Appropriateness Of Vancomycin Use Research Articles

Appropriate use of vancomycin in a cardiac surgical unit

BackgroundAntibiotic resistance is a rapidly growing problem. Methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are major worries, particularly in developing nations where cost-effectiveness is essential. Use of vancomycin must be restricted to prevent resistant to it. Examining the appropriateness rate of vancomycin use in light of the recommendations of the Infectious Disease Society of America (IDSA) in the cardiac surgery ward was the aim of this study.MethodologyThis study was a retrospective analysis of the medical records of patients who received vancomycin over the previous year, from January 2023 to December 2023. The collected patient data included demographics, indications for vancomycin use, culture and sensitivity test results, concurrent antibiotic medications, vancomycin serum levels, and diagnoses. The appropriateness of vancomycin use was classified according to the recommendations of the Infectious Diseases Society of America (IDSA).ResultsA total of 294 patients received vancomycin. The appropriate use of vancomycin was significantly higher than its inappropriate use (p = 0.001). Approximately 41% (n = 120) of patients were administered vancomycin for treatment purposes, while the remainder received it empirically, but not as surgical prophylaxis. Appropriate use of vancomycin was observed in 89.1% (n = 262) of patients. However, there remained a notable rate of inappropriate vancomycin use (n = 32, 10.9%). The most common reason for inappropriate use was the continuation of vancomycin beyond 72 h without further evidence of a Gram-positive infection (n = 21, accounting for 65.6% of all inappropriate use).ConclusionsThe current study demonstrated that 89.1% of vancomycin use was appropriate, while approximately 10% was inappropriate, potentially contributing to vancomycin resistance. The majority of inappropriate use stems from frequent empirical prescribing, which requires further review and monitoring.

Appropriate Vancomycin Use and Incidence of Vancomycin-Resistant Enterococci in Liver Transplant Recipients

Liver transplant recipients (LTRs) are at risk for vancomycin-resistant Enterococcus (VRE) infections which can lead to significant morbidity or mortality. Antibiotic exposure, including vancomycin, is associated with greater risk of VRE infection. This study aimed to assess the appropriateness of vancomycin use and rates of VRE infection in this population. We performed a retrospective cohort study of 327 patients who underwent liver transplantation at our center from January 1, 2012 to June 30, 2017. Sixty (18.3%) LTRs had at least one VRE-positive culture between six-months pre-transplant and six-months post-transplant. LTRs with VRE had greater vancomycin exposure as compared to VRE-negative LTRs (p < 0.05) and were more likely to receive prolonged vancomycin courses (> 72 hours, p < 0.05). Overall appropriateness of vancomycin use > 72 hours among VRE-positive LTRs was only 26.8%. Inappropriate vancomycin use most commonly occurred in patients with presumed sepsis without an identifiable source or pneumonia with negative respiratory cultures. Our findings illustrate an opportunity to improve antibiotic stewardship and reduce vancomycin use in the transplant population

Evaluation of vancomycin use in university-affiliated hospitals in Southern Khorasan Province (East Iran) based on HICPAC guidelines.

BackgroundVancomycin resistance has raised concerns about its effectiveness prospect in the treatment of patients with Gram-positive infections. The Healthcare Infection Control Practices Advisory Committee (HICPAC) has recently established guidelines to delineate improper use of vancomycin. In this light, we sought out to determine the appropriateness of vancomycin prescription using the HICPAC guidelines.SettingThe study was carried out in two university-affiliated hospitals, Valiasr and Imam Reza, with 297 and 234 beds, respectively, from May 2012 to May 2013.MethodsThis retrospective study evaluated the vancomycin prescription and usage in the hospitals. Total vancomycin use was determined and expressed as vancomycin courses per 298 admitted patients. The patient information was collected on a data collection sheet as follows: demographic variables, etiology and localization of infection, microbiological data, duration of vancomycin treatment, reasons for vancomycin prescription, prescribed antibiotic dosing, and patient regimen.ResultsThe average age of the patients and vancomycin treatment duration were 55.965 years and 10.5 days, respectively. Septicemia (15.7%) was the most common cause of vancomycin administration. Vancomycin use was documented to be appropriate and inappropriate in 236 (89.4%) and 28 (10.6%) patients, respectively. No statistically significant differences were found among the wards and hospitals (P values =0.66 and 0.54, respectively) in terms of appropriateness of vancomycin use based on the HICPAC criteria. In addition, 29.21% and 62% of all patients exhibited complete and partial recovery, respectively. We found that 90% of the cases showed compliance with the HICPAC recommendations.ConclusionComprehensive programs are required to improve the vancomycin use in the hospitals. Vancomycin use should be monitored due to its large-scale empiric use. The rate of improper use of vancomycin in the infection and intensive care unit services may be high, and pharmacists must take appropriate action to optimize the use of the drug.

