Sustained improvement in vancomycin dosing and monitoring post-implementation of guidelines: Results of a three-year follow-up after a multifaceted intervention in an Australian teaching hospital

Phillips, Cameron J; Woodman, Richard; Gordon, David L.

doi:10.1016/j.jiac.2017.09.010

Cited by 15 publications

(25 citation statements)

References 43 publications

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“…Five of the six studies were from the US 35 , 36 , 38 – 40 and one from Australia. 37 Three studies reported the population as number of patients, with 263 in the intervention group and 274 receiving usual care, 35 – 37 and one study reported treatment courses, with 200 in the intervention group and 279 receiving usual care. 38 Two studies that evaluated timing of blood samples for vancomycin assays exclusively reported only the number of concentrations: 387 in the intervention group and 288 receiving usual care.…”

Section: Resultsmentioning

confidence: 99%

“… 37 , 38 Two studies employed guidance and education meetings, 36 one utilized education meetings and dissemination of educational material, 40 and another used educational meetings only. 39 Of the four studies using guidance, two employed a clinical practice guideline, 37 , 38 one a nomogram, 36 and one an undefined policy change. 35 Dissemination of educational materials was employed in three studies using a pocket reference card ( Table 2 ).…”

Section: Resultsmentioning

confidence: 99%

“… 35 Dissemination of educational materials was employed in three studies using a pocket reference card ( Table 2 ). 37 , 38 , 40 Reported outcomes and effect sizes for studies employing interventions on dosing, monitoring, and nephrotoxicity outcomes are presented in Table 3 . Interventions involving implementation of clinical practice guidelines, educational meetings, and dissemination of educational resources had the highest effect on dosing outcomes (effect size 2.76–7.28, P <0.001).…”

Section: Resultsmentioning

confidence: 99%

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Interventions targeting the prescribing and monitoring of vancomycin for hospitalized patients: a systematic review with meta-analysis

Phillips¹,

Wisdom²,

Woodman³

et al. 2018

IDR

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PurposeVancomycin 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.MethodsWe 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.ResultsSix 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).ConclusionMultifaceted 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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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

Interventions targeting the prescribing and monitoring of vancomycin for hospitalized patients: a systematic review with meta-analysis

Phillips¹,

Wisdom²,

Woodman³

et al. 2018

IDR

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“…Our audit reflects current clinical practice for vancomycin in a large tertiary centre in Australia. Whilst internationally validated dosing guidelines for vancomycin are available, we have shown that best practice is not often followed, even in tertiary academic hospitals, despite the presence of multifaceted interventions such as dose calculators, hospital in‐service and availability of clinical pharmacists …”

Section: Discussionmentioning

confidence: 99%

Vancomycin: Audit of American guideline‐based intermittent dose administration with focus on overweight patients

Koyanagi

Anning

Loewenthal

et al. 2020

Brit J Clinical Pharma

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Aims: Vancomycin dosing and monitoring recommendations are poorly adhered to in many institutions internationally, with concerns of treatment failure and propelling antibiotic resistance. The primary aim of this study was to audit the rate of adherence to American guidelines, with particular interest in loading dose administration. The secondary aims were (i) to determine whether or not guideline adherence results in therapeutic concentrations across body mass index (BMI) groups and (ii) to determine whether or not this was in turn associated with morbidity and hospital mortality.Method: Data were collected in a single tertiary hospital on all patients who had two or more serum vancomycin concentrations measured.Result: In total, 107 patients met the inclusion criteria. Overall, 38.3% of patients were commenced on guideline adherent vancomycin doses, and 28.3% of overweight patients received an adherent first dose compared to 51.1% of non-overweight people (difference 23%, 95% CI 4% to 41%, P = 0.024). Overweight patients were more frequently underdosed compared to non-overweight patients (P = 0.039). The frequency and proportion of underdosing increased with BMI. Overweight patients spent a smaller fraction of their course within the therapeutic range, although the difference was not statistically significant (difference 7.7%; 95% CI 4% to 19.4%; P = 0.195). The overweight group had longer hospital length of stay (LOS), higher mortality and more treatment failures.Conclusion: Adherence to guideline-based prescription is poor, particularly in overweight patients. Patients who are initially underdosed have fewer therapeutic vancomycin days, regardless of BMI. Overweight patients have increased hospital LOS, hospital mortality and treatment failure. K E Y W O R D S guideline-based dosing, obesity, trough concentration, vancomycin

