Making the change to area under the curve–based vancomycin dosing

Heil, Emily L.; Claeys, Kimberly C; Mynatt, Ryan P.; Hopkins, Teri; Brade, Karrine D.; Watt, Ian; Rybak, Michael J.; Pogue, Jason M.

doi:10.2146/ajhp180034

Cited by 69 publications

(58 citation statements)

References 32 publications

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“…A robust roll‐out is required that provides significant education for pharmacy staff, but also nursing, phlebotomy, and prescribers. A detailed description of such is beyond the scope of this paper, but has been published elsewhere . Despite these challenges, after a successful launch, pharmacists found their leadership in vancomycin dosing and monitoring to be positive and empowering.…”

Section: Discussionmentioning

confidence: 99%

“…A comprehensive vancomycin dosing guide was provided to all pharmacists along with a one‐page brief of the process which was posted next to every workstation in the pharmacy. Postimplementation “vancomycin huddles” with challenging case reviews were completed during routine staff meetings, and direct feedback to pharmacists was provided as needed …”

Section: Methodsmentioning

confidence: 99%

“…Trough levels have been used as a surrogate marker for AUC, the PK/PD index of efficacy, due to their relative ease of monitoring. However, targeting aggressive trough concentrations of 15‐20 mg/L for severe infections may not be necessary to achieve an AUC target of at least 400 mg*hr/L . Additionally, these higher than necessary trough concentrations are associated with an increased risk of adverse drug events, in particular, acute kidney injury .…”

Section: Introductionmentioning

confidence: 99%

“…Therefore, a pharmacist‐to‐dose strategy was implemented in conjunction with AUC‐guided dosing at the University of Maryland Medical Center (UMMC) in Baltimore, Maryland in January of 2017. A full review of the implementation process is beyond the scope of this manuscript, but has been discussed in detail in a previous publication . Due to the substantial practice change both in vancomycin dosing and monitoring strategies, along with increased pharmacy involvement, the goal of this study was to understand pharmacists' perceptions of vancomycin dosing practices before and after this change.…”

Section: Introductionmentioning

confidence: 99%

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Pharmacists' perceptions of implementing a pharmacist‐managed area under the concentration time curve‐guided vancomycin dosing program at a large academic medical center

Claeys

Hopkins

Brown

et al. 2019

J Am Coll Clin Pharm

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Introduction A pharmacist‐managed area‐under the concentration time curve/minimum inhibitory concentration (AUC/MIC)‐based vancomycin dosing and monitoring strategy was implemented at the University of Maryland Medical Center (UMMC) in January 2017. Because this was a large change in practice and methodology, we sought to understand pharmacists' perceptions of the practice before and after implementation. Methods A mixed methods preimplementation survey was sent to all pharmacists, including residents, completing vancomycin dosing training at UMMC 1 month prior to transition to an AUC‐guided pharmacist‐to‐dose practice. The postimplementation survey was subsequently sent 8 months after program rollout to the same study participants. Results A total of 127 responses completed the survey: 78 in the preimplementation and 49 in the postimplementation arm. Clinical specialist pharmacists represented 53.8% vs 49.0%, clinical pharmacists represented 32.1% vs 36.7%, and residents represented 14.3% vs 14.1%, respectively. Prior to implementation, 42.3% responded that AUC/MIC was the ideal pharmacokinetic/pharmacodynamic parameter, compared with 93.9% postimplementation (P < 0.0001). Weight‐based dosing was primarily used preimplementation as opposed to postimplementation (46.2% vs 6.1%; P < 0.0001). The average time spent evaluating a vancomycin dose increased from 8 (interquartile range [IQR] 5‐15) minutes to 15 (IQR 10‐17.5) minutes (P < 0.0001). Respondents strongly agreed that pharmacist‐to‐dose AUC/MIC vancomycin for working at the top of their degree (53.1% preimplementation vs 61.5% postimplementation; P = 0.261). Main concerns regarding changes in vancomycin dosing practices included lack of pharmacist competency, which decreased after rollout (48.7% preimplementation vs 24.5% postimplementation; P = 0.081). Before implementation, respondents felt that practice problems and training sessions (69.2%) and computer decision support (57.7%) would be key to a successful rollout. Satisfaction with the rollout increased postimplementation (26.9% vs 49.0%, respectively P = 0.011). Conclusion Pharmacists were in support of pharmacist‐to‐dose AUC vancomycin dosing practices, but there were concerns regarding competency. Training sessions with practice problems and integrated clinical decision support improved the rollout process.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Pharmacists' perceptions of implementing a pharmacist‐managed area under the concentration time curve‐guided vancomycin dosing program at a large academic medical center

Claeys

Hopkins

Brown

et al. 2019

J Am Coll Clin Pharm

Self Cite

View full text Add to dashboard Cite

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“…Preserving patency of venous access in this population is of critical importance especially in patients with limited access options (e.g., patients with peripheral vascular disease) . Frequent trauma of veins in this population such as venipuncture for laboratory draws (including therapeutic drug monitoring), peripheral line insertion, and peripherally inserted central catheters (PICC) to administer antibiotics could compromise arteriovenous fistula (AVF) creation and the feasibility of long‐term dialysis . Several nephrology practice guidelines recommend selection of antibiotics which could be given through the dialysis access during active sessions, such as vancomycin, to prevent vascular trauma .…”

Section: Introductionmentioning

confidence: 99%

Factors predicting vancomycin therapy outcomes in hemodialysis outpatients and the role of the nephrology stewardship pharmacist

