Papadimos Thomas J, Grabarczyk Jennifer L, Grum Daniel F, Hofmann James P, Marco Alan P, Khuder Sadik A
Department of Anesthesiology, University of Toledo, College of Medicine, Toledo, USA.
Patient Saf Surg. 2007 Nov 7;1(1):2. doi: 10.1186/1754-9493-1-2.
Routine, initial, empiric vancomycin dosing by clinicians in postoperative coronary artery bypass grafting (CABG) patients was identified as a potential patient safety issue in the Cardiovascular Intensive Care Unit (CVICU) because the rate of postoperative acute renal insufficiency (ARI) and average patient Body Mass Index (BMI) > 35 kg/m2 were significantly higher in our institution than those of the Society of Thoracic Surgeons (STS) database. A vancomycin dosing nomogram was derived from the local patient population in the attempt to improve patient safety by convincing clinicians to use an evidence-based approach to vancomycin prescription.
We analyzed two different treatment strategies that were applied consecutively to an intensive care unit population. CABG patients dosed empirically with vancomycin (group 1, pre-nomogram) were compared with CABG patients dosed using a vancomycin dosing nomogram (group 2, post-nomogram) derived from the hospital population using an Internet program that facilitated creation of a local nomogram. The two groups were analyzed as to age, sex, body mass index, creatinine clearance, and vancomycin dosage using logistic regression and testing for continuous and categorical variables.
Nomogram use decreased the number of patients receiving the customary dose of one gram every 12 hours in those group 2 patients with diminished CrCl as compared with those in group 1 with diminished CrCl (group 2, 2/21 vs. group 1, 14/21, p < .0001), as well as in those with a normal creatinine clearance, (group 2, 2/15 vs. group 1, 26/34, p < .0001). Therefore, nomogram use affected the customary dose of one g vancomycin every 12 hours between the two groups overall (group 1, 40/55 vs. group 2, 4/36, p < .001), whereby 32/36 (88.9%) of group 2 patients had their dosing altered when compared to what would have been formerly prescribed, p < .0001. Furthermore, nomogram use resulted in fewer doses of antibiotics per year resulting in a cost savings to the hospital with no increase in the rates of infection.
Implementation of the nomogram resulted in a more appropriate antibiotic utilization, regardless of creatinine clearance, that decreased costs without increasing infection rates.
在心血管重症监护病房（CVICU）中，临床医生对冠状动脉搭桥术（CABG）术后患者常规初始经验性使用万古霉素被确定为一个潜在的患者安全问题，因为在我们机构中，术后急性肾功能不全（ARI）的发生率和患者平均体重指数（BMI）>35kg/m²显著高于胸外科医师协会（STS）数据库中的数据。为了通过说服临床医生采用基于证据的万古霉素处方方法来提高患者安全性，我们根据当地患者群体制定了万古霉素剂量计算图。
我们分析了连续应用于重症监护病房患者群体的两种不同治疗策略。将经验性使用万古霉素的CABG患者（第1组，剂量计算图制定前）与使用通过互联网程序从医院患者群体中得出的万古霉素剂量计算图（第2组，剂量计算图制定后）的CABG患者进行比较，该互联网程序有助于创建当地的剂量计算图。使用逻辑回归以及对连续变量和分类变量进行检验，对两组患者的年龄、性别、体重指数、肌酐清除率和万古霉素剂量进行分析。
与肌酐清除率降低的第1组患者相比，第2组肌酐清除率降低的患者中，使用剂量计算图减少了每12小时接受1克常规剂量万古霉素的患者数量（第2组，2/21 vs第1组，14/21，p <.0001），肌酐清除率正常的患者也是如此（第2组，2/15 vs第1组，26/34，p <.0001）。因此，总体上两组之间使用剂量计算图影响了每12小时1克万古霉素的常规剂量（第1组，40/55 vs第2组，4/36，p <.001），与之前的处方相比，第2组36名患者中有32名（88.9%）的剂量发生了改变，p <.0001。此外，使用剂量计算图导致每年使用的抗生素剂量减少，为医院节省了成本，且感染率没有增加。
剂量计算图的实施导致了更合理的抗生素使用，无论肌酐清除率如何，在不增加感染率的情况下降低了成本。
