title: Evaluation of a Pharmacist-Directed Vancomycin Dosing and Monitoring Pilot Program at a Tertiary Academic Medical Center.
abstract: BACKGROUND
  Consensus guidelines recommend vancomycin doses of 15 to 20 mg/kg every 8 to 12 hours in patients with normal renal function.
  
  
  OBJECTIVE
  To evaluate the effect of a pharmacist-directed vancomycin dosing and monitoring pilot program on the percentage of patients receiving targeted weight-based dosing recommendations.
  
  
  METHODS
  This was a pre-/postevaluation study, approved by the institutional review board at our institution, comparing retrospectively reviewed vancomycin dosing practices hospital-wide between September 1 and September 30, 2010 to patients prospectively managed by a pharmacist-directed vancomycin pilot program between February 1 and April 26, 2011. All adult inpatients receiving intravenous vancomycin were included, unless patients had a creatinine clearance less than or equal to 60 mL/min or indication for therapy was surgical prophylaxis or febrile neutropenia. The primary outcome was the percentage of patients who received optimal vancomycin dosing defined as ≥30 mg/kg/d within 24 hours of initiation of therapy. Secondary outcomes included number of pharmacist interventions, length of therapy and incidence of nephrotoxicity while receiving vancomycin.
  
  
  RESULTS
  A total of 319 patients were analyzed, 161 preimplementation and 158 postimplementation. The percentage of patients who received optimal vancomycin dosing was significantly higher postimplementation of the pilot program, 96.8 versus 40.4% (P < 0.001). Pharmacist-directed interventions postimplementation, resulted in 50% more patients being dosed optimally (P < 0.001). Patients in the pilot program also had a shorter length of therapy (10.0 vs 8.4 days, P < 0.003) and a lower incidence of nephrotoxicity (8.7% vs 3.2%, P = 0.006).
  
  
  CONCLUSIONS
  This pharmacist-directed vancomycin pilot program significantly increased the percentage of patients optimally dosed according to consensus guidelines within 24 hours of initiation of therapy.
authors.affiliation: Brigham and Women's Hospital, Boston, MA, USA kmarquis1@partners.org.
authors.forename: Kathleen A
authors.initials: KA
authors.lastname: Marquis
authors.affiliation: Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Jeremy R
authors.initials: JR
authors.lastname: DeGrado
authors.affiliation: Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Labonville
authors.affiliation: Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Kubiak
authors.affiliation: Brigham and Women's Hospital, Boston, MA, USA Northeastern University, Boston, MA, USA.
authors.forename: Paul M
authors.initials: PM
authors.lastname: Szumita
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000009:adverse effects; D016903:Drug Monitoring; D005260:Female; D006801:Humans; D015994:Incidence; D007674:Kidney Diseases / Q000139:chemically induced / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D010595:Pharmacists; D010607:Pharmacy Service, Hospital; D010865:Pilot Projects; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies; D062606:Tertiary Care Centers; D014640:Vancomycin / Q000008:administration & dosage* / Q000009:adverse effects
chemical_list: D000900:Anti-Bacterial Agents; D014640:Vancomycin
keywords: antibiotics; dosage; nomogram; protocols; vancomycin