4CPS-120 Role of pharmacists in improving therapeutic drug monitoring and dosing of vancomycin

<h3>Background and Importance</h3> Accurate dosing and therapeutic drug monitoring (TDM) of vancomycin are essential for effective treatment. However, achieving target concentrations often proves challenging due to weak compliance to institutional guidelines. Enhanced support and education, particularly involving pharmacists, are suggested to improve TDM practices of vancomycin. <h3>Aim and Objectives</h3> To evaluate the impact of pharmacist intervention on 1) the time to initial target attainment of vancomycin and 2) compliance with institutional TDM guidelines. Furthermore, TDM related issues were identified and factors influencing the time to target range were investigated. <h3>Material and Methods</h3> A retrospective and prospective cohort of hospitalised patients (≥ 18 years) receiving vancomycin (≥ 72 hours) intravenously were observed and compared over a period of 1.5 years. Patient characteristics, dosing and TDM data were collected for both cohorts. A pharmacy advisory service was set up during the prospective cohort over a period of three months. The service was weekly staffed by a clinical pharmacist and provided dosing and TDM recommendations of vancomycin. Outcome measures were time to initial target attainment of vancomycin and compliance with TDM guidelines. The impact of infection type, chronic kidney disease, age, and medical discipline on the time to target range were also evaluated. <h3>Results</h3> Analysis included 85 patients (94 vancomycin courses). The study revealed poor adherence to TDM guidelines, with only 43.1% of courses starting at a correct dose. Blood samples were incorrectly timed in 39.2% of cases, and only 46.5% of dose adjustments were made correctly. The pharmacy advisory service significantly improved TDM practices, with correctly timed blood samples increasing from 8.4% to 14.5% (p 0.029) and correct dose adjustments rising from 46.5% to 70.7% (p 0.001). Median time to target range shortened with one day (2.4 days; 95% CI 0.9–3.9) compared to courses without pharmacy advisory service (3.6 days; 95% CI 3.2–3.9; p 0.645). Non-severe infections, chronic kidney disease, and pharmacist involvement were significantly associated with a shorter time to target range of vancomycin (p ≤ 0.05). <h3>Conclusion and Relevance</h3> Provision of TDM guidelines alone is not sufficient in ensuring correct prescription and monitoring of vancomycin. Daily dosing guidance by pharmacists may enhance TDM practices and may shorten time to target attainment of vancomycin. <h3>References and/or Acknowledgements</h3> <h3>Conflict of Interest</h3> No conflict of interest