of a pharmacist-directed vancomycin dosing and monitoring pilot program on the percentage of patients receiving targeted weight-based dosing recommendations. METHODS This was a pre-/postevaluation study, approved by the institutional review board at our institution, comparing retrospectively reviewed vancomycin dosing practices hospital-wide between September 1 and September 30, 2010 to patients prospectively managed by a pharmacist-directed vancomycin pilot program between February 1 and April 26, 2011. All adult inpatients receiving intravenous vancomycin were included, unless patients had a creatinine clearance less than or equal to 60 mL/min or indication for therapy was surgical prophylaxis or febrile neutropenia. The primary outcome was the percentage of patients who received optimal vancomycin dosing defined as ≥30 mg/kg/d within 24 hours of initiation of therapy. Secondary outcomes included number of pharmacist interventions, length of therapy and incidence of nephrotoxicity while receiving vancomycin. RESULTS A total of 319 patients were analyzed, 161 preimplementation and 158 postimplementation. The percentage of patients who received optimal vancomycin dosing was significantly higher postimplementation of the pilot program, 96.8 versus 40.4% (P < 0.001). Pharmacist-directed interventions postimplementation, resulted in 50% more patients being dosed optimally (P < 0.001). Patients in the pilot program also had a shorter length of therapy (10.0 vs 8.4 days, P < 0.003) and a lower incidence of nephrotoxicity (8.7% vs 3.2%, P = 0.006). CONCLUSIONS This pharmacist-directed vancomycin pilot program significantly increased the percentage of patients optimally dosed according to consensus guidelines within 24 hours of initiation of therapy.
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Affiliation(s)
| | | | | | | | - Paul M Szumita
- Brigham and Women's Hospital, Boston, MA, USA Northeastern University, Boston, MA, USA
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Phillips CJ. Questioning the accuracy of trough concentrations as surrogates for area under the curve in determining vancomycin safety. Ther Adv Drug Saf 2014; 5:118-20. [PMID: 25083266 DOI: 10.1177/2042098614523819] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Cameron J Phillips
- SA Pharmacy, Flinders Medical Centre, Bedford Drive, Bedford Park, SA 5042, Australia
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Gillon JE, Cassat JE, Di Pentima MC. Validation of two vancomycin nomograms in patients 10 years of age and older. J Clin Pharmacol 2013; 54:35-8. [PMID: 24249098 DOI: 10.1002/jcph.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 08/22/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Jessica E Gillon
- Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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Gillaizeau F, Chan E, Trinquart L, Colombet I, Walton RT, Rège-Walther M, Burnand B, Durieux P. Computerized advice on drug dosage to improve prescribing practice. Cochrane Database Syst Rev 2013; 2013:CD002894. [PMID: 24218045 PMCID: PMC11393523 DOI: 10.1002/14651858.cd002894.pub3] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Maintaining therapeutic concentrations of drugs with a narrow therapeutic window is a complex task. Several computer systems have been designed to help doctors determine optimum drug dosage. Significant improvements in health care could be achieved if computer advice improved health outcomes and could be implemented in routine practice in a cost-effective fashion. This is an updated version of an earlier Cochrane systematic review, first published in 2001 and updated in 2008. OBJECTIVES To assess whether computerized advice on drug dosage has beneficial effects on patient outcomes compared with routine care (empiric dosing without computer assistance). SEARCH METHODS The following databases were searched from 1996 to January 2012: EPOC Group Specialized Register, Reference Manager; Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Ovid; EMBASE, Ovid; and CINAHL, EbscoHost. A "top up" search was conducted for the period January 2012 to January 2013; these results were screened by the authors and potentially relevant studies are listed in Studies Awaiting Classification. The review authors also searched reference lists of relevant studies and related reviews. SELECTION CRITERIA We included randomized controlled trials, non-randomized controlled trials, controlled before-and-after studies and interrupted time series analyses of computerized advice on drug dosage. The participants were healthcare professionals responsible for patient care. The outcomes were any objectively measured change in the health of patients resulting from computerized advice (such as therapeutic drug control, clinical improvement, adverse reactions). