Appropriate Use Of Vancomycin Research Articles

Retrospective Drug Utilization Evaluation of Vancomycin Usage in Infectious Wards and Intensive Care Units in Hamedan Teaching Hospitals, April to September 2020

Background: Drug utilization evaluation (DUE) was performed to assess using drugs with special conditions such as antibiotics. Vancomycin is one of the essential antibiotics that is effective on methicillin-resistant Staphylococcus aureus, but unreasonable use of vancomycin, in addition to cost, leads to outbreak microbial resistance, which is a concern for health care systems all around the world. The aim of this study was to evaluate vancomycin use in teaching hospitals in Hamedan, Iran. Methods: This retrospective study was performed on patients who received vancomycin for at least 72 hours in intensive care units and infectious wards between April and September 2020 in the teaching hospitals of Hamedan. Data were obtained from patients’ medical records and entered into predesigned checklists. Results: From 661 patients, 441 were males and 247 were females. They received vancomycin for an average of 5.75 days. The most prevalent indication for vancomycin use was surgery. Only 40 patients had sensitive microbial culture to vancomycin, while 356 of them (53.9%) had no microbial culture at all. According to HICPAC guidelines, the overall appropriate use of vancomycin was 44.8%. Conclusion: According to the results, the irrational use of vancomycin must be corrected to achieve maximum optimal use; thus, performing and adhering to microbial culture, deploying clinical pharmacists, and holding explanatory sessions for health care are recommended for this purpose.

1354. Reducing vancomycin utilization rate in a level 4 NICU

BackgroundVancomycin is frequently used empirically in suspected sepsis in neonatal intensive care unit (NICU). However, inappropriate or unnecessary use can lead to additional morbidities and emergence of drug resistant pathogens. Standardization of vancomycin use is imperative for safer and more efficient patient care.MethodsThis study was part of a QI initiative to optimize vancomycin use by revising a standardized late onset sepsis (LOS) guideline with defined indications and criteria for empiric vancomycin. The implementation was started in 9/19 after completion of providers’ education. To reduce seasonal variations, 1/19-3/19 (pre-guideline) and 12/19-2/20 (post-implementation) data was retrospectively compared, including demographics, antibiotic indications, days of therapy/1000 patient days (AUR), positive cultures, isolated pathogens and resistance profiles. Clinical outcomes and adherence to the guideline were evaluated. Wilcoxon rank sum test was applied for continuous variables and Pearson chi-square test was applied for categorical variables. p< 0.05 was considered significant.ResultsThere were 53 LOS antibiotic courses in 35 patients pre-guideline and 113 in 64 patients post-implementation. We found an overall increase in vancomycin AUR in the post-implementation period (66.92 vs. 70.72, respectively, p=0.79), however, largely due to appropriate use of vancomycin for documented infections with gram-positive pathogens (including CONS and MRSE). Mortality was not statistically significant between two periods (Table 1 and 2). Vancomycin was ordered significantly less empirically, as per guideline, in the post implementation period (71.43% vs 46.15%, p=0.02). Adherence to the LOS antibiotics guideline was 69%.Table 1: Demographic characteristics of infants pre and post-guideline Table 2: Therapy indication, medication exposure and clinical outcomes 30 days after LOS treatment pre and post-guideline ConclusionDevelopment of a standardized guideline for empiric antibiotic therapy is important to reduce unnecessary and inappropriate use of vancomycin. We demonstrated that use of a guideline significantly decreased vancomycin ordering as an empiric antibiotic. Further analysis is needed in order to identify safety of the guideline’s criteria, factors contributing to unnecessary vancomycin use, as well as educational needs to ensure appropriate antibiotic use.Disclosures All Authors: No reported disclosures