Evaluation of vancomycin therapy in the adult ICUs of a teaching hospital in southern Iran.

BackgroundVancomycin resistance in intensive care units (ICUs) accounts for significant morbidity and excess costs. The objective of the present study was to determine the appropriateness of vancomycin use in the various ICUs of Nemazee Hospital, Shiraz, Iran.MethodsThis prospective study was performed on 95 critically ill patients (48 males and 47 females) who were treated with vancomycin for at least 3 subsequent doses in 6 ICUs during 12 months. Required demographic, clinical, and paraclinical data were collected by a pharmacist. Fifteen indexes were considered for evaluation of vancomycin use.ResultsVentilator-associated hospital-acquired pneumonia (22.6%), sepsis (22.1%) and CNS infection (12.6%) were found to be the most important indications for vancomycin prescription. Vancomycin was prescribed empirically in 81% of patients. None of the patients received loading dose, and most of the patients received fixed dose. The rate of prolonged empiric antibiotic therapy was 68.5% in patients who received vancomycin. The mean score of vancomycin use in the ICUs of Nemazee Hospital was 7.1±0.6 out of 15, implying that the rate of vancomycin use was in accordance with the guideline proposed by the Department of Clinical Pharmacy of Nemazee Hospital based on Infectious Diseases Society of America by 47.3%.ConclusionBased on our results, the weakness in using vancomycin was related to not administering loading dose, the practice of prescribing fixed-dose vancomycin and prolonged duration of empiric therapy. Efforts to improve the pattern of vancomycin prescription and utilization in these ICUs should be undertaken.

Vancomycin use, dosing and serum trough concentrations in the pediatric population: a retrospective institutional review.

Background:Vancomycin is used primarily for Gram-positive infections. Recommended dosage regimens and targeted therapeutic levels vary between institutions.Objectives:This study aims to describe therapeutic levels according to initial vancomycin doses and patient’s age. A secondary objective was to evaluate appropriateness of vancomycin use in our hospital.Methods:A retrospective chart review was conducted at the Children’s Hospital of Eastern Ontario. Patients included in this study were classified by age (neonates, infants, children and adolescents) and categorized into those who received vancomycin ≤5 and >5 days. Initial vancomycin dosing regimens and corresponding initial trough levels obtained were evaluated. Initial trough levels drawn in relation to the third, fourth, or fifth doses corresponding to the first course of therapy were analyzed. Acceptable trough levels ranged from 5-20 mg/L.Results:One-hundred-and-sixty-four patients who received intravenous vancomycin in 2013 were included. Of the 229 courses of vancomycin, 190 (83%) were used 5 days or less (mean 4.9 days). Sixteen infants (88.9%) and 21 adolescents (100%), who received vancomycin empiric dosing of 60 mg/kg/day, had initial trough levels >5mg/L. However, in the children’s group 20 (37.7%) did not reach levels >5 mg/L. None of vancomycin minimum inhibitory concentration (MIC) values were >1mg/L for the four patients who had infections due to methicillin-resistant Staphylococcus aureus strains.Conclusions:In our institution, initial empiric vancomycin dosing of 60 mg/kg/day resulted in levels ≥5mg/L in most infants and adolescents. It remains unclear why some children aged 1-12 years did not achieve these levels.

