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Bridging the Gap between Theory and Practice; the Active Role of Inpatient Pharmacists in Therapeutic Drug Monitoring

King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, 21423 Jeddah, Saudi Arabia
Pharmaceutical Care Services, Prince Mohammed Bin Abdulaziz Hospital, MNGHA, 42221 Madinah, Saudi Arabia
Pharmaceutical Care Services, King Khalid Hospital, MNGHA, 21589 Jeddah, Saudi Arabia
Author to whom correspondence should be addressed.
Pharmacy 2019, 7(1), 20;
Received: 23 November 2018 / Revised: 12 February 2019 / Accepted: 13 February 2019 / Published: 18 February 2019
PDF [777 KB, uploaded 18 February 2019]


Many hospitals face barriers in the implementation of TDM services, this study aimed to evaluate a pharmacist-led TDM service to optimize patients’ outcomes. Adult patients who were administered vancomycin, gentamicin, or amikacin were included. The pre-phase included a retrospective assessment of patients and the intervention phase consisted of an educational program. The post-phase assessed patients based on TDM services provided by inpatient pharmacists on a 24-h, 7-day basis for 3 months. The primary outcome was to assess the mean difference in proportion of correct initial doses of prescribing orders. Secondary outcomes included assessing the mean differences in proportions of correct dose adjustments and correct drug sampling time. Seventy-five patients in each phase were eligible. Patients who received optimal initial dosing in the post-phase showed a higher statistical significance, mean difference of 0.31, [95% CI (0.181–0.4438), p < 0.0001]. Patients in the post-phase received more optimal dose adjustments, mean difference of 0.1, [95% CI (−0.560–0.260), p = 0.2113]. Drug levels were ordered more correctly in the post-phase, mean difference of 0.03, [95% CI (−0.129–0.189), p = 0.7110]. This study demonstrated the important role of TDM services led by pharmacists in optimizing the initial dosing for these antibiotics. View Full-Text
Keywords: drug monitoring; vancomycin; aminoglycosides; TDM; inpatient; pharmacist drug monitoring; vancomycin; aminoglycosides; TDM; inpatient; pharmacist

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Alhameed, A.F.; Khansa, S.A.; Hasan, H.; Ismail, S.; Aseeri, M. Bridging the Gap between Theory and Practice; the Active Role of Inpatient Pharmacists in Therapeutic Drug Monitoring. Pharmacy 2019, 7, 20.

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