Barriers and facilitators for therapeutic drug monitoring of beta-lactams and ciprofloxacin in the ICU: a nationwide cross-sectional study

Abstract

Background Recent studies demonstrated that failure of achieving pharmacodynamic targets of commonly used antibiotics is common in critically ill patients. Therapeutic drug monitoring (TDM) can contribute to optimize the exposure of beta-lactams and ciprofloxacin. While evidence for TDM of these antibiotics is growing, translation into clinical implementation remains limited. Therefore, perceived barriers and facilitators are important for implementing TDM in this population. The primary aim of this study was to identify healthcare professionals’ barriers and facilitators for the implementation of TDM of beta-lactams and ciprofloxacin in Dutch intensive care units (ICU). Methods We conducted a nationwide cross-sectional online survey among healthcare professionals (HCPs) involved in antibiotic treatment of ICU patients. An adapted version of the Measurement Instrument for Determinants of Innovations was sent out. Items were considered barriers when ≥ 20% of participants responded with a negative answer. If ≥ 80% of the participants responded with a positive answer, the item was considered a facilitator. Results Sixty-four HCPs completed the survey, of which 14 were from academic hospitals, 25 from general hospitals, and 25 from teaching hospitals. Most participants were hospital pharmacists (59%) or medical specialists (23%). Eleven barriers and four facilitators for implementation of TDM of beta-lactams were identified; 17 barriers for TDM of ciprofloxacin and no facilitators. The most important barriers were a lack of conclusive evidence, organizational support, and low availability of assays. Additional barriers were a lack of consensus on which specific patients to apply TDM and which pharmacodynamic targets to use. Identified facilitators for beta-lactam TDM implementation are low complexity and high task perception, combined with the perception that TDM is important to prevent side effects and to adequately treat infections. Twenty-eight percent of participants reported that flucloxacillin could be analyzed in their hospital. Assay availability of other beta-lactams and ciprofloxacin was lower (3–17%). Conclusion Several barriers were identified that could obstruct the implementation of TDM of beta-lactams and ciprofloxacin in the ICU. In particular, education, clear guidelines, and organizational support should be considered when creating tailored implementation strategies. Finally, evidence of beneficial clinical outcomes on TDM of beta-lactams and ciprofloxacin can enhance further implementation.

Assessment of the practical impact of adjusting beta-lactam dosages based on therapeutic drug monitoring in critically ill adult patients: a systematic review and meta-analysis of randomized clinical trials and observational studies

“…In fact, it is rarely available in ICU wards, even in countries with a high national income 31 . The profound significance of overcoming organizational and technical difficulties in successfully implementing TDM-guided treatments has recently been discussed by Ewoldt et al 32 . The lack of formal agreements by management, and the absence of clear evidence of effectiveness and cost-effectiveness were identified as the key barriers.…”

The clinical application of beta-lactam antibiotic therapeutic drug monitoring in the critical care setting

“…The lack of evidence on survival benefit has been a limitation to the uptake of beta-lactam TDM when compared with other antimicrobial TDM. 20 However, there are important reasons why mortality benefits may have not been demonstrated in the clinical studies published thus far. First, patients who are critically ill and admitted to ICUs often receive beta-lactam antibiotics but may never culture a causative organism or have an infection at all yet are still included in beta-lactam trials.…”

Implementation Strategies Addressing Stakeholder-Perceived Barriers and Enablers to the Establishment of a Beta-Lactam Antibiotic Therapeutic Drug Monitoring Program: A Qualitative Analysis

“…Although insufficient data on improved mortality and clinical outcomes is cited as a major limitation to the widespread acceptance of beta-lactam TDM; these factors did not emerge as a key barrier in this study. 28 Instead, stakeholders were highly motivated by a desire to provide individualized patient care and strongly believed in the efficacy of precision dosing in reducing unnecessary overexposure and identifying underexposure. Regular audits and feedback on the value of TDM during the implementation and postimplementation phases were viewed as important motivators for sustained uptake.…”