Retrospective Analysis of Vancomycin Use in Febrile Neutropenic Patients

Background Febrile neutropenia is a complication of cancer treatment that can result in life-threatening infections. Guidelines recommend empiric use of vancomycin in febrile neutropenia for patients with specific risk factors for gram-positive infection. The purpose of this study is to evaluate the guideline criteria for vancomycin use in patients with febrile neutropenia by describing clinical outcomes and identifying potential areas for practice improvement. Methods This study was a retrospective review of 275 patients. The primary outcome was to compare the number of patients meeting the criteria for vancomycin in those receiving and not receiving vancomycin. Secondary outcomes were to compare the guideline criteria in patients with and without identified gram-positive infections, determine the accuracy of the guideline criteria for vancomycin use in predicting gram-positive infections, assess discontinuation of vancomycin at 48 hours, and compare clinical outcomes between those receiving and not receiving vancomycin. Results Of the identified febrile neutropenia patients, 91.3% met the criteria for empiric vancomycin use. Although 85.1% of patients tested negative for gram-positive bacteria, 89.7% of them met the criteria to receive vancomycin. Discontinuation of vancomycin within 48 hours occurred in 56.4% of patients. Clinically, those receiving vancomycin had a significantly longer median time to defervescence, length of stay, and duration of antibiotics. Conclusion Vancomycin use is common, and despite adherence to guideline concordant prescribing, those receiving vancomycin had poorer clinical outcomes. There is a need for identification of more specific risk factors for gram-positive infections, and more education on the appropriate use of vancomycin to promote proper utilization and ensure optimal patient outcomes.

Effect of Pharmacists’ Interventions on the Appropriateness of Empiric Vancomycin Therapy in Oncology Patients with Febrile Neutropenia

The purpose of this observational study is to evaluate the effect of an active pharmacy intervention to facilitate timely discontinuation of empiric vancomycin therapy in oncology patients with febrile neutropenia who lack objective evidence of a Gram-positive infection. This was a two-phase study. Vancomycin use was evaluated retrospectively on all oncology patients with febrile neutropenia over four weeks (phase I). In a parallel four weeks a year later, vancomycin use in this patient population was evaluated prospectively (phase II). In the absence of evidence of Gram-positive infection after 72 hours of treatment initiation, the team was contacted by a pharmacist to encourage discontinuation. Usage was compared between both phases. Forty-three patients in phase I and 25 patients in phase II were treated with vancomycin with no evidence for Gram-positive infections. Pharmacists’ interventions were documented on 18 patients in phase II. Of these, 56% of interventions to discontinue vancomycin were accepted, but only 33.3% of patients had treatment stopped within 72 hours of initiation. Although not significant, a trend in more appropriate use of vancomycin in oncology patients with febrile neutropenia was observed. Pharmacist’s interventions might have played a role in this observation.

Effect of serum concentration and concomitant drugs on vancomycin-induced acute kidney injury in haematologic patients: a single-centre retrospective study.

Appropriate use of vancomycin (VCM) is important in preventing acute kidney injury (AKI). Because of the high frequency of VCM use for febrile neutropenia and concomitant use of other nephrotoxic drugs, haematologic patients have a different nephrotoxic background compared with patients with other diseases. Therefore, it is unclear whether the risk factors of VCM-induced AKI identified in other patient groups are also applicable to haematologic patients. Herein, we performed a single-centre retrospective analysis to identify the factors associated with VCM-induced AKI in haematologic patients. We retrospectively analysed 150 haematologic patients to whom VCM was administered between April 2010 and March 2018 at Tokushima University Hospital. VCM-induced AKI was defined according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariate logistic regression analyses were performed to identify risk factors for VCM-induced AKI. Seventeen patients had VCM-induced AKI. Multivariate analysis revealed that the risk factors of VCM-induced AKI were an initial VCM trough concentration of > 15mg/L and concomitant use of tazobactam/piperacillin (TAZ/PIPC) and liposomal amphotericin B (L-AMB). Patients with an initial VCM trough concentration of < 10mg/L showed significantly lower efficacy in febrile neutropenia. Interestingly, concomitant L-AMB use increased the incidence of VCM-induced AKI in a VCM concentration-dependent manner, whereas concomitant TAZ/PIPC increased the incidence in a VCM concentration-independent manner. The optimal initial VCM trough concentration was 10-15mg/L in haematologic patients, considering safety and effectiveness. There were differences in the effect of VCM-induced AKI between nephrotoxic drugs.