Nekidy

El-Masri

Ghazi

et al. 2019

Hemodialysis International

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Background Vancomycin is the default antibiotic to treat methicillin‐resistant Staphylococcus aureus (MRSA) in hemodialysis (HD) units. Current guidelines recommend a vancomycin trough range of 15 to 20 mg/L for serious infections. Data regarding the clinical success of these recommendations are scarce in HD patients. Purpose The purpose of this studies is to evaluate the treatment outcomes of vancomycin in HD patients. Methods A retrospective chart review of HD outpatients who received parenteral vancomycin for suspected or documented MRSA infections in a community hospital in southwestern Ontario, Canada. Stepwise binary logistic regression analysis was conducted to identify the independent predictors of the treatment outcomes. Results Of 77 HD patients, 113 vancomycin treatment courses were identified. The unadjusted bivariate comparisons suggested that there was no difference between treatment success and failure groups in terms of: mean loading dose (1663.6 ± 451.9 mg vs. 1614.3 ± 471 mg, P = 0.621), mean pre‐HD concentration after loading dose (12.78 ± 4.4 mg/L vs. 13.34 ± 4.5 mg/L, P = 0.601), and mean maintenance dose (1012.1 ± 108 mg vs. 1069.7 ± 227 mg, P = 0.093). The groups were, however, different on their mean pre‐HD drug concentration after maintenance dose (15.99 ± 4.6 mg/L vs. 19.9 ± 5.8 mg/L, P = 0.002). The adjusted logistic regression results, however, suggested that the type of infection was the only independent predictor of vancomycin success (OR = 11.07; 95% confidence interval [CI] = 3.2–38.48). Specifically, patients treated for bacteremia were 11 times more likely to experience cure as compared with diabetic foot infection and/or osteomyelitis. Similarly, those with skin and soft tissue infections were 10.7 times more likely to experience cure than those with diabetic foot infection and/or osteomyelitis (OR = 10.7; 95% CI = 3.63–31.58). Conclusion The suggested vancomycin pre‐HD concentration in the guidelines did not predict the treatment outcomes. Patients with bacteremia and/or skin or soft tissue infections were more likely to achieve clinical cure than patients with diabetic foot/osteomyelitis infections.

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Conversion from Vancomycin Trough Concentration–Guided Dosing to Area Under the Curve–Guided Dosing Using Two Sample Measurements in Adults: Implementation at an Academic Medical Center

et al. 2019

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STUDY OBJECTIVE The optimal pharmacodynamic parameter for the prediction of efficacy of vancomycin is the area under the concentration-time curve (AUC), and current published data indicate that dosing based on vancomycin trough concentrations is an inaccurate substitute. In this study, our objective was to compare the achievement of therapeutic target attainment after switching from a trough-based to an AUC-based dosing strategy as a part of our institution's vancomycin-per-pharmacy protocol. DESIGN Prospective observational quality assurance study. SETTING Academic medical center. PATIENTS A total of 296 hospitalized adults who received vancomycin and monitoring under our institution's vancomycin-per-pharmacy protocol were included in the analysis. The preimplementation retrospective comparison group consisted of 179 patients in whom vancomycin was initiated using a trough-based dosing strategy between November 22, 2017, and January 22, 2018. The postimplementation group included 117 patients in whom vancomycin was initiated using an AUC-based dosing strategy using two-point sampling between June 19, 2018, and July 19, 2018, after hospital-wide implementation of this protocol on June 19, 2018. MEASUREMENTS AND MAIN RESULTS AUC values were calculated from two vancomycin concentrations (peak and trough). The primary outcome was achievement of therapeutic AUC values (400-800 mgÁhr/L) in the postimplementation group or therapeutic trough level values (10-20 mg/L) in the preimplementation group. Only 98 (55%) of 179 initial trough values were therapeutic in the preimplementation group (trough-only dosing method) versus 86 (73.5%) of 117 initial AUC values in the postimplementation group (AUC-based dosing method) (p=0.0014). A lower proportion of supratherapeutic AUC values was observed in the postimplementation group compared with supratherapeutic trough concentrations in the preimplementation group (1.7% vs 18%, p<0.0001). Overall, 62% of patients with initially therapeutic AUC values had subsequent trough value increases of 25% or greater, occurring at a median of 6 days of vancomycin therapy. Nephrotoxicity occurred in 11% of patients in the preimplementation versus 9.4% in the postimplementation group (p=0.70). CONCLUSION Compared with a trough concentration-based dosing strategy, AUC-based dosing using two-point sampling improved therapeutic target attainment. Implementation is feasible at any hospital that performs vancomycin peak concentration testing and is a workable alternative to using Bayesian software for estimating AUC. This approach should also be directly compared with AUC-based dosing using Bayesian software.

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Making the change to area under the curve–based vancomycin dosing

Cited by 69 publications

References 32 publications

Pharmacists' perceptions of implementing a pharmacist‐managed area under the concentration time curve‐guided vancomycin dosing program at a large academic medical center

Pharmacists' perceptions of implementing a pharmacist‐managed area under the concentration time curve‐guided vancomycin dosing program at a large academic medical center

Factors predicting vancomycin therapy outcomes in hemodialysis outpatients and the role of the nephrology stewardship pharmacist

Conversion from Vancomycin Trough Concentration–Guided Dosing to Area Under the Curve–Guided Dosing Using Two Sample Measurements in Adults: Implementation at an Academic Medical Center

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