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4CPS-044 Impact of clinical pharmacist-vancomycin monitoring on patient safety outcome
  1. R Al-ruwaisan,
  2. R Bahmaid,
  3. N Albanyan
  1. King Fahad Medical City, Pharmacy Services Administration, Riyadh. KSA, Saudi Arabia


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.

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