Avaliação da prescrição, administração e monitorização da vancomicina em pacientes adultos internados no Hospital das Clínicas da Faculdade de Medicina de Botucatu
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2018-12-11
Autores
Prado, Iara Ranona Sousa
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Universidade Estadual Paulista (Unesp)
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Introdução: A vancomicina é um antibiótico estratégico no tratamento de infecções por bactérias gram-positivas. Controvérsias quanto a sua posologia e monitorização se revestem de importância devido ao risco de nefrotoxicidade e à emergência de cepas resistentes. Objetivos: Caracterizar a população, descrever padrões de prescrição da vancomicina para pacientes adultos, observar a administração da vancomicina, a coleta da vancocinemia e o momento do posterior ajuste da dose da vancomicina, além de avaliar a conformidade entre prescrição, administração e monitorização da vancomicina em Hospital Universitário (HU) e assim, a confiabilidade do prontuário eletrônico. Metodologia: Para a caracterização dos sujeitos, avaliação de dados de prescrição e administração, coleta da vancocinemia e ajuste de dose realizou-se um estudo transversal, enquanto para a determinação dos desfechos realizou-se um estudo longitudinal e retrospectivo. Foram incluídos pacientes adultos internados em quatro enfermarias clínicas e cirúrgicas e em duas alas do serviço de terapia intensiva (SETI) em uso de vancomicina. Foram realizadas seis visitas às enfermarias de Clínica Médica, Neurologia e Ortopedia e cinco visitas a enfermaria de Cirurgia Vascular e aos SETIs, nos quais foram avaliados 67 pacientes e 989 prescrições, coletados dados do prontuário e observadas as rotinas de enfermagem e médica quanto a administração da vancomicina, coleta da vancocinemia e ajuste do antibiótico. Resultados: Não houve diferença entre as unidades quanto ao sexo, níveis basais de creatinina, tempo de internação, dias de uso de vancomicina e peso, com predomínio de pacientes mais jovens na Neurologia e com maior média de idade na Cirurgia Vascular. A dose de ataque foi prescrita em 83,8% dos pacientes, enquanto a diluição e o tempo de infusão foram prescritos, respectivamente, em 768 (77,6%) e 212 (21,4%) das prescrições. Os SETIs apresentaram taxas de adequação da dose de ataque e de frequência de prescrição de diluição e tempo de infusão estatisticamente superiores às das enfermarias (p 0,02, p 0,04 e p <0,001, respectivamente). Do total de diluições prescritas, 56,4% foram adequados. A Clínica Médica liderou na proporção de diluições corretamente prescritas (82,8%, p<0,05), em oposição ao Serviço de terapia intensiva – Ala 1 (SETI 1) e à Neurologia, os quais apresentaram as menores taxas de adequação, de 36,4% e 36,1%, respectivamente. O tempo de infusão foi prescrito corretamente em 169 (79,7%) registros. Na Neurologia, o tempo de infusão não foi prescrito em nenhuma vez e, na Ortopedia, em nenhuma delas foi adequado. Nos demais setores, o tempo de infusão, estava adequado na sua maioria, observando-se uma tendência discrepante entre as Alas 1 e 2 do SETI (p 0,058). Em análise SETIs versus enfermarias, verificou-se maiores taxas de adequação do tempo de infusão prescrito nos SETIs (p 0,003). Houve nove casos de reação cutânea à vancomicina (13,4%). Observou-se relação inversa entre a prescrição adequada quanto ao tempo de infusão e a frequência da apresentação de reação cutânea adversa. Foram observadas 56 administrações, com 32 (57,1%) em desacordo com o prescrito. Dos 59 pacientes em uso do primeiro esquema de vancomicina na internação há dois ou mais dias, 52 (88,1%) tinham pelo menos uma vancocinemia coletada, com a 1ªvancocinemia coletada predominantemente no 2º dia de antibioticoterapia em todos os setores. Não foi possível estabelecer comparações entre os setores acerca das coletas e ajustes de dose devido ao reduzido número de coletas de vancocinemia observadas. Dentre os 265 níveis de vancocinemia registrados, 132 (49,8%) foram classificados como adequados. A lesão renal aguda (LRA) desenvolveu-se em 13 (31,7%) do total de 41 pacientes avaliados para este desfecho e foi mais frequente nos SETIs comparado às enfermarias (p<0,001). Comparando-se o dia de antibioticoterapia com vancomicina em que cada paciente se encontrava na ocasião da dosagem da última creatinina e os valores da 1ªvancocinemia, verificou-se mediana de dias e níveis de vancocinemia superiores dentre os pacientes que desenvolveram LRA (p 0,06 e p 0,002, respectivamente). Conclusão: Há falhas na prescrição, administração e monitorização da vancomicina em todos os setores desse HU. O Serviço de terapia intensiva – Ala 2 (SETI 2) e a Clínica Médica foram os setores que melhor preencheram os critérios de prescrição adequada. Verifica-se necessidade de implantação de medidas de capacitação e treinamento dos profissionais médicos e de enfermagem, bem como de ações de fiscalização quanto ao rigor da prescrição e administração. Os dados de prontuário não se mostraram completamente fidedignos ao realizado na prática, no entanto, o estudo não foi capaz de reduzir a importância do prontuário como ferramenta de coleta de dados.