Vancomycin Use in Patients Discharged From the Emergency Department: A Retrospective Observational Cohort Study

BackgroundInfections due to methicillin-resistant Staphylococcus aureus (MRSA) are associated with significant morbidity and mortality and are typically treated with intravenous vancomycin. Given vancomycin's time-dependent mechanism of action, it is unlikely that vancomycin administration in the emergency department (ED) prior to disposition home could be beneficial. Study ObjectivesTo characterize the indications, dosing, and appropriateness of vancomycin use in patients discharged from the ED. MethodsThis is a single-center retrospective observational cohort study of patients who received vancomycin in an urban, academic, tertiary care ED. The subjects were consecutive adult patients administered intravenous vancomycin in the ED and then discharged home over an 18-month period. Outcomes were measured 1) to characterize patients receiving vancomycin prior to discharge home from the ED; and 2) to identify patients that did not meet indications for appropriate use based on the 2011 Infectious Diseases Society of America guidelines for treating MRSA infections. ResultsThere were 526 patients that received vancomycin in the ED prior to discharge during the study period. In this cohort, 368 (70%) patients were diagnosed with skin and soft tissue infections. A MRSA risk factor was present in 396 (75%) patients. Prior to discharge, one dose of vancomycin was administered to 357 (68%) patients. Underdosing of vancomycin occurred in 239 (73%) patients. ConclusionsVancomycin was given frequently to patients discharged home from the ED, most commonly for conditions where vancomycin was not indicated, such as skin and soft tissue infections. The majority of these patients received a vancomycin dosing strategy that is not only unlikely to lead to clinical improvement, but also has the potential to contribute adversely to the development of antibiotic resistance. Further investigation is needed into the impact of vancomycin use, the emergence of vancomycin resistance, and the role of ED-based antibiotic stewardship.

Assessment of vancomycin use in chronic haemodialysis patients: room for improvement

Vancomycin is frequently prescribed for the management of infections in haemodialysis patients. We evaluated the appropriateness of vancomycin use in our chronic haemodialysis population. Charts of all chronic haemodialysis patients who received vancomycin between 1 March 2003 and 1 March 2004 were retrospectively reviewed. Indication was assessed according to the modified Hospital Infection Control Practices Advisory Committee guidelines for vancomycin prescription. The prescribed dosing regimens were evaluated. A total of 163 courses of vancomycin in 105 patients were assessed. Of all courses, 88% were considered to be initially appropriate, but this decreased to 63% once culture and sensitivity results were available. Use of vancomycin for the management of beta-lactam-sensitive organisms accounted for the majority of inappropriate use. The most common vancomycin-dosing regimen prescribed was 500 mg intravenously at each haemodialysis session (51%); however, considerable variability was observed. Although the initial indication for vancomycin use was generally appropriate, inappropriate continuation of this antibiotic, failure to obtain proper cultures to guide therapy and potentially subtherapeutic dosing regimens were some of the challenges identified. Centres providing chronic haemodialysis should take steps to optimize vancomycin prescription to improve clinical outcomes and reduce the risk of antimicrobial resistance.

Analysis of vancomycin use and associated risk factors in a university teaching hospital: a prospective cohort study

BackgroundVancomycin use is considered inappropriate in most hospitals. A particular concern is the recent emergence of S. aureus with decreased susceptibility to vancomycin, making it important to reduce overall exposure to vancomycin to minimize the incidence of VRE (vancomycin-resistant enterococci). The aim of this work was to analyze the use of vancomycin and the risk factors associated with inappropriate treatment.MethodsA prospective survey was conducted on all patients receiving vancomycin between 1st March 2002 and 30th September 2002 in a university-school hospital. Appropriateness of vancomycin use was assessed, according to the criteria established by the Centers for Disease Control and Prevention (CDC), at two time points: first, at the beginning of therapy, and second, continuing after 72 hours.ResultsA total of 557 patients received vancomycin. Three hundred seventy-four (67.1%) were under 60 years old, 374 (67.1%) had prolonged stays (>two weeks) in hospital, and 455 (81.7%) were in the intensive care unit (ICU). Two hundred sixty-three patients (47.2%) had some invasive device. In 324 (58.2%) patients the duration of vancomycin treatment was up to two weeks. Vancomycin was inappropriately used in 65.7% during the first 24 hours and in 67% at the 72 hours point according to CDC criteria [4]. The inappropriateness of vancomycin use during the first 24 hours was related to: patients aged less than 60 (OR 1.7; CI 95% 1.1–2.5), non-ICU patients (OR 1.5; CI 95% 1.0–2.4) and patients without neutropenia (OR 7.5; CI 95% 2.4–22.7). At 72 hours, the inappropriateness of vancomycin use was related to: patients aged less than 60 (OR 1.5; CI 95% 1.0–2.3), non-ICU patients (OR 1.7; CI 95% 1.1–2.7) and patients without neutropenia (OR 8.0; CI 95% 2.6–24.3).ConclusionVancomycin was abused. Patients aged less than 60, non-ICU patients and those who did not present neutropenia were the principal groups at risk of inappropriate use.

