Aim A guideline for the use of intermittent intravenous vancomycin in children was designed and implemented in our Trust in 2016. This introduced the use of a loading dose, increased dosing and increased frequency compared to the BNFC recommendations. The changes were based on the outcomes of a national NPPG project and local focus groups. The aim of this audit was assess compliance with the guideline and to establish if the time taken to reach target vancomycin levels had been reduced as a result of using the new guidance.
Methods 30 paediatric patients (≥1 month old) prescribed intermittent intravenous infusions of vancomycin were identified by ward pharmacists over a 2 month data collection period. 4 patients required treatment with adult dosing due to their weight. 2 patients were switched onto continuous infusion following pharmacist intervention. The results of the remaining 24 patients were compiled into an excel spreadsheet for analysis.
Results Audit pre-implementation of the guideline had highlighted the lack of a support for staff to use appropriate dosing and monitoring.1 Overall, usage of the new guideline was positive. The loading dose was used appropriately in 83% patients. Levels were taken at appropriate times in 90% patients. The percentage of levels in therapeutic range at 48 hours increased from 7% to 40%. 100% of patient had a review at this time. Half of the patients out of range at 48 hours had treatment stopped or changed to a more appropriate treatment, reducing the need for unnecessary complex dose adjustment/monitoring plans. At 48 hours, there remained 30% of the total patient group requiring dose adjustment in order continue vancomycin treatment. The main area of concern was that review of these out of range levels was only carried out in accordance with the guideline in 40% of cases. This was improved to 80% with pharmacist intervention. A limitation of this data was the small patient group size. One patient had the level taken at the wrong time so could not be interpreted properly.
Conclusion Compliance with the new guideline was good overall. This audit has shown that the use of the new guideline improved the percentage of patients with vancomycin levels in range at 48 hours from 7 to 40%. The main theme from this audit was that pharmacist intervention was the key to directing the medical teams towards prescribing the most appropriate form of treatment. Education can only improve compliance to a certain degree and this drug is not used often enough to be familiar to the average junior doctor. The use of vancomycin in complex and requires an understanding of pharmacokinetics and drug handling unique to the pharmacist skill set. Our aim for the future is that as our pharmacist team acquires more independent prescribers, direct adjustment of treatment plans will become a pharmacist role within the Trust.
Haylor J. Vancomycin use in paediatrics - prescribing and monitoring. University Hospitals Bristol Foundation Trust Clinical Audit 2014.
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