Effects of clinical decision support on initial dosing and monitoring of tobramycin and amikacin

Abstract

Purpose Clinical decision support (CDS) systems could be valuable tools in reducing aminoglycoside prescribing errors. We evaluated the impact of CDS on initial dosing, interval, and pharmacokinetic outcomes of amikacin and tobramycin therapy. Methods A complex CDS advisor to provide guidance on initial dosing and monitoring, using both traditional and extended interval dosing strategies, was integrated into computerized provider order entry (CPOE) and compared to a control group which featured close pharmacy monitoring of all aminoglycoside orders. A random sample of 118 patients from an academic, tertiary care medical center prescribed amikacin and tobramycin prior to advisor implementation was compared to 98 patients admitted following advisor implementation. Primary outcome was an initial dose within 10% of a dose calculated to be adherent to published dose guidelines. Secondary outcomes were a guideline-adherent interval, trough and peak concentrations in goal range, and incidence of nephrotoxicity. Results Of 216 patients studied, 97 were prescribed amikacin and 119 were prescribed tobramycin. The primary outcome of initial dosing consistent with guideline-based care increased from 40% in the pre-advisor arm to 80% in the post-advisor arm (p<0.001), with a number needed to treat of 3 patients to prevent one incorrect dose. Correct initial interval based on renal function also increased from 63% to 87% (p<0.001). The changes in initial dosing and interval resulted in an increase of trough concentrations in the goal range from 59% pre-advisor to 89% post-advisor implementation (p=0.0004). There was no significant difference in peak concentrations in goal range or incidence of nephrotoxicity (25% vs. 17%, p=0.2). Conclusion An advisor for aminoglycoside dosing and monitoring integrated into CPOE significantly improves initial dosing, selection of interval, and trough concentrations at goal compared to unassisted physician dosing.

Systematic review of clinical decision support interventions with potential for inpatient cost reduction

“…Of the studies focused on pharmacotherapy, the most common areas of specific focus were nephrotoxic drugs (23.8%) [24,41,60,69,76-78,85,90], antibiotics (21.4%) [20,23,26,35,54,62,68,71],[88], and insulin management (14.3%) [39,40,57,59,65,79]. …”

Bayesian Network to Optimize the First Dose of Antibiotics: Application to Amikacin

“…All these methods use observed serum concentrations to individualize the future therapy, but are not suited for the calculation of the first dose. Some authors proposed formulas to estimate patient pharmacokinetic parameters using clinical descriptors only [31][32][33]. These formulas are based on simple relationships between clinical parameters and descriptors (often linear relationships, between body weight and volume of distribution, for example), and are unable to take into account missing values.…”

Impact of vendor computerized physician order entry on patients with renal impairment in community hospitals

“…When applied to patients with renal impairment, CPOE with clinical decision support has been associated with decreased lengths of stay, reduced use of contraindicated medications, improved dosing and drug monitoring, and improved general prescribing practices . Even so, the observed benefit of CPOE on ADE rates has been variable, with some studies reporting reductions, whereas others are unable to detect differences . These studies, however, limited their case definition of ADEs to strictly declining renal function, or adverse events directly resulting from anti‐infective drugs .…”