229. The Role of Antimicrobial Stewardship Program on Appropriate Use, Dose, and Duration of Vancomycin Treatment

BackgroundIn an era of increasing bacterial resistance, antimicrobial stewardship programs (ASP) are essential in guiding judicious antibiotic use and improving patient safety goals. A prior medication use evaluation of vancomycin conducted at Stony Brook University Hospital (SBUH) identified three areas for improvement: (1) vancomycin dosing to achieve target trough concentration, (2) treatment duration, (3) and the use of vancomycin drug assay. As a result, the ASP at SBUH implemented an interdisciplinary team which consists of pharmacists and physicians to optimize these areas.MethodsA prospective quality improvement program was implemented from October 1, 2017 to December 31, 2017. Patients on two medicine units (60 patient beds) were enrolled in the program if they received vancomycin for more than one day and were not on hemodialysis. The ASP monitored for appropriate use of vancomycin as well as providing real-time guidance on dosing and serum concentration monitoring. If vancomycin was not indicated or de-escalation was warranted, the physician was contacted for discontinuation or de-escalation. To evaluate the impact of the program, we selected comparable patients from two other medicine units during the same period as the control group. Duration of vancomycin therapy, the percentage of patients achieving target trough level and 24-hour AUC within 72 hours, and use of vancomycin drug assay were compared.ResultsThere were 84 patients in the intervention group and 142 patients in the control group with similar age, weight, and creatinine clearance. The intervention group achieved a 20% reduction in the days of vancomycin use (median days of therapy 4.55 vs. 5.7 days, P = 0.071), a higher percentage of patient achieving trough level of 10–20 μg/mL (80.65% vs. 51.79%, P = 0.0001) and 24 hour AUC >400 mg hours/L (95.16% vs. 74.6%, P = 0.001), and a lower number of trough levels per course (1.51 vs. 2.54, P = 0.007). The 3-month medication cost savings from the program on these two units was over $6,000.ConclusionAn ASP supervised program led to a reduction in vancomycin days of therapy, early attainment of optimal exposure, and decreased use of laboratory resources. Moreover, the program lowered the overall healthcare cost.Disclosures All authors: No reported disclosures.

Appropriate Use of Vancomycin in NICU Despite Free-for-All Policy.

Because of increases in antimicrobial resistance, the use of vancomycin in late-onset sepsis has come under scrutiny. The primary outcome of this study was to determine if vancomycin for the treatment of late-onset sepsis in the neonatal intensive care unit (NICU) was being discontinued within 72 hours according to the existing protocol. Secondary outcomes included the appropriateness of therapeutic drug monitoring associated with vancomycin, and renal dysfunction associated with the use of vancomycin in the NICU outside of the 72-hour policy. A retrospective chart review was completed for patients in the NICU who received vancomycin for the treatment of late-onset sepsis between the dates of January 1, 2014, and July 1, 2014. There were 125 vancomycin treatment courses, of which 97 were included. Appropriate use of vancomycin, per policy, occurred in a total of 87 of 97 courses (89.6%). Therapeutic drug monitoring was evaluated by the number of appropriate troughs, determined using renal function and previous trough concentrations. There was not a statistically significant difference in the number of inappropriate troughs drawn between those that were continued on vancomycin appropriately (n = 17 courses; 4 of 44 inappropriate troughs) versus inappropriately (n = 10 courses; 1 of 22 inappropriate troughs; p = 0.66), despite the large number of troughs drawn. Adverse renal outcomes were not statistically significant in patients continued inappropriately on vancomycin (p = 1.0). Vancomycin use in the NICU for late-onset sepsis is appropriate per the existing antibiotic policy. Therapeutic drug monitoring could be improved, and adverse renal outcomes due to inappropriate continuation of vancomycin are rare.

