Educational Interventions to Decrease the Number of Vancomycin Levels in a Pediatric Hospital

To the Editor: Vancomycin is a glycopeptide antibiotic with broad gram positive coverage including methicillin-resistant Staphylococcus aureus (MRSA). Monitoring of vancomycin can include both peak and trough levels; because peak levels are not considered clinically useful, the routine monitoring of these levels is not recommended in the adult, pediatric, and neonatal populations. With the emergence of vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus (VISA and VRSA) and new clinical guidance, traditional trough levels for vancomycin have also changed. In February 2011, the Infectious Disease Society of America (IDSA) advocated for an increase in trough levels to 15-20 mcg/mL for MRSA in pediatric patients. A retrospective review of laboratory data and pharmacy purchasing data on vancomycin from January 1, 2006 to December 31, 2010 was conducted in a tertiary care free-standing pediatric hospital. In May 2009, a Clinical Pharmacy Specialist in Pediatric Critical Care began clinical work in the Pediatric Intensive Care Unit (PICU). As part of an effort to increase more judicious monitoring of vancomycin, educational interventions were designed for the hospital. Medical residents rotate through the PICU for 2 months during their second year. Lectures by the pharmacy specialist and clinical practice allowed the residents to become more familiar with vancomycin monitoring. In October of 2009, a grand rounds was presented to the medical staff on vancomycin monitoring. A separate lecture was also presented to the hematology and oncology medical staff. Nursing education included lectures to the PICU staff on 2 occasions. An interactive workshop for all medical residents was conducted by the clinical specialist to allow for additional clinical practice of vancomycin monitoring. In both 2007 and 2008, there were approximately 1,300 vancomycin peaks obtained. In 2009, there were 1,118 peak levels, which represent an 18% decrease from 2008. In 2010, there were 612 peak levels, which represent a 45% decrease from 2009 and a 55% decrease from 2008. As compared to 2008, the number of vancomycin random levels obtained decreased by 22% in 2009 and 94% in 2010. The number of trough levels decreased by 11% in 2009 and 13% in 2010. To account for the recommendation of increased vancomycin trough levels, pharmacy vancomycin purchasing data were obtained. The amount of vancomycin purchased remained the same in 2007 and 2008. In 2009, there was a 10% increase from 2008. There was a 4% increase from 2009 to 2010 and a 13% increase from 2008. From 2006 to 2010, the overall increase in vancomycin purchasing was 37% (see Figure 1). From 2008 to 2009, the estimated savings due to the decrease in the number of vancomycin levels obtained was $156,000. The cost savings from 2009 to 2010 was estimated at $145,000. These data provide evidence that despite an increase in vancomycin use hospitalwide, there has been a decrease in the number of vancomycin peak, random, and trough levels reported. Prior to the education sessions, it was routine practice for many of the medical residents to order vancomycin peak levels. After presentation of the current evidence and recommendations to the medical and nursing staff, there has been a significant decrease in the number of peak levels ordered. These results produced a considerable cost savings for the hospital. Despite multiple educational sessions, peak vancomycin levels are still being obtained throughout the hospital, and additional strategies are being designed to decrease these numbers further.