Experience of Vancomycin Therapeutic Drug Monitoring in Two Multidisciplinary Hospitals in Latvia

Publisher Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland.Background and Objectives: Management of infectious diseases is a huge burden to every healthcare system worldwide. Antimicrobial resistance, including antibacterial resistance, is an increasing problem worldwide; therefore, more new antibiotics are necessary to be discovered. Meanwhile, “old” antibacterial agents are still administered to fight infectious diseases caused by resistant bacteria. One of these antibacterial agents is vancomycin, which is effective in treating serious systemic infections caused by gram-positive bacteria. Thus, it is necessary to perform vancomycin concentration measurements in plasma due to its narrow therapeutic index. Various approaches are implemented for more precise therapy, including therapeutic drug monitoring (TDM) of vancomycin and with a supervision of a clinical pharmacist. The purpose of the study was to investigate if the TDM practice is improved with a local vancomycin TDM protocol applied in a hospital. The results of TDM in two multidisciplinary hospitals, one with a local TDM protocol implemented and applied and the other with no local TDM protocol implemented and applied, were compared. Materials and Methods: A retrospective study was performed in two multidisciplinary hospitals in Latvia. The data were collected for a time period of 4 years (2016–2020) in a hospital without a local TDM protocol and for a time period of 2 years (2018–2020) in a hospital with a local TDM protocol, starting with a period of time when the vancomycin TDM protocol was developed. The data about the patients included in the study were analyzed based on gender, age, body weight, and renal function. Vancomycin therapy was analyzed based on dosing schemes (vancomycin dose and dosing interval), data about loading and maintenance doses, vancomycin concentration, and details about vancomycin concentration (sampling time and concentration level). Results: Differences between the hospitals were found in terms of the initiation of vancomycin administration and concentration sampling. In the hospital with a TDM protocol compared with the hospital without a TDM protocol, more accurate initiation was found, alongside adaption of therapy (97.22% vs. 18.95%, p < 0.001), better performance of administration of a loading dose (22.73% vs. 1.29%, p < 0.01), and reaching of target concentration (55.56% vs. 35.29%, p < 0.01). Concentration sampling in the correct timeframe before the vancomycin dose and vancomycin administration did not show statistically better results in either of the hospitals (4.60% vs. 6.29%, p = 0.786). Conclusions: Better results of adequate adjustments of vancomycin therapy were achieved in the hospital with a TDM protocol. In the long term, sustainable results and regular medical professionals’ training is necessary.publishersversionPeer reviewe

Analysis of vancomycin therapeutic drug monitoring in two multidisciplinary hospitals in Latvia, with and without a monitoring protocol

Klīniskā farmācijaVeselības aprūpeClinical PharmacyHealth CareVankomicīns ir glikopeptīdu grupas antibiotika, kas darbojas pret dažāda veida Gram pozitīviem mikroorganismiem, tai skaitā, meticilīn-rezistento Staphylococcus aureus. Sistēmiskas infekcijas ārstēšanai, tas tiek ievadīts intravenozi, devas pielāgojot atkarībā no ķermeņa masas un nieru funkcijas. Vankomicīnam šaurā terapeitiskā indeksa dēļ terapijas laikā ir nepieciešams veikt terapeitisko zāļu monitoringu. Tas palīdz sasniegt adekvātu terapeitisko iedarbību, vienlaikus samazinot toksicitātes attīstības risku. Taču, lai gan ir izveidotas dažādas vadlīnijas vankomicīna terapijas nodrošināšanai, vēl joprojām liela daļa pacientu nesasniedz rekomendācijās noteikto mērķa koncentrāciju. Kā vienu no iemesliem literatūrā bieži min neatbilstošu vankomicīna terapeitiskā zāļu monitoringa (TZM) procedūru, tāpēc pētījumos tiek izvērtētas dažādas metodes, ieskaitot klīniskā farmaceita iesaistīšanu, ar kuras palīdzību varētu uzlabot vankomicīna TZM praksi. Retrospektīvs pētījums tika veikts divās Latvijas daudzprofilu slimnīcās, stacionārā “Gaiļezers” un Vidzemes slimnīcā. Darba mērķis bija izpētīt vankomicīna terapeitiskā monitoringa praksi šajās slimnīcās un noskaidrot klīniskā farmaceita izveidota monitoringa protokola ietekmi uz precīzāku terapijas pielāgošanu. Tika noskaidrots, ka vairākās niansēs, piemēram, vankomicīna devas ievadīšanas sākuma un asins parauga paņemšanas laika dokumentācijas aizpildīšanā (18,95 % / 97,22 %, p < 0,001), piesātinošās devas pielietošana sākotnējās terapijas shēmā (1,59 % / 22,73 %, p < 0,01) un mērķa koncentrācijas sasniegšanā (35,29 % / 55,56 %, p < 0,01), protokola monitoringa ieviešana uzrādīja statistiski nozīmīgu uzlabojumu vankomicīna TZM norisē. Pareizā laikā paņemtas vankomicīna analīzes neuzrādīja statistiski labāku rezultātu, salīdzinot abas slimnīcas (4,60 % / 6,29 %, p = 0,786). Lai arī kopumā var teikt, ka klīniskā farmaceita izveidots monitoringa protokols uzlabo vankomicīna TZM procedūru, ilglaicīgai rezultātu uzturēšanai un uzlabošanai ir nepieciešamas pastāvīgas apmācību programmas medicīnas personālam par visiem monitoringa posmiem, ko apstiprina arī zinātniskā literatūra.Vancomycin is a glycopeptide antibiotic that acts against a variety of Gram-positive microorganisms, including methicillin-resistant Staphylococcus aureus. For the treatment of systemic infections, it is injected intravenously, with doses adjusted according to body weight and kidney function. Due to the narrow therapeutic index of vancomycin, therapeutic drug monitoring is required during treatment. However, despite various guidelines for vancomycin therapy, a large proportion of patients still do not reach the recommended target concentration. Inadequate vancomycin therapeutic drug monitoring (TDM) procedures are often cited in the literature as a reason, and studies are evaluating various methods, including the involvement of a clinical pharmacist, to improve the course of vancomycin TDM. A retrospective study was carried out in two Latvian multi-profile hospitals, stationary “Gaiļezers” and Vidzeme hospital. The aim of this study was to investigate the practice of therapeutic monitoring of vancomycin in these hospitals and to find out the impact of a monitoring protocol developed by a clinical pharmacist on more accurate therapy. It was found that in several nuances, for example, appropriate documentation of vancomycin dose administration time and blood sampling time (18.95% / 97.22%, p<0.001), the use of a loading dose in the initial treatment regimen (1.59% / 22.73%, p<0.01) and the achievement of the target concentration (35.29% / 55.56%, p<0.01), the implementation of protocol monitoring showed a statistically significant improvement in vancomycin TDM. Appropriately collected blood samples used to measure vancomycin trough, did not show a statistically superior result between the two hospitals (4.60% / 6.29%, p=0.786). Although in general it can be said that the monitoring protocol developed by the clinical pharmacist improves the TDM procedure of vancomycin, long-term maintenance and improvement of results requires continuous training programs for medical staff at all stages of monitoring, as complemented by the scientific literature