An Antibiotic Order Form Intervention Does Not Improve or Reduce Vancomycin Use

To determine whether a paper-based antibiotic ordering system is an effective antibiotic stewardship measure. An antibiotic order form (AOF) was introduced in July 2001 at a pediatric tertiary care hospital. Vancomycin courses prescribed before and after the AOF introduction were retrospectively reviewed based on Hospital Infection Control Practices Advisory Committee guidelines. The impact of the AOF on the appropriateness of vancomycin prescribing was evaluated in univariate and multivariable analyses that adjusted for other factors associated with appropriateness of vancomycin use. The density of vancomycin use after introduction of the AOF was also assessed. Compliance with the AOF was poor (<50%) during the planned study period; therefore an additional 2 months of improved compliance (70-80%) were included. Rates of inappropriate vancomycin use increased during the study periods: 35% before AOF; 39% post-AOF; and 51% during the improved compliance period. On adjusted analysis, vancomycin utilization was significantly more inappropriate after introduction of the AOF. Vancomycin doses per 1000 patient days increased after introduction of the AOF. Inappropriate vancomycin use and vancomycin use overall increased after the introduction of an AOF. An AOF intervention did not have its intended effect of improving and reducing vancomycin use.

Risk factors for acquisition of vancomycin-resistant enterococci among patients on a renal ward during a community hospital outbreak

Background: During an outbreak of vancomycin-resistant enterococcal (VRE) infection and colonization at a community hospital in Indianapolis, Indiana, we performed a case-control study of patients on the hospital's renal unit to determine risk factors for acquisition of VRE among this potentially high-risk patient population. Methods: Twenty-four renal patients with VRE colonization/infection (ie, case-patients) were compared by univariate and multivariate analyses with 29 renal patients with nosocomially acquired vancomycin-susceptible enterococcal infection and colonization (ie, controls). Results: Age and length of hospitalization were similar between the VRE case-patients and the vancomycin-susceptible enterococcal control-patients, but case-patients had higher Acute Physiology and Chronic Health Evaluation II scores and received significantly greater numbers of antimicrobials and significantly more days of antimicrobials during the 60 days preceding the first positive enterococcal culture. In an assessment of the appropriateness of vancomycin use, one third of vancomycin orders were found to be inappropriate in both patient groups. Conclusions: Our data show that among renal patients, those who are severely ill and receive multiple and prolonged courses of antimicrobials are at greatest risk for acquiring VRE infection or colonization. The Centers for Disease Control and Prevention recommends that hospitals develop a comprehensive plan to prevent and control infection and colonization of patients with VRE. This plan should include prompt identification of affected patients, initiation of isolation precautions to prevent patient-to-patient transmission of VRE, and prudent use of antimicrobials, including vancomycin. (AJIC Am J Infect Control 2000;28:282-5)

Practical guidelines for vancomycin usage, with prospective drug-utilization evaluation.

To strengthen guidelines for vancomycin use, practical guidelines were developed. A prospective survey was conducted of all patients receiving vancomycin during two 1-month periods, 1 year apart, during which significant improvements were noted. Practical guidelines may contribute to appropriateness of vancomycin use, serve as educational tools, and facilitate improved surveillance.

