This study was conducted at a tertiary care hospital in the western region of Saudi Arabia, with a capacity of 400 beds. The pediatric services at this hospital include a general pediatric floor (28 beds), a pediatric surgery floor (20 beds), a neonatal intensive care unit (24 beds), a pediatric intensive care unit (10 beds), and a pediatric oncology unit (24 beds). The ambulatory care clinics at this facility have four half-day general pediatric clinics per week that see 20 to 30 patients per clinic. A retrospective cohort study of 300 randomly collected, physician-prescribed antibiotic order sheets was performed over a 2-week period within three different settings in our hospital (inpatient unit = 100; ambulatory care clinic = 100; emergency department = 100). The order sheets were evaluated for dosing errors, dosing interval, and weight documentation. Antibiotic prescriptions for pediatric patients (14 years old or younger) were included in this study. In this study, a dosing error was defined as the presence of a daily antibiotic dose that was 110% or more of the maximum recommended daily dose or below 90% of the minimum recommended daily dose.19
Additionally, the appropriate dosing interval for the prescribed antibiotic was evaluated and compared with the recommend dosing interval provided by the up-to-date version of two pediatric drug references, the Harriet Lane Handbook
(Custer J, Rau RE (eds). 18th Edition, Elsevier Health Sciences, New York, NY) and the Pediatric & Neonatal Dosage Handbook
(Taketomo C (ed). 18th
Edition. Lexi-Comp, Inc., Denver, CO) .
This study found dosing errors in 34.5% of the prescribed antibiotics. In response, we created a departmental policy and procedures that included an antibiotic dosing table with precalculated dosages for different pediatric weight ranges to address antibiotic dosing standardization for pediatric patients in our hospital. All physicians in our hospital who treat pediatric patients were instructed to write orders for antibiotics using the standardized dosing table for oral and parenteral antibiotics ( and ). The pediatric standardized dosing table for oral and parenteral antibiotics was created by clinical pharmacists and received the approval of the antimicrobial subcommittee at this hospital. Dosing of 10 oral and 5 parenteral antibiotics, including the antibiotics most commonly prescribed at our hospital and those associated with the most dosing errors (based on our study), was standardized according to pediatric weight. All standard doses provided in these tables were within the therapeutic range for a child’s weight; in addition, the standard oral antibiotic dosing table provided the appropriate strength and volume of medication to be dispensed in milliliters.
Standardized Dosing for Pediatric Oral Antibiotics
Standardized Dosing for Pediatric Parentral Antibiotics.
Pediatric infectious disease consultants in our hospital suggested preserving this dosing practice for patients who present with mild-to-moderate infections. Patients who present with severe infection or sepsis or who are immuno-compromised should not be candidates for this dosing policy as providers must use the maximum recommended daily dosing. Furthermore, patients with abnormal kidney or liver function should not be candidates for this dosing policy. Those patients who were not candidates for the standardized dosing policy were excluded from the study.
To improve the acceptance of the new policy and practice, we printed the dosing tables in a card-sized format that easily fit into a physician’s laboratory coat pocket. Additionally, dosing tables were printed in 8.5 × 11.5 inch size format and posted on the walls of each inpatient care unit. At the time of this policy implementation, the hospital did not have computerized prescriber order entry, and we created these simple, low-technology tools to improve the accuracy of antibiotic orders.
The pharmacy and therapeutic committee approved this policy for implementation. A team of 10 members (2 clinical pharmacists, 5 nurses, 3 pediatricians) was established and given the responsibilities of teaching the hospital staff how to use the policy and overseeing the implementation process. The educational program was presented to physicians, pharmacists, and nurses. It took 8 weeks to implement the new policy and apply it throughout the hospital. Three months after the implementation phase was completed, we evaluated the impact of the standard dosing table to determine whether there was a reduction in dosing errors for the selected antibiotics.
We assumed the rate of dosing errors prior to implementation of antibiotic dosing standardization to be 20%, and we aimed for a poststandardization dosing error rate of 5%. We needed at least 113 antibiotic order sheets for each group to detect significant differences between the two groups, with level of significance of at least 5% with 90% power. We anticipated that some order sheets would lack documentation of patient weight, so we decided to increase the sample size and we collected a total of 300 order sheets. Data were entered into an Excel 2007 spreadsheet (Microsoft, Redmond, WA) and were analyzed using SPSS version 19 statistics software (IBM, Armonk, NY) for descriptive statistics. Differences in rates of dosing errors, appropriateness of dosing intervals, and weight documentation prior to and following implementation of the antibiotic dosing standardization policy were analyzed using the Pearson chi-square test.