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. We grouped the results from the included studies by drug used and the effect aimed at for aminoglycoside antibiotics, amitriptyline, anaesthetics, insulin, anticoagulants, ovarian stimulation, anti-rejection drugs and theophylline. We combined the effect sizes to give an overall effect for each subgroup of studies, using a random-effects model. We further grouped studies by type of outcome when appropriate (i.e. no evidence of heterogeneity). MAIN RESULTS Forty-six comparisons (from 42 trials) were included (as compared with 26 comparisons in the last update) including a wide range of drugs in inpatient and outpatient settings. All were randomized controlled trials except two studies. Interventions usually targeted doctors, although some studies attempted to influence prescriptions by pharmacists and nurses. Drugs evaluated were anticoagulants, insulin, aminoglycoside antibiotics, theophylline, anti-rejection drugs, anaesthetic agents, antidepressants and gonadotropins. Although all studies used reliable outcome measures, their quality was generally low.This update found similar results to the previous update and managed to identify specific therapeutic areas where the computerized advice on drug dosage was beneficial compared with routine care:1. it increased target peak serum concentrations (standardized mean difference (SMD) 0.79, 95% CI 0.46 to 1.13) and the proportion of people with plasma drug concentrations within the therapeutic range after two days (pooled risk ratio (RR) 4.44, 95% CI 1.94 to 10.13) for aminoglycoside antibiotics;2. it led to a physiological parameter more often within the desired range for oral anticoagulants (SMD for percentage of time spent in target international normalized ratio +0.19, 95% CI 0.06 to 0.33) and insulin (SMD for percentage of time in target glucose range: +1.27, 95% CI 0.56 to 1.98);3. it decreased the time to achieve stabilization for oral anticoagulants (SMD -0.56, 95% CI -1.07 to -0.04);4. it decreased the thromboembolism events (rate ratio 0.68, 95% CI 0.49 to 0.94) and tended to decrease bleeding events for anticoagulants although the difference was not significant (rate ratio 0.81, 95% CI 0.60 to 1.08). It tended to decrease unwanted effects for aminoglycoside antibiotics (nephrotoxicity: RR 0.67, 95% CI 0.42 to 1.06) and anti-rejection drugs (cytomegalovirus infections: RR 0.90, 95% CI 0.58 to 1.40);5. it tended to reduce the length of time spent in the hospital although the difference was not significant (SMD -0.15, 95% CI -0.33 to 0.02) and to achieve comparable or better cost-effectiveness ratios than usual care;6. there was no evidence of differences in mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants.For all outcomes, statistical heterogeneity quantified by I(2) statistics was moderate to high. AUTHORS' CONCLUSIONS This review update suggests that computerized advice for drug dosage has some benefits: it increases the serum concentrations for aminoglycoside antibiotics and improves the proportion of people for which the plasma drug is within the therapeutic range for aminoglycoside antibiotics.It leads to a physiological parameter more often within the desired range for oral anticoagulants and insulin. It decreases the time to achieve stabilization for oral anticoagulants. It tends to decrease unwanted effects for aminoglycoside antibiotics and anti-rejection drugs, and it significantly decreases thromboembolism events for anticoagulants. It tends to reduce the length of hospital stay compared with routine care while comparable or better cost-effectiveness ratios were achieved.However, there was no evidence that decision support had an effect on mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants. In addition, there was no evidence to suggest that some decision support technical features (such as its integration into a computer physician order entry system) or aspects of organization of care (such as the setting) could optimize the effect of computerized advice.Taking into account the high risk of bias of, and high heterogeneity between, studies, these results must be interpreted with caution.