Appropriate Use of Vancomycin in a Pediatric Emergency Department Through the Use of a Standardized Electronic Guideline

(a) Compare utilization of vancomycin in the ED prior to and after implementation of standardized treatment guideline and order template (STGOT); (b) assess the appropriate use as initial therapy based on indication versus admitting diagnosis. Chart audits on all patients who received vancomycin and were admitted. Overall utilization and appropriateness of starting therapy were compared pre-and post-STGOT implementation. Overall utilization of vancomycin was 4% pre-STGOT compared to 3% post-STGOT; 98% of patients pre-STGOT compared to 99% post-STGOT received vancomycin appropriately. There was no difference in vancomycin utilization and appropriateness of initiating therapy after STGOT implementation.

Appropriate vancomycin use in a Malaysian tertiary hospital based on current HICPAC recommendations.

Antibiotic resistance is a rapidly emerging problem. A major concern is methicillin-resistant Staphylococcus aureus (MRSA), especially in developing countries where cost-effectiveness is imperative. Restriction of vancomycin usage is necessary to reduce the emergence of vancomycin-resistant organisms. The aim of this study was to look into the appropriate use of vancomycin based on the Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines and to investigate serum levels of vancomycin. The study was performed retrospectively. Medical records of patients treated with vancomycin for the past year were identified and selected. Overall, 118 patients were treated with vancomycin. Appropriate use of vancomycin was significantly higher than inappropriate use (p = 0.001). Approximately 85% (n = 100) of patients were given vancomycin for treatment, whereas the rest were given it for prophylaxis. Appropriate use of vancomycin was observed in 67% (n = 79) of patients. However, there was still a high rate of inappropriate vancomycin use for prophylaxis and treatment (n = 39, 33.1%). The most common reason for inappropriate use was non-neutropenic and non-line related sepsis (n = 36, 30.8%). Therapeutic drug monitoring of vancomycin was performed in 79 patients (67%). Most patients (n = 53, 67%) demonstrated sub-therapeutic levels during the first measurement. There was no significant difference between trough levels achieved with a higher (> 15 mg/kg) versus a lower dose (< 15 mg/kg). This study demonstrates that there was still a high level of inappropriate vancomycin use, which could potentially contribute to vancomycin resistance.

Underestimation of rat serum vancomycin concentrations measured by an enzyme‐multiplied immunoassay technique and the strategy for its avoidance

An enzyme-multiplied immunoassay technique (EMIT) has been widely adopted for the measurement of serum concentrations of vancomycin (VCM) in clinical practice. Because of the growing demand for its application to fundamental pharmacokinetic studies, we examined whether VCM concentrations in rat serum were accurately measured by EMIT. It was found that measured values of known amounts of VCM spiked to rat serum were markedly underestimated with a large analytical variance. When ultrafiltrated rat serum was used as the sample matrix, interference was significantly improved, and the degree of underestimation was attenuated also by diluting samples with physiological saline. These results suggest that endogenous substances of a high molecular weight in rat serum interfere with the analysis of VCM concentrations by EMIT. However, measured values of rat serum VCM concentrations by EMIT were restored to theoretical levels by exposing samples to 70°C for 3-7 min. A likely explanation for the avoidance of interference is that an appropriate thermal force eliminated the immunological function of endogenous substances falsely recognizing VCM without affecting the VCM molecule itself. Regarding serum samples collected from rats that were administered VCM, values measured by EMIT following the heat-treatment agreed well with those by the high performance liquid chromatography (HPLC) method. This is the first report showing interference by endogenous high-molecular substances in the measurement of drug concentrations in rat serum using EMIT. Our findings will contribute to the appropriate use of VCM based on evidence provided by clinical-oriented rat experiments requiring the measurement of serum VCM concentrations by EMIT.

