Evaluation of a Pharmacy Directed Vancomycin and Monitoring Pilot Program at an Academic Pediatric Hospital

Abstract

Background. Rapid eradication of methicillin resistant Staphylococcus aureus (MRSA) infection is recognized with increased survival with effective treatment within 48 hours, especially in pneumonia. Arguably, the simplest method of measuring efficacy of vancomycin (van) is obtaining therapeutic troughs (TT). In most pediatric hospitals the primary medical team decides the van dosing (VD). This study looks at a pharmacy driven initiative achieve a TT within 48 hours of the initial dose at a pediatric quaternary academic medical center. Methods. This is a prospective quality improvement (QI) project initiated in September 2015 over 1 year. Baseline comparison data is a 13 month retrospective review of admitted patients ( pts) receiving van with physician driven VD. Adapted from the 2009 Infectious Disease Society of America (IDSA) Guidelines on van, appropriateness was based on the following primary endpoints (PE): 1. Discontinuation of van within 48 hours with one or fewer levels 2. TT within the first or second laboratory draw without additional levels within 3 days Pts with severe baseline renal dysfunction and/or dependence on renal replacement therapy requiring van "random" based VD were excluded. Acute kidney injury (AKI) was defined as an increase of >=0.5 mg/dL within 48 hrs of starting van. Results. The baseline data showed that pharmacists were not involved in VD, the physicians had a mean success rate of 51.04% to meeting the PE (range 34.62%- 76.19%). During the intervention phase, the average success to the PE was 94.73% for the first 6 months of the QI (table 1). The median number of blood draws per course of van was 5 in the baseline and 1 in the post-intervention period. The incidence of AKI was 34 cases/718 van days (4.7%) in the retrospective period. After the QI was initiated for seven months there has been an incidence of 4 cases/664 van days (0.4%) of AKI. The QI developed a dose adjustment nomogram after the first level received that achieved TT 93% of the time (table 2). Conclusion. Pharmacy-driven VD improved the achievement of TT within 48 hours from an average of 51.08% to 94.73%, with fewer blood draws and AKI. The strength of our approach was in achieving TT 93% of the time by pharmacists after obtaining the first level. (Figure Presented) .