Many hospitals face barriers in the implementation of TDM services, this study aimed\nto evaluate a pharmacist-led TDM service to optimize patientsâ?? outcomes. Adult patients who\nwere administered vancomycin, gentamicin, or amikacin were included. The pre-phase included a\nretrospective assessment of patients and the intervention phase consisted of an educational program.\nThe post-phase assessed patients based on TDM services provided by inpatient pharmacists on a\n24-h, 7-day basis for 3 months. The primary outcome was to assess the mean difference in proportion\nof correct initial doses of prescribing orders. Secondary outcomes included assessing the mean\ndifferences in proportions of correct dose adjustments and correct drug sampling time. Seventy-five\npatients in each phase were eligible. Patients who received optimal initial dosing in the post-phase\nshowed a higher statistical significance, mean difference of 0.31, [95% CI (0.181-0.4438), p < 0.0001].\nPatients in the post-phase received more optimal dose adjustments, mean difference of 0.1, [95% CI\n(-0.560-0.260), p = 0.2113]. Drug levels were ordered more correctly in the post-phase, mean\ndifference of 0.03, [95% CI (-0.129-0.189), p = 0.7110]. This study demonstrated the important role of\nTDM services led by pharmacists in optimizing the initial dosing for these antibiotics.
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