Effectiveness of a Guideline to Reduce Vancomycin Use in the Neonatal Intensive Care Unit

The Centers for Disease Control and Prevention recommend hospitals develop guidelines for the appropriate use of vancomycin as part of comprehensive antimicrobial stewardship. The objective of this study was to evaluate the effectiveness and safety of a guideline to restrict vancomycin use in the neonatal intensive care unit (NICU). A vancomycin use guideline was introduced in 2 tertiary care NICUs with low incidences of methicillin-resistant Staphylococcus aureus infections. We compared all infants >72 hours of age who were evaluated for late-onset infection before and after implementation of this guideline. Vancomycin start rates were reduced from 6.9 to 4.5 per 1000 patient-days (35% reduction; P = 0.01) at Brigham and Women's Hospital, and from 17 to 6.4 per 1000 patient-days (62% reduction; P < 0.0001) at Massachusetts General Hospital. The number of infants exposed to vancomycin decreased from 5.2 to 3.1 per 1000 patient-days (40% reduction; P = 0.008) at Brigham and Women's Hospital, and 10.8 to 5.5 per 1000 patient-days (49% reduction; P = 0.009) at Massachusetts General Hospital. Causes of infection, duration of bacteremia, and incidence of complications or deaths attributable to late-onset infection did not change significantly at either institution. Implementation of a NICU vancomycin use guideline significantly reduced exposure of newborns to vancomycin without adversely affecting short-term patient safety. Further studies are required to evaluate the long-term effect of vancomycin restriction on NICU patient safety and microbial ecology, particularly among institutions with higher rates of methicillin-resistant Staphylococcus aureus infections.

Vancomycin: Understanding Its Past and Preserving Its Future

The increase in vancomycin use in the 1980s to treat antibiotic-associated colitis and methicillin-resistant Staphylococcus aureus (MRSA) is largely responsible for the appearance of vancomycin-resistant enterococcus, which in turn spawned isolated cases of vancomycin-resistant S. aureus. Perhaps most worrisome to clinicians are strains of MRSA that are heteroresistant to vancomycin; these isolates are difficult to detect. Appropriate use of vancomycin coupled with awareness of infection control measures is paramount to abrogating the emergence of new vancomycin-resistant MRSA organisms and preserving its future efficacy. The continued reliance on vancomycin for the treatment of MRSA infections will depend on whether vancomycin resistance can be minimized. Newer antibacterial agents, particularly those with activity toward MRSA and vancomycin-resistant enterococcus, such as linezolid, quinupristin/dalfopristin, daptomycin, and tigecycline, may take a more prominent clinical role when gram-positive bacteria resistance to vancomycin further escalate.

Effectiveness of pharmacy policies designed to limit inappropriate vancomycin use: a population-based assessment.

In Oregon in 1994, a population-based study of 66 nonpsychiatric hospitals indicated that 40% of vancomycin orders were inappropriate according to Centers for Disease Control and Prevention guidelines. We repeated the study to determine whether vancomycin use had been affected by pharmacy policies implemented following the 1994 study. We surveyed pharmacists in nonpsychiatric hospitals in Oregon regarding vancomycin use policies in their hospitals. Using pharmacy records, we identified and abstracted the charts of all patients in Oregon hospitals receiving vancomycin during a 3-week period to determine appropriate use of vancomycin. Thirteen (20%) of 64 hospitals had implemented a vancomycin restriction policy since 1994; none ofthe remaining hospitals in the study had a policy. In 1999, hospitals with vancomycin restriction policies had substantially decreased rates of inappropriate vancomycin use compared with hospitals without such policies (1.0 vs 1.8 orders per 1,000 patient-days; P = .01). Compared with 1994 baseline rates of inappropriate use, hospitals that adopted policies experienced a decrease (from 1.5 orders per 1,000 patient-days in 1994 to 1.0 in 1999; P= .13), whereas hospitals without policies experienced a statistically significant increase (from 0.9 orders per 1,000 patient-days in 1994 to 1.8 in 1999; P= .001). Restriction policies were most effective at reducing rates of inappropriate use for treatment of confirmed gram-positive infections and prophylaxis. Vancomycin restriction policies were associated with a decrease in inappropriate therapeutic and prophylactic vancomycin use, but had no effect on inappropriate empiric use. Hospitals considering limits regarding inappropriate use should consider implementation of institution-based vancomycin restriction policies as part of an overall strategy.

Indications for vancomycin in dialysis patients.

