Evaluation of the prescription, administration and monitoring of vancomycin in adult patients admitted to a tertiary hospital

Abstract

Introduction: Vancomycin is a strategic antibiotic in the treatment of infections caused by gram-positive bacteria. Controversies regarding its dosage and monitoring are important due to the risk of nephrotoxicity and the insurgency of resistant strains. Objectives: To describe vancomycin prescription patterns for adult patients, to observe vancomycin administration, vancocinemia collection and the timing of subsequent vancomycin dose adjustment, and to evaluate the conformity between prescription, administration and monitoring of vancomycin in a University Hospital (HU). Methodology: This was a  cross-sectional and prospective study that included adult patients admitted to four clinical and surgical wards and two wards of the intensive care unit (SETI) using vancomycin. Six visits were made to the Internal Medicine, Neurology and Orthopedics wards and five visits to the Vascular Surgery and SETI wards, in which 67 patients and 989 prescriptions were evaluated, data from medical records were collected and nursing and medical routines regarding vancomycin administration, vancocinemia collection and antibiotic adjustment were observed. Results: There was no difference between the units in terms of gender, baseline creatinine levels, length of hospital stay, days of vancomycin use, and weight, with a predominance of younger patients in Neurology and a higher mean age in Vascular Surgery. The loading dose was prescribed in 83.8% of the patients, while dilution and infusion time were prescribed, respectively, in 768 (77.6%) and 212 (21.4%) of the prescriptions. The SETIs had rates of adequacy of the loading dose and frequency of dilution prescription and infusion time statistically higher than those of the wards (p 0.02, p 0.04 and p <0.001, respectively). Of the total dilutions prescribed, 56.4% were adequate. Internal medicine led in the proportion of correctly prescribed dilutions (82.8%, p<0.05), as opposed to the Intensive Care Unit – Ward 1 (SETI 1) and Neurology, which had the lowest adequacy rates, of 36.4% and 36.1%, respectively. The infusion time was correctly prescribed in 169 (79.7%) records. In Neurology, the infusion time was not prescribed at any time, and in Orthopedics, it was not adequate at any time. In the other sectors, the infusion time was mostly adequate, with a discrepant trend observed between SETI Wards 1 and 2 (p 0.058). In the analysis of SETIs versus wards, there were higher rates of adequacy of the prescribed infusion time in SETIs (p 0.003). There were nine cases of cutaneous reaction to vancomycin (13.4%). An inverse relationship was observed between the appropriate prescription for infusion time and the frequency of adverse skin reaction. A total of 56 administrations were observed, with 32 (57.1%) not being in accordance with the prescribed. Of the 59 patients using the first vancomycin regimen during hospitalization for two or more days, 52 (88.1%) had at least one vancokineemia collected, with the 1st vankokineemia collected predominantly on the 2nd day of antibiotic therapy in all sectors. It was not possible to establish comparisons between the sectors regarding dose collections and adjustments due to the reduced number of vancocinemia collections observed. Among the 265 levels of vanchokineemia recorded, 132 (49.8%) were classified as adequate. Acute kidney injury (AKI) developed in 13 (31.7%) of the total of 41 patients evaluated for this outcome and was more frequent in SETIs compared to wards (p<0.001). Comparing the day of antibiotic therapy with vancomycin that each patient was on at the time of the last creatinine measurement and the values of the 1st vanchokineemia, a median number of days and higher vanchokineemia levels were found among the patients who developed AKI (p 0.06 and p 0.002, respectively). Conclusion: There are failures in the prescription, administration and monitoring of vancomycin in all sectors of this UH. The Intensive Care Service – Ward 2 (SETI 2) and the Internal Medicine were the sectors that best met the criteria for adequate prescription. There is a need to implement measures to qualify and train professionals, as well as inspection actions regarding the rigor of prescription and administration. The data from medical records were not completely reliable to what was done in practice, however, the study was not able to reduce the importance of medical records as a data collection tool.

DOI:https://doi.org/10.56238/sevened2024.001-051