Introduction and Evaluation of a Guideline for Vancomycin Administered via Continuous Intravenous (CIV) Infusion

Pharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Background: Vancomycin continuous intravenous (CIV) infusion is an alternative to intermittent intravenous (IIV) dosing for patients in whom therapeutic levels are difficult to achieve, maintain, or monitor. There is evidence from observational trials that vancomycin CIV is as effective as IIV with a decreased risk of nephrotoxicity. At KHSC, there was formerly no standardized method for prescribing, administering, or monitoring vancomycin CIV. Objective: To implement a guideline and associated order set, then evaluate appropriateness, for the use of vancomycin CIV in adult patients. Methods: An institutional vancomycin CIV guideline and order set were developed with stakeholder support. These were introduced to pharmacists and internal medicine residents through educational rounds. Over 6 weeks, all patients receiving IV vancomycin were identified from the pharmacy information system and reviewed to assess eligibility according to the guideline to receive vancomycin CIV (i.e. unable to reliably achieve target levels on vancomycin IIV or upon recommendation from the Infectious Diseases/Antimicrobial Stewardship services, and expected duration at least 7 days) and determine whether it was actually prescribed. Pregnant/breastfeeding patients and those receiving dialysis were excluded. No patient-specific interventions were made by the resident investigator. Results: 139 patients prescribed IV vancomycin were screened to identify 24 patients who were eligible for vancomycin CIV, none of whom were initiated on or transitioned from IIV to CIV. Of the 24 patients, 20 (84%) did not have a therapeutic serum vancomycin level by day 3 and 13 (54%) received a concomitant nephrotoxin during vancomycin therapy. Three CIV-eligible patients were discharged home on IV vancomycin. Conclusions: While no patients were initiated on vancomycin CIV during the project timeline, the results revealed that patients may experience delays in reaching therapeutic levels using IIV therapy. No patients were started inappropriately on vancomycin CIV. Future studies should explore barriers to initiation of vancomycin CIV in patients who may benefit the most