Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
Biostatistics Collaboration Team, Research Core Center, Research Institute of National Cancer Center, Goyang, South Korea.
Int J Med Inform. 2021 May;149:104403. doi: 10.1016/j.ijmedinf.2021.104403. Epub 2021 Feb 4.
A vancomycin loading dose is recommended for the treatment of serious methicillin-resistant Staphylococcus aureus (MRSA) infections. However, clinicians often do not adhere to these recommendations, mainly due to nephrotoxicity risk, unfamiliarity with the guideline, or complexity of calculating an individual dose. Therefore, we introduced a computerised clinical decision support system (CDSS) for vancomycin loading (hereafter Vancomycin CDSS) to promote the use of vancomycin loading dose.
We describe a quasi-experimental study spanning 6 months before and 18 months after the deployment of a Vancomycin CDSS. The Vancomycin CDSS was integrated into the hospital's electronic medical record system in the form of a vancomycin order set. Our primary endpoint was the incidence of nephrotoxicity; the secondary endpoint was mean initial vancomycin trough levels. We also conducted a survey to evaluate the reasons why clinicians opted not to utilise a vancomycin loading dose.
After implementation of Vancomycin CDSS, 363 out of 746 patients (49 %) who were first administered vancomycin received a loading dose. We did not find significant differences in nephrotoxicity between the pre- and post-intervention groups, nor between the loading- and non-loading groups. In the pre-intervention group, the mean initial vancomycin trough level was 7.10 mg/L, which was significantly lower than that in the post-intervention group of 11.11 mg/L. In the vancomycin loading group, the mean initial trough level was 11.95 mg/L, compared to 7.55 mg/L in the non-loading group. The main reason stated for not prescribing a vancomycin loading dose was concern about nephrotoxicity.
Introduction of the Vancomycin CDSS did not increase nephrotoxicity and increased the mean initial dose and trough level of vancomycin.
万古霉素负荷剂量推荐用于治疗严重耐甲氧西林金黄色葡萄球菌（MRSA）感染。然而，临床医生通常不遵守这些建议，主要是由于肾毒性风险、不熟悉指南或计算个体剂量的复杂性。因此，我们引入了一种计算机化临床决策支持系统（CDSS）用于万古霉素负荷剂量（以下简称万古霉素 CDSS），以促进万古霉素负荷剂量的使用。
我们描述了一项为期 6 个月的前瞻性队列研究，在部署万古霉素 CDSS 前后分别进行了 6 个月和 18 个月的研究。万古霉素 CDSS 以万古霉素医嘱集的形式集成到医院的电子病历系统中。我们的主要终点是肾毒性的发生率；次要终点是初始万古霉素谷浓度的平均值。我们还进行了一项调查，以评估临床医生选择不使用万古霉素负荷剂量的原因。
在实施万古霉素 CDSS 后，746 名首次接受万古霉素治疗的患者中有 363 名（49%）接受了负荷剂量。我们没有发现干预前后组之间、负荷剂量组与非负荷剂量组之间的肾毒性差异。在干预前组，初始万古霉素谷浓度的平均值为 7.10mg/L，明显低于干预后组的 11.11mg/L。在负荷剂量组，初始谷浓度的平均值为 11.95mg/L，而非负荷剂量组为 7.55mg/L。未开万古霉素负荷剂量的主要原因是担心肾毒性。
引入万古霉素 CDSS 并未增加肾毒性，并增加了万古霉素的初始平均剂量和谷浓度。