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“…Most studies of antimicrobial education for health professionals have been non‐specific, focusing on all antimicrobials, not vancomycin alone . While studies that report specifically on vancomycin education strategies report a reduction of inappropriate prescribing and improved TDM, it is important to note that these education strategies were delivered alongside other vancomycin‐specific interventions, including restricted prescribing or decision‐support systems . Thus, it is difficult to discern the contribution of the educational strategies alone to the improvements observed in vancomycin use.…”

Section: Introductionmentioning

confidence: 99%

Education to improve vancomycin use: the perspectives of educators and education recipients

Dort

Baysari

Carland

et al. 2020

Internal Medicine Journal

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Background: Vancomycin is the primary treatment for methicillin-resistant Staphylococcus aureus infections. Hospital audits have showed that dosing and therapeutic drug monitoring practices for vancomycin are suboptimal. Limited studies have examined the current educational resources used to support vancomycin use.Aims: To explore and compare the perceptions of health educators and recipients of education on the methods currently used to educate health professionals about vancomycin and to identify ideal methods of education.Methods: Semi-structured interviews were conducted with health educators around Australia and with recipients of education (doctors and nurses). Interview questions explored previous experiences of education and perceptions of ideal methods of education. Interviews were audio-taped, transcribed and thematically analysed.Results: Health educators explained that current vancomycin education comprises large-scale presentations, but they perceived these to be ineffective. The recipients of vancomycin education reported a lack of formal education on vancomycin. Despite this, both educators and recipients agreed on the ideal methods of education: nurses are reported to be protocol driven, and education for nurses should be through in-services or e-learning modules, while doctors require an evidenced-based approach. Senior doctors initially require convincing that education is needed. Once convinced, they respond well to brief emails and case-based and one-on-one education strategies. Technologybased strategies and problem-based learning were observed to be effective methods for junior doctors.Conclusions: Vancomycin dosing and therapeutic drug monitoring involves multiple health professionals, but current education strategies do not take this into account. Ideal education strategies need to be multimodal and targeted to specific health profession groups. AbstractBackground: Dedicated geriatric models of care are becoming more prevalent due to the complexity of, and increase in, acute healthcare presentations for older patients. For older people, a long stay in the emergency department (ED) may reflect the complexity of their presentation, or deficiencies in systems that manage these complexities.Aims: To identify predictors of a long ED length of stay (LLoS) for patients ≥65 years old. Methods: Linked hospital information systems data from a large, public Australian ED were analysed in this retrospective cohort study. LLoS was defined as the 75th percentile (617 min). Multivariate regression identified LLoS predictors for admissions and discharges separately.Results: Of 16 791 ED presentations made by older people, 4192 experienced a LLoS; 55% were admitted. Increasing age was associated with an increasing ED LoS. Factors most predictive of LLoS for both admitted and discharged patients included: investigations (both pathology and imaging), less urgent Australasian triage scale categories and after-hours arrival. Ambulance arrival did not increase the risk of a LLoS for patients eventually admitted...

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Sustained improvement in vancomycin dosing and monitoring post-implementation of guidelines: Results of a three-year follow-up after a multifaceted intervention in an Australian teaching hospital

Cited by 15 publications

References 43 publications

Interventions targeting the prescribing and monitoring of vancomycin for hospitalized patients: a systematic review with meta-analysis

Interventions targeting the prescribing and monitoring of vancomycin for hospitalized patients: a systematic review with meta-analysis

Vancomycin: Audit of American guideline‐based intermittent dose administration with focus on overweight patients

Education to improve vancomycin use: the perspectives of educators and education recipients

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