Introduction: Vancomycin is a strategic antibiotic in the treatment of gram-positive bacterial infections. Controversies regarding dosage and monitoring are important because of the risk of nephrotoxicity and the emergence of resistant strains. Objectives: To characterize the population, to describe vancomycin prescribing standards for adult patients, to observe the administration of vancomycin, collect serum vancomycin and the vancomycin dose adjust, and to evaluate the compliance between vancomycin prescription, administration and monitoring in the University Hospital (HU) and thus, the reliability of the electronic medical record. Methodology: A cross-sectional study was carried out to description of the subjects, evaluation of prescription and administration data, collection of vancocinemia and dose adjustment, while a longitudinal and retrospective study was performed to determination of outcomes. Were included adult patients hospitalized in four clinical and surgical wards and two intensive care unit’s wards (ICU) using vancomycin. Six visits to the General practice, Neurology and Orthopedic wards were carried out, and five visits to the Vascular Surgery ward and to the ICUs were carried out, in which 67 patients and 989 prescriptions were collected, data from the medical record and nursing and medical routines were observed for administration of vancomycin, collection of serum vancomycin and adjustment of antibiotic. Results: There were no differences between the units regarding sex, baseline creatinine levels, length of hospital stay, days of vancomycin use and weight, with a predominance of younger patients in Neurology and with a higher average age in Vascular Surgery. The loading dose was prescribed in 83.8% of patients, while dilution and infusion time were prescribed, respectively, in 768 (77.6%) and 212 (21.4%) prescriptions. ICUs showed statistically superior rates of loading dose and prescriptions frequency of dilution and time of infusion compared to wards (p 0.02, p 0.04 and p <0.001, respectively). Of the total dilutions prescribed, 56.4% were adequate. The General practice led in the proportion of adequately prescribed dilutions (82.8%, p <0.05), as 11 opposed to the Intensive Care Unit - Ward 1 (ICU 1) and Neurology, which had the lowest compliance rates of 36.4% and 36.1%, respectively. The infusion time was correctly prescribed in 169 (79.7%) of records. In Neurology, infusion time was not prescribed at any time, and in Orthopedics, none was adequate. In other sectors, the infusion time was mostly adequate, observing a discrepant trend between ICU wings 1 and 2 (p 0.058). In the ICUs versus infirmary analysis, the rates of adequacy of the infusion time prescribed in ICUs (p 0.003) were found to be higher. There were nine cases of cutaneous reaction to vancomycin (13.4%). There was an inverse relation between the appropriate prescription for infusion time and the frequency of adverse cutaneous reaction. A total of 56 administrations were observed, with 32 (57.1%) disagreeing with what was prescribed. Among the 59 patients on the first vancomycin regimen who had been hospitalized for two or more days, 52 (88.1%) had at least one level of serum vancomycin collected, with the first collected predominantly on the second day of antibiotic therapy in all wards. It was not possible to establish comparisons among wards regarding collection and dose adjustments because of the reduced number of collections observed. Among 265 registered levels of serum vancomycin, 132 (49.8%) were classified as adequate. Acute renal injury (AKI) developed in 13 (31.7%) of the 41 patients evaluated for this outcome and was more frequent in ICUs compared to the wards (p <0.001). Comparing the day of vancomycin antibiotic therapy in which each patient was at the time of the last creatinine dosing and the values of the 1st serum vancomycin level, larger median of days and higher serum vancomycin levels were observed among patients who developed AKI (p 0.06 and 0.002, respectively). Conclusion: There are shortcomings in the prescription, administration and monitoring of vancomycin in all sectors of this HU. The Intensive Care Unit - Ward 2 (ICU 2) and the General practice were the sectors that best met the appropriate prescription criteria. There is a need to implement preparation measures and training for medical and nursing professionals, as well as inspection actions regarding the strictness of prescription and administration. The medical record data did not prove to be completely reliable in practice, however, the study was not able to decrease the importance of medical records as a tool for data collection.
