European Journal of Clinical Pharmacology

, Volume 74, Issue 11, pp 1523–1529 | Cite as

Barriers and facilitators of appropriate vancomycin use: prescribing context is key

  • Joanne Oi Sze ChanEmail author
  • Melissa Therese Baysari
  • Jane Ellen Carland
  • Indy Sandaradura
  • Maria Moran
  • Richard Osborne Day
Pharmacoepidemiology and Prescription



Audit studies reveal frequent non-compliance with dosing and monitoring guidelines for vancomycin. This study aimed to qualitatively explore the barriers and facilitators of compliance with vancomycin dosing and monitoring guidelines.


Interviews were conducted with 16 prescribers in a large tertiary teaching hospital in Sydney, Australia. Questions explored knowledge, attitudes, and perceived complexities associated with vancomycin use. Interviews were analysed using thematic analysis.


Prescribers reported utilising vancomycin guidelines, citing familiarity with guidelines, a positive perception of guidelines, awareness of poor guideline compliance, and assistance from specialist staff as facilitators of the uptake of guideline recommendations. Barriers existing within the prescribing environment such as the prescribing culture, a lack of time, and poor communication and coordination of therapeutic drug monitoring processes were identified as hindrances to guideline compliance.


The provision of guidelines may not be sufficient in ensuring appropriate prescribing and monitoring of vancomycin when barriers relating to the prescribing environment exist. Developing interventions targeted toward these barriers, such as having dedicated phlebotomists for vancomycin blood sampling, fostering better handover processes, and educating staff on poorly understood aspects of guidelines, is likely to improve the uptake of guideline recommendations for vancomycin and other medications requiring therapeutic drug monitoring.


Vancomycin Guidelines Qualitative Interview Drug monitoring 



We wish to acknowledge the participation and contribution of all the doctors interviewed in this study. In addition, we would like to thank Dr. Emma Tay for her help in participant recruitment.

Author contribution

JOC helped acquire, analyse, and interpret the data and drafted the article. MTB and ROD conceived and designed the study, helped analyse and interpret the data, and revised the article for publication. JEC, IS, and MM helped interpret the data and revised the article for publication. All authors had full access to all of the data and can take responsibility for the integrity of the data and the accuracy of the data analysis and had final approval of the version to be published.


This study was funded by the National Health and Medical Research Council Program (grant number 1054146).

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

228_2018_2525_MOESM1_ESM.pdf (520 kb)
ESM 1 (PDF 520 kb)


