P15 Two-cycle audit on paediatric vancomycin prescribing and monitoring: tertiary centre experience
Authors: Chin Maxx King Yau , Williams Emma 
Published: April 2023

Aims

In 2018, a new guideline for the use of intravenous vancomycin in children was implemented in a tertiary centre. The guideline differed from BNFC recommendations,1with increased dosing and increased frequencies. These differences were based on the results of a national NPPG project in 2016.2

The aim of this two-cycle audit was firstly to investigate compliance with the guideline, and secondly to assess the impact of changes made after the first cycle, on compliance and the quality of vancomycin prescriptions and monitoring.

Methods

This two-cycle audit was carried out on all paediatric patients (>30 days and <17 years) who received intravenous vancomycin at a tertiary centre, during the two audit periods. Retrospective, fully anonymised data collection was completed between the dates of 1st January 2019 and 30th June 2019 for the first cycle, and between 1st August 2021 and 31st January 2022 for the second cycle. Exclusion criteria were patients who received intrathecal doses, single isolated surgical prophylaxis doses, and patients who were treated under Paediatric Haematology or Oncology. Descriptive analyses were performed, and categorical variables were reported as percentages. Data analyses, statistical analyses and graphs were performed or produced using R (R Version 3.4.1) and Microsoft Excel.

Results

A total of 29 patients were included for the first cycle, and 28 patients for the second cycle. In the first cycle, 75.9% of patients were prescribed the correct frequency, but only 58.6% were prescribed the correct first dose. Compliance to monitoring was better, with 89.7% of patients having their concentrations taken at the correct time. Only 24.1% had a therapeutic first vancomycin concentration, and 70.4% were under the therapeutic range. For the second vancomycin concentration, 61.9% were in therapeutic range. Overall, there was good compliance with the guidelines but room for improvement. Significant changes were made to the electronic prescription and concentration report templates. Guidelines were recirculated to all paediatric prescribers. In the second cycle, large improvements were seen in both prescribing and monitoring. 92.6% were prescribed the correct frequency, and 71.4% were prescribed the correct first dose. 96.2% of patients had their concentrations taken at the correct time. However, only 19.2% had a therapeutic first vancomycin concentration, and 65.4% were under the therapeutic range. For the second vancomycin concentration, 57.9% were in therapeutic range.

Conclusions

This two-cycle audit showed that incidences of non-compliance with prescribing were due to prescribers following BNFC recommendations, rather than the trust guidelines. Compliance was improved through changes to electronic prescribing and recirculation of guidelines to all paediatric prescribers. Despite improvements in prescribing and monitoring of intravenous vancomycin in children, therapeutic drug concentrations were still not achieved in over 80% of patients. Sub-therapeutic vancomycin concentrations in children within current dosing recommendations has been highlighted in the literature, and sub-therapy is a clinical issue and potential driver for antibiotic resistance.3Our findings warrant an urgent need for the re-evaluation of vancomycin guidelines to overcome the increasing prevalence of vancomycin resistance4and sub-therapy.

References

Joint Formulary Committee. British National Formulary for Children. 2017th–8th ed. London: BMJ Group and Pharmaceutical Press. 2018.

Nash C, Gooding N, Muller H. Intermittent intravenous vancomycin in children aged over 1 month: Empirical dosing for optimum trough levels. Report to the Neonatal and Paediatric Pharmacist Group January 2016 Neonatal and Paediatric Pharmacists Group. 2016;1–40.

Bakke V, Sporsem H, Von der Lippe E,et al. Vancomycin levels are frequently subtherapeutic in critically ill patients: a prospective observational study.Acta Anaesthesiologica Scandinavica2017;61:627–35.

Weiner LM, Webb AK, Limbago B,et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2011–2014.Infect Control Hosp Epidemiol2016;37:1288–1301.