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Affiliation(s)
- Florence Gillaizeau
- French Cochrane Center, Hôpital Hôtel-Dieu, 1 place du Parvis Notre-Dame, Paris, France, 75004
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Frankel KC, Rosini JM, Levine BJ, Papas MA, Jasani NB. Computerized provider order entry improves compliance of vancomycin dosing guidelines in the emergency department. Am J Emerg Med 2013; 31:1715-6. [PMID: 24144562 DOI: 10.1016/j.ajem.2013.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 09/10/2013] [Accepted: 09/16/2013] [Indexed: 11/25/2022] Open
Affiliation(s)
- Kathryn C Frankel
- Department of Emergency Medicine, Morristown Memorial Hospital, Morristown, NJ
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Eldemiry EMB, Sabry NA, Abbassi MM, Abdel Shafy SS, Mokhtar MS, Abdel Bary A. A specially tailored vancomycin continuous infusion regimen for renally impaired critically ill patients. SAGE Open Med 2013; 1:2050312113507921. [PMID: 26770686 PMCID: PMC4687768 DOI: 10.1177/2050312113507921] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Vancomycin remains the gold standard for treatment of methicillin-resistant Staphylococcus aureus. Specially designed continuous infusion of vancomycin leads to better therapy. Methodology: A total of 40 critically ill patients who suffered from pneumonia susceptible to vancomycin, had serum creatinine >1.4 mg%, and oliguria <0.5 mL/kg/h for 6 h were included in the study with respiratory culture sensitivity to vancomycin ≤2 mg/L. Patients’ clinical, microbiological, and biological data were obtained by retrospective analysis of the corresponding medical files before and after vancomycin treatment. Patients with serum creatinine level ≥4 mg% and patients who received renal replacement therapy during the treatment period were excluded. The patients were divided into two groups—group 1 (intermittent dosing) and group 2 (continuous infusion) based on the following formula: rate of vancomycin continuous infusion (g/day) = [0.0205 creatinine clearance (mL/min) + 3.47] × [target vancomycin concentration at steady state (µg/mL)] × (24/1000). Trough vancomycin serum levels were also assessed using high-performance liquid chromatographic technique. Patients’ outcomes such as clinical improvement, adverse events, and 15-day mortality were reported. Results: Group 2 showed significant reduction in blood urea nitrogen, creatinine serum levels, white blood cells, partial carbon dioxide pressure, body temperature, and Sequential Organ Failure Assessment score, while significant increase in partial oxygen pressure and saturated oxygen was also observed. A significantly shorter duration of treatment with a comparable vancomycin serum levels was also reported with group 2. Conclusion: After treatment, comparison in patients’ criteria supports the superiority of using continuous infusion of vancomycin according to this equation in renally impaired patients.
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Affiliation(s)
| | | | | | | | - Mohamed S Mokhtar
- Critical Care Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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14
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Devabhakthuni S, Gonzales JP, Tata AL, Lee S, Shah P, Offurum AI, Gulati M. Evaluation of Vancomycin Dosing and Monitoring in Adult Medicine Patients. Hosp Pharm 2012. [DOI: 10.1310/hpj4706-451] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Purpose To assess the clinical impact of a vancomycin dosing protocol and monitoring tool on initial dose, dosing interval, and trough concentrations in adult medicine patients. Methods This was a retrospective chart review of adult medicine patients who received at least one dose of vancomycin and were admitted during the pre-implementation period, February 1 to April 2009, or during the post-implementation period, June 1 to October 31, 2009. All outcomes for patients in the pre-implementation group were compared to those in the post-implementation group. The primary outcomes were frequency of appropriate initial vancomycin dose and dosing interval. The secondary outcomes included frequency of appropriate initial vancomycin trough concentrations, mean number of levels drawn per patient, and mean duration of therapy. Results A total of 450 patients were identified, with 225 patients in each study group. Patients with an appropriate initial vancomycin dose significantly increased in the post-implementation group (56% vs 40%; P < .001). The number of patients with an appropriate original dosing interval (67% vs 63%; P = 0.32), appropriate initial trough concentration (44% vs 45%; P = 0.89), mean number of levels drawn (1.9 vs 2.1; P = 0.56), and duration of therapy (4.9 vs 5.0; P = 0.77) was similar between the 2 groups. Conclusions The implementation of a vancomycin empiric dosing protocol and monitoring tool had a significant impact on the initial dose. Further education regarding vancomycin dosing and monitoring is warranted to improve initial dosing interval, initial trough concentration, number of levels drawn, and duration of therapy.