  1. 1.
    Rybak M, Lomaestro B, Rotschafer JC et al (2009) Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 66:82–98. CrossRefPubMedGoogle Scholar
  2. 2.
    Gross AS (1998) Best practice in therapeutic drug monitoring. Br J Clin Pharmacol 46:95–99. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Al Za’abi M, Al Muqbali J, Al-Waili K (2015) Sampling time and indications appropriateness for therapeutically monitored drugs at a teaching university hospital in Oman. Saudi Pharm J 23:458–462. CrossRefPubMedGoogle Scholar
  4. 4.
    Koppula S, Ruben S, Bangash F et al (2015) Pitfalls in dosing vancomycin. Am J Med Sci 349:137–139. CrossRefPubMedGoogle Scholar
  5. 5.
    Roustit M, François P, Sellier E et al (2010) Evaluation of glycopeptide prescription and therapeutic drug monitoring at a university hospital. Scand J Infect Dis 42:177–184. CrossRefPubMedGoogle Scholar
  6. 6.
    Morrison AP, Melanson SE, Carty MG et al (2012) What proportion of vancomycin trough levels are drawn too early?: frequency and impact on clinical actions. Am J Clin Pathol 137:472–478. CrossRefPubMedGoogle Scholar
  7. 7.
    Traugott KA, Maxwell PR, Green K et al (2011) Effects of therapeutic drug monitoring criteria in a computerized prescriber-order-entry system on the appropriateness of vancomycin level orders. Am J Health Syst Pharm 68:347–352. CrossRefPubMedGoogle Scholar
  8. 8.
    Hidayat LK, Hsu DI, Quist R et al (2006) High-dose vancomycin therapy for methicillin-resistant Staphylococcus aureus infections: efficacy and toxicity. Arch Intern Med 166:2138–2144. CrossRefPubMedGoogle Scholar
  9. 9.
    Jeffres MN, Isakow W, Doherty JA et al (2007) A retrospective analysis of possible renal toxicity associated with vancomycin in patients with health care-associated methicillin-resistant Staphylococcus aureus pneumonia. Clin Ther 29:1107–1115. CrossRefPubMedGoogle Scholar
  10. 10.
    Lee JY, Howden BP (2015) Vancomycin in the treatment of methicillin-resistant Staphylococcus aureus - a clinician’s guide to the science informing current practice. Expert Rev Anti-Infect Ther 13:855–869. CrossRefPubMedGoogle Scholar
  11. 11.
    Spellberg B, Powers JH, Brass EP et al (2004) Trends in antimicrobial drug development: implications for the future. Clin Infect Dis 38:1279–1286. CrossRefPubMedGoogle Scholar
  12. 12.
    Boucher HW, Talbot GH, Bradley JS et al (2009) Bad bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America. Clin Infect Dis 48:1–12. CrossRefPubMedGoogle Scholar
  13. 13.
    Dellit TH, Owens RC, McGowan JE et al (2007) Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 44:159–177. CrossRefPubMedGoogle Scholar
  14. 14.
    Charani E, Castro-Sanchez E, Sevdalis N et al (2013) Understanding the determinants of antimicrobial prescribing within hospitals: the role of “prescribing etiquette”. Clin Infect Dis 57:188–196. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Chaves N, Cheng A, Runnegar N et al (2014) Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals. Intern Med J 44:568–574. CrossRefPubMedGoogle Scholar
  16. 16.
    Cortoos PJ, De Witte K, Peetermans WE et al (2008) Opposing expectations and suboptimal use of a local antibiotic hospital guideline: a qualitative study. J Antimicrob Chemother 62:189–195. CrossRefPubMedGoogle Scholar
  17. 17.
    De Souza V, MacFarlane A, Murphy AW et al (2006) A qualitative study of factors influencing antimicrobial prescribing by non-consultant hospital doctors. J Antimicrob Chemother 58:840–843. CrossRefPubMedGoogle Scholar
  18. 18.
    Diasinos N, Baysari M, Kumar S et al (2015) Does the availability of therapeutic drug monitoring, computerised dose recommendation and prescribing decision support services promote compliance with national gentamicin prescribing guidelines? Intern Med J 45:55–62. CrossRefPubMedGoogle Scholar
  19. 19.
    Giblin TB, Sinkowitz-Cochran RL, Harris PL et al (2004) Clinicians’ perceptions of the problem of antimicrobial resistance in health care facilities. Arch Intern Med 164:1662–1668. CrossRefPubMedGoogle Scholar
  20. 20.
    Livorsi D, Comer A, Matthias MS et al (2015) Factors influencing antibiotic-prescribing decisions among inpatient physicians: a qualitative investigation. Infect Control Hosp Epidemiol 36:1065–1072. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Livorsi D, Comer AR, Matthias MS et al (2015) Barriers to guideline-concordant antibiotic use among inpatient physicians: a case vignette qualitative study. J Hosp Med 11:174–180. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Mattick K, Kelly N, Rees C (2014) A window into the lives of junior doctors: narrative interviews exploring antimicrobial prescribing experiences. J Antimicrob Chemother 69:2274–2283. CrossRefPubMedGoogle Scholar
  23. 23.
    Melanson SE, Mijailovic AS, Wright AP et al (2013) An intervention to improve the timing of vancomycin levels. Am J Clin Pathol 140:801–806. CrossRefPubMedGoogle Scholar
  24. 24.
    Mol P, Rutten W, Gans R et al (2004) Adherence barriers to antimicrobial treatment guidelines in teaching hospital, the Netherlands. Emerg Infect Dis 10:522–525. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Newham R, Thomson A, Semple Y et al (2015) Barriers to the safe and effective use of intravenous gentamicin and vancomycin in Scottish hospitals, and strategies for quality improvement. Eur J Hosp Pharm 22:32–37. CrossRefGoogle Scholar
  26. 26.
    Schouten JA, Hulscher ME, Natsch S et al (2007) Barriers to optimal antibiotic use for community-acquired pneumonia at hospitals: a qualitative study. BMJ Qual Saf 16:143–149. CrossRefGoogle Scholar
  27. 27.
    Tan J, Naik V, Lingard L (2006) Exploring obstacles to proper timing of prophylactic antibiotics for surgical site infections. BMJ Qual Saf 15:32–38. CrossRefGoogle Scholar
  28. 28.
    Teo CK, Baysari MT, Day RO (2013) Understanding compliance to an antibiotic prescribing policy: perspectives of policymakers and prescribers. J Pharm Pract Res 43:32–36. CrossRefGoogle Scholar
  29. 29.
    Warburton J, Hodson K, James D (2014) Antibiotic intravenous-to-oral switch guidelines: barriers to adherence and possible solutions. Int J Pharm Prac 22:345–353. CrossRefGoogle Scholar
  30. 30.
    Antibiotic Expert Group (2016). Therapeutic Guidelines: Antibiotic (Version 15). Accessed 26 January 2018
  31. 31.
    Lapadat JC (2010) Thematic analysis. In: Mills AJ, Durepos G, Wiebe E (eds) Encyclopedia of case study research. SAGE Publications, Inc., California, pp 925–927Google Scholar
  32. 32.
    Thomas DR (2006) A general inductive approach for analyzing qualitative evaluation data. Am J Eval 27:237–246. CrossRefGoogle Scholar
  33. 33.
    Lewis PJ, Tully MP (2009) Uncomfortable prescribing decisions in hospitals: the impact of teamwork. J R Soc Med 102:481–488. CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Ross S, Ryan C, Duncan EM et al (2013) Perceived causes of prescribing errors by junior doctors in hospital inpatients: a study from the PROTECT programme. BMJ Qual Saf 22:2297–2102. CrossRefGoogle Scholar
  35. 35.
    Payne CE, Stein JM, Leong T et al (2012) Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. BMJ Qual Saf 21:925–932. CrossRefPubMedGoogle Scholar
  36. 36.
    Zakrison TL, Rosenbloom B, McFarlan A et al (2016) Lost information during the handover of critically injured trauma patients: a mixed-methods study. BMJ Qual Saf 25:929–936. CrossRefPubMedGoogle Scholar
  37. 37.
    Egan S, Murphy PG, Fennell JP et al (2012) Using six sigma to improve once daily gentamicin dosing and therapeutic drug monitoring performance. BMJ Qual Saf 21:1042–1051. CrossRefPubMedGoogle Scholar
  38. 38.
    Swartling M, Gupta R, Dudas V et al (2012) Short term impact of guidelines on vancomycin dosing and therapeutic drug monitoring. Int J Clin Pharm 34:282–285. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.School of Medical SciencesUniversity of New South WalesSydneyAustralia
  2. 2.Department of Clinical Pharmacology and ToxicologySt Vincent’s HospitalSydneyAustralia
  3. 3.Australian Institute of Health InnovationMacquarie UniversityNorth RydeAustralia
  4. 4.Centre for Infectious Diseases and MicrobiologyWestmead HospitalSydneyAustralia

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