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(searched for: Impact of Clinical Pharmacist-Vancomycin Monitoring on Patient Safety Outcome)
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Rana Al-Ruwaisan, Reem Bahmaid, Nora Al-Banyan
Archives of Clinical and Biomedical Research, Volume 4, pp 441-452; doi:10.26502/acbr.50170116

Abstract:
Introduction: Vancomycin is frequently used to treat gram-positive infections especially methicillin- resistant Staphylococcus aureus (MRSA). Vancomycin level in the blood should be kept in a specific range to give the optimal antimicrobial killing and avoid the development of resistant and nephrotoxicity with low or high serum levels, respectively. This is known as "Therapeutic Drug Monitoring (TDM)." We aimed to evaluate the safety consequence of clinical pharmacist- based vancomycin TDM versus physician-based vancomycin TDM. Methods: Our study is a retrospective cohort study conducted at a single tertiary hospital, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia. It included two groups one for physicians and one for clinical pharmacists. The patients were all adults more than 18 years old started on vancomycin intravenously for more than 24 hours for suspected or proven infection. The primary outcome was the development of nephrotoxicity. In addition to several secondary outcomes, that include appropriate vancomycin initial dosing, sampling time, interpretation of vancomycin level, and the development of other adverse reactions related to the use of vancomycin. Results: A total of 100 patients were enrolled in the study with 53 patients in the physician group. There were no significant differences in baseline characteristics between the two groups. The defined endpoint was reported as 3.8% (n=2) in physician group and 12.8% (n=6) in Clinical pharmacist group with a P value of 0.143. Moreover, there was a significant difference in the defined secondary endpoints that include appropriate vancomycin initial dosing, sampling time, interpretation of vancomycin level, and other adverse reactions with a P value of less than 0.001. Conclusion: There is a non-statistically significant higher rate of nephrotoxicity in vancomycin patients monitored by clinical pharmacists compared with those followed by physicians.
R Al-Ruwaisan, R Bahmaid, N Albanyan
Published: 1 March 2019
by BMJ
Section 4: Clinical Pharmacy Services, Volume 26; doi:10.1136/ejhpharm-2019-eahpconf.193

Abstract:
Background Vancomycin is frequently used to treat gram-positive infections, especially methicillin-resistant staphylococcus aureus (MRSA). The level of vancomycin in blood should be kept in a specific range to give the optimal antimicrobial killing and avoid the development of resistant and nephrotoxicity with low or high serum levels, respectively. This is known as therapeutic drug monitoring (TDM). Vancomycin TDM in our hospital is performed by either clinical pharmacists or physicians. Purpose In order to unify the practice and serve our patients with the best care, this study aimed to evaluate the safety consequences including nephrotoxicity of clinical pharmacist-based vancomycin TDM versus physician-based vancomycin TDM. Material and methods This was a retrospective cohort study conducted at a single tertiary hospital. It included two groups of vancomycin TDM, one for physicians and one for clinical pharmacists. The patients included were all adults more than 18 years’ old started on vancomycin intravenously for more than 24 hours for suspected or proven infection. The primary outcome was the development of nephrotoxicity. The secondary outcomes included appropriate vancomycin initial dosing, sampling time and interpretation of vancomycin level. Results A total of 100 patients were enrolled in the study, with 53 patients in the physician group. There were no significant differences in the baseline characteristics between the two groups. Nephrotoxicity was reported as 3.8% (n=2) in the physician group and 12.8% (n=6) in the clinical pharmacist group, with a P-value of 0.143. Moreover, there were significant differences in the defined secondary endpoints that included appropriate vancomycin initial dosing, sampling time and interpretation of vancomycin level. The results were reported as 84.9% (n=45), 37.7% (n=20) and 11.3% (n=6) in the physician group and 87.5% (n=28), 62.5% (n=20) and 48.9% (n=23) in the clinical pharmacist group, respectively, with the same P-value of less than 0.001. Conclusion Although there was a non-statistically significant higher rate of nephrotoxicity in patients who received vancomycin TDM by clinical pharmacists compared to those monitored by physicians, the difference in appropriate vancomycin initial dosing, sampling time and interpretation of vancomycin level was statistically significant. favouring the clinical pharmacists group. References and/or acknowledgements We thank our colleagues from the research centre in our hospital who provided insight and expertise that greatly assisted the research statistical analysis. No conflict of interest.
Zhe Han, Natasha N. Pettit, Emily M. Landon, Benjamin D. Brielmaier
Published: 1 April 2017
Hospital Pharmacy, Volume 52, pp 273-279; doi:10.1310/hpx5204-273

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SpringerPlus, Volume 4, pp 1-14; doi:10.1186/s40064-015-1146-9

Abstract:
Outcomes data for the efficacy of interventions designed to decrease the time to initial target vancomycin troughs are sparse. A vancomycin therapeutic drug monitoring (TDM) program was initiated to reduce the time to initial target troughs and to examine the impact on clinical outcomes. Single-center, pre- and post-intervention observational study in a 250 bed teaching facility. Adult inpatients treated with physician-guided, vancomycin therapy (historical control, CTRL) were compared to high trough, pharmacist-guided vancomycin therapy (TDM). Nephrotoxicity analyses were conducted to the ensure safety of the TDM. Clinical outcome analysis was limited to patients with normal renal function and culture-confirmed gram positive infections and a pre-defined MRSA subset. 340 patients met initial inclusion criteria for the nephrotoxicity analysis (TDM, n = 173; CTRL, n = 167). Acute kidney injury occurrence was similar between the CTRL (n = 20) and TDM (n = 23) groups (p = 0.7). Further exclusions yielded 145 patients with gram positive infections for clinical outcomes evaluation (TDM, n = 66; CTRL, n = 75). The time to initial target trough was shorter in the TDM group (3 vs. 5 days, p < 0.001). Patients in the TDM group discharged from the hospital more rapidly, 7 vs. 14 days (Hazards Ratio (HR), 1.41; 95% Confidence Interval [CI] 1.08–1.83; p = 0.01), reached clinical stability faster, 4 vs. 8 days (HR, 1.51; 95% CI 1.08–2.11; p = 0.02), and had shorter courses of vancomycin, 4 vs. 7 days (HR, 1.5; 95% CI 1.15–1.95; p = 0.003). In the MRSA infection subset (TDM, n = 36; CTRL, n = 35), patients in the TDM group discharged from the hospital more rapidly, 7 vs. 16 days (HR, 1.89; 95% CI 1.08–3.3; p = 0.03), reached clinical stability faster, 4 vs. 6 days (HR, 2.69; 95% CI 1.27–5.7; p = 0.01), and had shorter courses of vancomycin, 5 vs. 8 days (HR, 2.52; 95% CI 1.38–4.6; p = 0.003). Attaining initial target troughs in
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