Vancomycin use in pediatric neurosurgery patients

Objective: The objective of this article is to describe a pediatric neurosurgery patient population receiving vancomycin and examine the indications for and appropriateness of vancomycin use. Methods: A cross-sectional study was performed on the pediatric neurosurgery patients at Egleston Children’s Hospital who received vancomycin from January 1 through December 31, 1996. Vancomycin use was compared with the Centers for Disease Control and Prevention Hospital Infection Control Practices Advisory Committee recommendations for vancomycin use. Results: Thirty patients received 115 doses of vancomycin. The median patient age was 8.0 years, and 17 (56.7%) were male. Vancomycin was used for prophylaxis in 28 (93.3%) patients and empiric therapy in 3 (10.0%) patients; one patient received vancomycin for surgical prophylaxis followed by empiric therapy for suspected meningitis. Vancomycin prophylaxis was initiated after the incision in 6 (21.4%) patients and was continued as prophylaxis for more than one dose in 26 (92.9%) patients. Conclusions: Vancomycin was used primarily as surgical prophylaxis in pediatric neurosurgery patients, and use was not consistent with the Hospital Infection Control Practices Advisory Committee recommendations. These data suggest that for certain subpopulations, such as pediatric neurosurgery patients, there is a need for more specialized recommendations. Furthermore, prudent vancomycin use is warranted to successfully decrease the risk of further emergence of vancomycin resistance. Because vancomycin use may be prevalent in this population, assessment of vancomycin use in pediatric neurosurgery patients followed by establishment of vancomycin clinical guidelines may help improve the appropriateness of vancomycin use in this population. (AJIC Am J Infect Control 1999;27:482-7)

Vancomycin use in pediatric cardiothoracic surgery patients.

Vancomycin use in pediatric cardiothoracic surgery patients.

Improving the appropriateness of vancomycin use by sequential interventions

Background: Vancomycin usage is directly associated with the incidence of vancomycin-resistant enterococci. Optimal methods to reduce inappropriate use have not been delineated. We determined the appropriateness of vancomycin prescribing at our hospital on the basis of national guidelines and assessed the effect of sequential administrative and educational interventions. Methods: In this prospective 3-phase study conducted in a Veterans Affairs Medical Center, we monitored vancomycin prescribing at baseline and in 2 follow-up periods. Administrative interventions included discussions with service chiefs and revising routine perioperative antibiotic prophylaxis orders. Educational interventions included in-services about vancomycin-resistant enterococci and appropriate vancomycin prescribing. In each monitoring period, 50 consecutive new vancomycin orders that could be evaluated were classified for appropriateness and categorized by indication. Results: At baseline, 70% of vancomycin use was inappropriate. Surgical services accounted for 84% of orders. Interventions targeted services with high or frequently inappropriate vancomycin use. After administrative interventions, inappropriate vancomycin use dropped to 40% of orders ( P = .003). Improvements were noted in targeted services. Educational interventions further decreased inappropriate vancomycin use, but the effect appeared transient. Conclusions: The simple, nonrestrictive administrative interventions used resulted in a statistically significant (30%) reduction in inappropriate vancomycin prescribing. However, educational interventions provided only transient benefit on institutional prescribing patterns. (AJIC Am J Infect Control 1999;27:84-90)

Appropriateness of Vancomycin Use in the Emergency Department

Study objective: The emergence of vancomycin-resistant organisms is a major problem at many hospitals. Vancomycin use is associated with development of resistance. The objective of this study was to determine the appropriateness of vancomycin use in the emergency department. In addition, we sought to determine whether appropriateness of vancomycin use increased after the publication of the Centers for Disease Control and Prevention guidelines for prudent vancomycin use. Methods: This retrospective study was conducted at a tertiary care university hospital, and all patients who received vancomycin while in the ED during the first 6 months of each year from 1995–1997 were eligible for study. We developed appropriateness criteria based on national and local guidelines. Vancomycin use was determined to be appropriate or inappropriate according to these guidelines. Results: Vancomycin use increased each year of the 3-year study period; 40% of use was considered inappropriate. However, appropriateness increased in a linear fashion ( P <.001). A resistant organism was cultured from 17% of those with appropriate use and none of those with inappropriate use. Most patients, regardless of the appropriateness of drug use, continued to receive vancomycin after admission. Conclusion: Overall vancomycin use rose each year despite an increase in the proportion with appropriate use. However, inappropriate use remained common. Emergency physicians and consultants should become familiar with national and local guidelines for prudent vancomycin use.[Wright SW, Wrenn KD: Appropriateness of vancomycin use in the emergency department. Ann Emerg Med November 1998;32:531-536.]