Introduction: Vancomycin is a strategic antibiotic in the treatment of gram-positive bacterial infections. Controversies regarding dosage and monitoring are important because of the risk of nephrotoxicity and the emergence of resistant strains. Objectives: To characterize the population, to describe vancomycin prescribing standards for adult patients, to observe the administration of vancomycin, collect serum vancomycin and the vancomycin dose adjust, and to evaluate the compliance between vancomycin prescription, administration and monitoring in the University Hospital (HU) and thus, the reliability of the electronic medical record. Methodology: A cross-sectional study was carried out to description of the subjects, evaluation of prescription and administration data, collection of vancocinemia and dose adjustment, while a longitudinal and retrospective study was performed to determination of outcomes. Were included adult patients hospitalized in four clinical and surgical wards and two intensive care unit’s wards (ICU) using vancomycin. Six visits to the General practice, Neurology and Orthopedic wards were carried out, and five visits to the Vascular Surgery ward and to the ICUs were carried out, in which 67 patients and 989 prescriptions were collected, data from the medical record and nursing and medical routines were observed for administration of vancomycin, collection of serum vancomycin and adjustment of antibiotic. Results: There were no differences between the units regarding sex, baseline creatinine levels, length of hospital stay, days of vancomycin use and weight, with a predominance of younger patients in Neurology and with a higher average age in Vascular Surgery. The loading dose was prescribed in 83.8% of patients, while dilution and infusion time were prescribed, respectively, in 768 (77.6%) and 212 (21.4%) prescriptions. ICUs showed statistically superior rates of loading dose and prescriptions frequency of dilution and time of infusion compared to wards (p 0.02, p 0.04 and p <0.001, respectively). Of the total dilutions prescribed, 56.4% were adequate. The General practice led in the proportion of adequately prescribed dilutions (82.8%, p <0.05), as 11 opposed to the Intensive Care Unit - Ward 1 (ICU 1) and Neurology, which had the lowest compliance rates of 36.4% and 36.1%, respectively. The infusion time was correctly prescribed in 169 (79.7%) of records. In Neurology, infusion time was not prescribed at any time, and in Orthopedics, none was adequate. In other sectors, the infusion time was mostly adequate, observing a discrepant trend between ICU wings 1 and 2 (p 0.058). In the ICUs versus infirmary analysis, the rates of adequacy of the infusion time prescribed in ICUs (p 0.003) were found to be higher. There were nine cases of cutaneous reaction to vancomycin (13.4%). There was an inverse relation between the appropriate prescription for infusion time and the frequency of adverse cutaneous reaction. A total of 56 administrations were observed, with 32 (57.1%) disagreeing with what was prescribed. Among the 59 patients on the first vancomycin regimen who had been hospitalized for two or more days, 52 (88.1%) had at least one level of serum vancomycin collected, with the first collected predominantly on the second day of antibiotic therapy in all wards. It was not possible to establish comparisons among wards regarding collection and dose adjustments because of the reduced number of collections observed. Among 265 registered levels of serum vancomycin, 132 (49.8%) were classified as adequate. Acute renal injury (AKI) developed in 13 (31.7%) of the 41 patients evaluated for this outcome and was more frequent in ICUs compared to the wards (p <0.001). Comparing the day of vancomycin antibiotic therapy in which each patient was at the time of the last creatinine dosing and the values of the 1st serum vancomycin level, larger median of days and higher serum vancomycin levels were observed among patients who developed AKI (p 0.06 and 0.002, respectively). Conclusion: There are shortcomings in the prescription, administration and monitoring of vancomycin in all sectors of this HU. The Intensive Care Unit - Ward 2 (ICU 2) and the General practice were the sectors that best met the appropriate prescription criteria. There is a need to implement preparation measures and training for medical and nursing professionals, as well as inspection actions regarding the strictness of prescription and administration. The medical record data did not prove to be completely reliable in practice, however, the study was not able to decrease the importance of medical records as a tool for data collection.
Descrição
Palavras-chave
Vancomicina, Vancocinemia, Monitorização, Nefrotoxicidade, Vancomycin, Serum vancomycin, Monitoring, Nephrotoxicity