Improving voriconazole therapeutic drug monitoring-guided dosing through a clinical decision support system: enhancing antifungal stewardship

Voriconazole (VCZ) is a first-line antifungal agent for treating invasive fungal infections. However, due to its narrow therapeutic index and high pharmacokinetic variability, standard dosing can be subtherapeutic or toxic. Therapeutic Drug Monitoring (TDM) is recommended to optimize VCZ therapy. To enhance TDM based dosing, we implemented a Clinical Decision Support System (CDSS) integrated into our electronic health record (EHR) that generates alerts at VCZ prescribing and dispensing points. These alerts display the most recent TDM result and interpretation and include an option to request a new TDM order. The study comprised three phases: pre-implementation, transitional, and post-implementation. We reviewed VCZ orders extracted from the EHR, analyzing a total of 2199 orders with recent TDM results. Physician compliance with TDM-guided dosing notably increased from 52.2% in the pre-implementation period to 94.7% post-implementation (<i>p</i> < .05). Pharmacist compliance also rose from 90.5% to 95.6% during the same timeframe (<i>p</i> < .05). The CDSS also supported more patients reaching therapeutic levels and reduced prescriptions for extreme doses. Integrating TDM recommendations into a CDSS significantly improved adherence by physicians and pharmacists to TDM-guided VCZ dosing. This approach highlights the value of health information systems in optimizing personalized antifungal therapy and stewardship.