Vancomycin prescription and monitoring guidelines have been reported to be poorly followed by various centers.
Abstract
Background
Vancomycin prescription and monitoring guidelines have been reported to be poorly followed by various centers.
Aims
Identifying barriers to compliance with vancomycin dosing and therapeutic drug monitoring guidelines (TDM) and possible ways to enhance compliance based on the healthcare providers’ (HCPs) perspective.
Methods
A qualitative study based on semi-structured interviews with HCP (physicians, pharmacists, and nurses) was conducted at two Jordanian Teaching Hospitals. Interviews were audio-recorded and analyzed through thematic analysis. The COREQ criteria for qualitative research were utilized to report the study findings.
Results
A total of 34 HCPs were interviewed. HCP perceived several factors as barriers to guideline recommendation compliance. Such factors included negative perception towards prescription guidelines, lack of knowledge regarding TDM guidelines, the hierarchy of medication management, work pressure, and ineffective communication among healthcare providers. Potential strategies to optimize guidelines adaptation included providing HCPs with more training and decision support tools in addition to activating the role of clinical pharmacists.
Introduction
Vancomycin, a glycopeptide antibiotic, is of the most frequently used antibiotics, especially in critically ill patients and pediatric wards [1–3]. It is considered the first-line antibiotic for managing serious methicillin-resistant Staphylococcus aureus (MRSA) infections such as sepsis, meningitis, and endocarditis. Unfortunately, vancomycin has been commonly implicated in causing medication related-patient harm due to its narrow therapeutic index [4]. Prescribing antibiotics, in general, can be challenging for prescribers. For instance, underdosing has been frequently described [5, 6]. Furthermore, overuse of antibiotics is prevalent. This might be associated with the fact that physicians lacking enough experience can have the perception that the benefits of antibiotic treatment out ways long-term risks, which include resistance and reduced efficacy [7]. For vancomycin as an example, many researchers reported excessive and prolonged empiric prescription [8, 9]. To guide its use and minimize adverse drug effects due to overdosing and inefficacy due to underdosing, Therapeutic Drug Monitoring (TDM) is recommended for prolonged courses. At the study institutions, vancomycin TDM is based mainly on trough monitoring. Despite its simplicity, compared to other TDM methods, many researchers reported suboptimal trough monitoring practice.
Material and methods
Study design and ethics
The current study was a qualitative study based on face-to-face semi-structured interviews with HCPs involved in vancomycin prescription/ TDM. The study was conducted over a period of two months, starting on August 2021 and extending until October 2021. The study was conducted in two university teaching hospitals in Jordan. The first was the Jordan University Hospital (JUH). JUH is the first university teaching hospital in Amman, the Capital of Jordan, with a capacity of up to 600 beds. The second is the King Abdallah University Teaching Hospital (KAUH). It is considered the largest medical structure in the north of Jordan, with a bed capacity of 678. Institutional Review Board approvals were obtained from participating centers (JUH and KAUH).
Results
A total of 34 HCPs working at different hospital wards, such as pediatric wards, internal wards, surgical and intensive care units, we interviewed in the present study. Due to the design of the study response rate could not be determined. The interviews ranged in duration from 11 to 38 minutes, and data saturation was achieved. Table 1 shows the general characteristics of interview participants.
Discussion
The present study highlights the complexity of vancomycin prescribing and therapeutic drug monitoring and the need for interprofessional communication, activation of the role of clinical pharmacists, and further education and support to optimize its use.
HCPs were generally not aware of the presence of any guidelines related to vancomycin TDM. Nevertheless, prescribers were aware of the presence of vancomycin prescription guidelines (mainly international). However, they were negatively perceived as outdated and noncomprehensive, and they highlighted the need for guidelines based on local susceptibility patterns. This contrasts with the findings of Chan et al. [12], where prescribes found guidelines clear and valuable, which facilitates adaptation of guideline recommendations in their daily practice. In our study, some prescribers reported that they find their patient population different, so it can’t fit the structured guideline recommendations for the average patient. Thus, their prescription may differ. In addition, they doubted the ability of guidelines to guide them in the management of complicated cases. This finding comes in line with the finding of Livorsi et al. [17],
Conclusion
For enhancing vancomycin prescription and TDM, the present study highlights the need for creating effective communication networks between HCP, reducing workload, and adapting local guidelines in clinical practice suitable for implementation in the local context. For TDM specifically, a strong organizational structure for the TDM process is needed to consolidate different TDM aspects and accommodate effective interprofessional communication. This is quite important as TDM is not only unique for vancomycin, and such structure, if proven useful, can be utilized for the TDM of other drugs.
Acknowledgments
Citation: Abdel Jalil MH, Ηijazeen R, Khaled Abu-Mahfouz F, Abu Hammour K, Hasan Matalqah M, Saleh Khaleel Albadaineh J, et al. (2023) Vancomycin prescribing and therapeutic drug monitoring: Challenges of real clinical practice. PLoS ONE 18(5): e0285717. https://doi.org/10.1371/journal.pone.0285717
Editor: Mona Nabulsi, American University of Beirut Medical Center, LEBANON
Received: November 26, 2022; Accepted: May 2, 2023; Published: May 17, 2023
Copyright: © 2023 Abdel Jalil et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The datasets generated during and/or analysed during the current study are not publicly available due to constraints imposed by the consent form and the IRB committee. However, a request to access the data can be requested from the research ethics committee at JUH hospital (sssaleh@ju.edu.jo).
Funding: This project was funded by the deanship of scientific research at the University of Jordan.
Competing interests: NO authors have competing interests.