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Affiliation(s)
- Sandeep Devabhakthuni
- Cardiology/Critical Care, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Jeffrey P. Gonzales
- Critical Care, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
- University of Maryland Medical Center, Baltimore, Maryland
| | - Asha L. Tata
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
- University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Shirley Lee
- Department of Clinical Pharmacy, University of California, San Francisco
| | | | - Ada Ibe Offurum
- Department of Internal Medicine, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mangla Gulati
- Department of Internal Medicine, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, Maryland
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15
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Cox ZL, Nelsen CL, Waitman LR, McCoy JA, Peterson JF. Effects of clinical decision support on initial dosing and monitoring of tobramycin and amikacin. Am J Health Syst Pharm 2012; 68:624-32. [PMID: 21411805 DOI: 10.2146/ajhp100155] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The impact of clinical decision support (CDS) on initial doses and intervals and pharmacokinetic outcomes of amikacin and tobramycin therapy was evaluated. METHODS A complex CDS advisor to provide guidance on initial dosing and monitoring of aminoglycoside orders, using both traditional-dosing and extended-interval-dosing strategies, was integrated into a computerized prescriber-order-entry (CPOE) system and compared with a control group whose aminoglycoside orders were closely monitored by pharmacists. The primary outcome measured was an initial dose within 10% of a dose calculated to be adherent to published dose guidelines. Secondary outcomes included a guideline-adherent interval, trough and peak concentrations in goal range, and rate of nephrotoxicity. RESULTS Of 216 patients studied, 97 were prescribed amikacin and 119 were prescribed tobramycin. The number of orders with initial doses consistent with reference standards increased from 40% in the preadvisor group to 80% in the postadvisor group (p < 0.001). Selection of the correct initial interval based on renal function increased from 63% to 87% (p < 0.001). The changes in the initial dosing and interval resulted in an increase of trough concentrations at goal (59% in the preadvisor group versus 89% in the postadvisor group, p = 0.0004). There was no significant difference in peak concentrations in the goal range or rate of nephrotoxicity. CONCLUSION An advisor for aminoglycoside dosing and monitoring integrated into a CPOE system significantly improved selection of initial doses and intervals and resulted in an improvement in the rate of trough serum drug concentrations at goal compared with standard provider dosing.
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
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16
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Traugott KA, Maxwell PR, Green K, Frei C, Lewis JS. Effects of therapeutic drug monitoring criteria in a computerized prescriber-order-entry system on the appropriateness of vancomycin level orders. Am J Health Syst Pharm 2011; 68:347-52. [DOI: 10.2146/ajhp090661] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Kristi A. Traugott
- Ochsner Health System, New Orleans, LA; at the time of writing she was Infectious Diseases Pharmacy Resident, South Texas Veterans Health Care System, San Antonio
| | - Pamela R. Maxwell
- Solid Organ Transplant, and Residency Program Director, Department of Pharmacy Services
| | - Kay Green
- Neonatal Intensive Care Unit, and Pharmacy Residency Program Coordinator/Continuing Education Administrator, Department of Pharmacy Services, University Health System
| | - Christopher Frei
- Pharmacotherapy Division, College of Pharmacy, University of Texas at Austin, and Assistant Professor, Department of Medicine, Division of Infectious Diseases and Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio
| | - James S. Lewis
- Department of Pharmacy Services, University Health System
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