Resistance to vancomycin has emerged among Staphylococcus aureus, coagulase-negative staphylococci (CNS), and enterococci, and this emergence has particular prevalence in dialysis units. It has therefore become imperative that physicians use vancomycin judiciously. General recommendations regarding the appropriate use of vancomycin have been developed. Although in theory implementation of these guidelines should not be difficult, the medical community may be unable or unwilling to make the necessary adjustments in practice. The onslaught of cost constraints and bureaucratic encumbrance has occurred simultaneously with the increase in vancomycin resistance among pathogens commonly isolated among the dialysis population. When a patient responds to empiric antibiotic therapy and susceptibility data indicate that an antibiotic other than vancomycin would be appropriate, the clinician far too often does not make the change to this alternative. Previously there was no biological imperative to change the antibiotic. That complacency has infected an entire generation of physicians, and especially nephrologists. Furthermore, there is an active movement against change, driven by concerns such as malpractice accusations and frank errors in the interpretation of medical facts.

Knowledge of Centers for Disease Control and Prevention guidelines for the use of vancomycin at a large tertiary care children’s hospital

Objective: In 1994, the Centers for Disease Control and Prevention (CDC) published guidelines to encourage prudent use of vancomycin. We sought to determine whether physicians could demonstrate knowledge consistent with the guidelines. Design: Survey consisting of 18 clinical vignettes based on the CDC guidelines. Participants: All residents, fellows, and attending physicians involved in pediatric inpatient services. Setting: Tertiary care children’s hospital providing service to an inner-city population and community referral base. Main outcome measures: Comparison of survey scores and individual responses among respondents. Results: Survey scores did not vary with level of training or whether the respondent was a pediatrician or non-pediatrician. Average scores of attending physicians, fellows, and residents were 74.1% (SD = 13.1), 77.2% (SD = 11.5), and 73.4% (SD = 10.5), respectively, and did not differ significantly. Questions incorrectly answered by more than 30% of respondents concerned the use of vancomycin as: (1) first-line treatment of Clostridium difficile colitis, (2) a topical solution for wound infection, (3) initial, empiric treatment of patients with fever and neutropenia, (4) peri-operative prophylaxis, (5) a preferred agent over β-lactam antimicrobial agents. Conclusion: Deficits in knowledge regarding appropriate vancomycin use can be localized to certain clinical settings. This observation lends optimism to the notion that targeted educational intervention may improve the appropriate use of vancomycin. (J Pediatr 2000;137:694-700)

Vancomycin use in a university medical center: effect of a vancomycin continuation form.

To examine the impact of a new policy to ensure appropriate use of vancomycin in a 461-bed tertiary-care hospital. We instituted a policy that allowed physicians to prescribe vancomycin but that required them to complete a vancomycin continuation form and document that use conformed to Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines if they wished to continue the drug beyond 72 hours. Vancomycin was stopped automatically at 72 hours if use was not consistent with guidelines, if an infectious diseases consultant did not approve the drug, or if the form was not completed. A pharmacist and infectious diseases specialist monitored use of vancomycin prospectively and interacted with prescribers when indicated. Educational efforts were limited to printing the HICPAC guidelines on the form and providing information about the policy in a newsletter. Patterns of prescribing and the economic impact of the form were evaluated over a 6-month period. Only 29% to 48% of vancomycin orders initially met HICPAC guidelines, but 77% to 96% of use was appropriate after 72 hours when the form was used. Inappropriate surgical prophylaxis, empirical therapy of intensive-care unit and transplant patients, and therapy for inadequately documented coagulase-negative staphylococcal infections remained problems. Vancomycin use fell from a mean of 136 (+/-52) g/1,000 patient days in the 12 months before the form to 78 (+/-22) g/1,000 patient days in the 9 months after institution of the form (P<.05). Net vancomycin acquisition costs and costs of ordering vancomycin serum levels fell by $357 and $19 per 1,000 patient days, respectively (P<.05). This represented annualized saving of approximately $47,000 in drug and monitoring costs. No adverse patient outcomes were seen as a result of the program. A vancomycin continuation form can decrease inappropriate vancomycin use and may save money. Additional educational efforts may be required to increase compliance with HICPAC guidelines during initial prescribing.

Vancomycin use in pediatric cardiothoracic surgery patients.

Vancomycin use in pediatric cardiothoracic surgery patients.

A Vancomycin Monitoring Program at a Community Hospital

Because of concern about patients' increased risk of developing resistance to vancomycin, a vancomycin monitoring program involving education, not restriction, on the prudent use of vancomycin was developed at the Barnes-Jewish Christian (BJC) North Region hospitals in St Louis. The program was spearheaded by the pharmacy department and monitored by interdisciplinary committees within the hospital. An educational note based on a Centers for Disease Control and Prevention (CDC) guideline for prudent use of vancomycin was prepared and placed in patient charts by a designated pharmacist. This intervention was tracked along with the medical staff's response to the note. In a one-year period, the rate of appropriate use of vancomycin increased from 59% to 80% (p < 0.01), whereas the number of care interventions involving vancomycin usage decreased by approximately 75%. A community hospital can promote appropriate use of antibiotics, in this case vancomycin. The fact that the rate at which vancomycin was appropriately prescribed increased and the number of pharmacist interventions (notes) decreased suggests that the vancomycin note reminders and related educational material were successful. Although these numbers do not represent 100% compliance, treatment with vancomycin may have been clinically appropriate for some of the cases even if the situation was not listed as an appropriate use in the CDC guideline. The vancomycin monitoring program, which represents a simple means of intervening and maintaining continuous monitoring and quality improvement in a clinical area, continues at the BJC North Region hospitals.

高齢者のＭＲＳＡ感染症に対するＶａｎｃｏｍｙｃｉｎ Ｈｙｄｒｏｃｈｌｏｒｉｄｅの使用法

Objectives: A dose of vancomycin should be reduced for treatment of methicillinresistant Staphylococcus aureus (MRSA) infections in elderly patients with decreased renal function to avoid nephrotoxicity and ototoxicity. By adjusting doses and dosing intervals with therapeutic drug monitoring (TDM), we studied the most appropriate use of vancomycin in 6 elderly patients with MRSA infections.Method: The dosage-regimen was as follows: Vancomycin was abministered intravenously over 60 min at a dose of 0.5 g, b.i.d. in all patients. The same dosage-regimen was maintained when the trough vancomycin concentration was less than 10 μg/ml on the 3rd day with TDM. If the trough concentration was≥10μg/ml, 0.5 g of vancomycin was given once daily. Three days after a change of dosing interval, the dose of vancomycin was reduced to 0.25 g if the trough concentration was≥10μg/ml with TDM, otherwise the second dosage-regimen was maintained. The primary endpoint was disappearance of MRSA and the second was improvement of clinical findings (CRP, body temperature, white cell count).Results: MRSA disappeared in all patients. Adjustment of the dosage-regimen was made in 4 out of 6 patients through the treatment. The global improvement rating was 83.3% in this study. Adverse events included the mild increase of serum GOT, GPT and ALP in only one patient. The values of these enzymes returned to normal range after cessation of the antibiotic without additional medical treatment.Conclusion: We recommend a dosage-regimen of vancomycin of 0.5 g, b.i.d. at the start of treatment of MRSA infections in elderly patients. TDM should be performed after steady-state vancomycin concentration is reached (usually 3 days after the start of treatment) in order to assure efficacy and safety of the antibiotic. Patients with decreased renal function (CLCR≤40 ml/min) should be treated with a much lower dose or a longer interval from the start of treatment, and TDM is strongly recommended for those patients.

Treatment and prevention of vancomycin-resistant enterococcus

Efforts to find antimicrobial agents which are effective against vancomycin-resistant enterococcus have been unsuccessful. One promising antibiotic, quinupristin/dalfopristin, has, however, been used with a success rate of approximately 60%. Other antibiotics are under investigation. Prevention is the best policy for the control of vancomycin-resistant enterococcus and includes contact isolation, the cohorting of patients, the appropriate use of vancomycin and education of patients and staff.