Empirical Use Of Vancomycin Research Articles

1130. Vancomycin Use in Pediatric Severe Sepsis at a Freestanding Children’s Hospital

BackgroundSurviving Sepsis Campaign guidelines recommend antibiotics be administered within 1 hour of severe sepsis (SS) onset, but do not suggest which agents to give. Vancomycin (VAN) is often chosen as empiric therapy for severe sepsis (SS) in children without evidence of the prevalence or risk factors for infections requiring VAN. As VAN is associated with significant nephrotoxicity, this study was performed to measure the risk-benefit ratio of empiric VAN use in pediatric sepsis.MethodsThis was a retrospective study of children with SS between 1/1/2015 to 6/30/2018 at the Women and Children’s Hospital of Buffalo, as captured by billing data and sent to state Department of Health for mandated reporting. SS cases were assessed for risk factors for Gram-positive infections, including presence of a central venous line (CVL) or other invasive device; history of MRSA infection or nasal colonization within the last 2 years; skilled nursing facility (SNF) residence; and prolonged hospitalization of >1 month. Invasive infections for which vancomycin is an optimal agent, specifically culture-proven methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative Staphylococcus (CoNS), and ampicillin-resistant Enterococcus infections, were defined as vancomycin requiring (VAN-req). Acute kidney injury (AKI) was defined as having a serum Creatinine of twice normal per age-related reference values.ResultsOf 304 identified SS cases, 8.9% had VAN-req infections. VAN was empirically given to 58.2% of cases (177); 86.4% ultimately did not have VAN-req infections. 9.2% of all SS cases had AKI at SS onset; this included 15.8% of patients (28) receiving VAN, of which only 1 (3.6%) had a VAN-req infection. History of a past MRSA infection, prolonged hospitalization, SNF residence, and CVL presence were found to be independent risk factors for a VAN-req infection (Table 1). VAN-req infections in patients lacking these four risk factors was 3.1% (4/130).ConclusionVAN was given empirically in the majority of pediatric SS cases, but culture-proven infections requiring the drug were infrequent, especially in patients without specific risk factors. The use of empiric VAN for SS should be guided by well-defined criteria, as the drug’s potential risks are likely to outweigh any benefit in most patients. Disclosures All authors: No reported disclosures.

2007. Impact of Combining Rapid Diagnostics with an Interpretation Guide on Vancomycin Usage for Contaminant Blood Cultures Growing Coagulase-Negative Staphylococci (CoNS)

BackgroundContaminant blood cultures can lead to unnecessary antibiotic use, longer admissions and increased costs. Rapid diagnostics, like the BioFire® FilmArray® Blood Culture Identification (BCID) Panel, can potentially lessen these harms. BioFire BCID was implemented at VA Greater Los Angeles in 7/2017. When providers review BCID results, they are also directed to an interpretation guide developed by our antimicrobial stewardship program. This study aimed to determine the impact of BioFire BCID with this interpretation guide on unnecessary vancomycin use for contaminant blood cultures growing CoNS.MethodsThis was a retrospective cohort study on adult inpatients with contaminant blood cultures positive for CoNS. We evaluated cases before BCID (April 2016–July 2017) and after BCID (July 7/2017–December 2018) implementation. Cases with patients who died or were discharged prior to preliminary results, polymicrobial cultures, no empiric vancomycin use, or where vancomycin was indicated were excluded. We defined a “case” as anytime a provider concurrently ordered blood cultures and empiric antibiotics. Our primary outcome was the duration of unnecessary vancomycin. Secondary outcomes were time to discontinuation/modification of any empiric antibiotic, length of stay (LOS), LOS in ICU and 30-day mortality.ResultsA total of 99 cases were included (N = 45 pre-BCID; N = 54 post-BCID). Demographics between the 2 groups were largely similar except the post-BCID group had more patients with end-stage renal disease (ESRD) (14 vs. 4, P = 0.037) and more frequent infectious disease (ID) consultation (21 vs. 8, P = 0.027). The post-BCID group had shorter mean duration of unnecessary vancomycin (53.0 hours vs. 38.1 hours, P = 0.0029). After controlling for ESRD and ID involvement, the mean duration of unnecessary vancomycin was not significantly different between the 2 groups (P = 0.30 and P = 0.49, respectively). There was no difference in time to modification/discontinuation of any empiric antibiotic (44.6 hr vs. 35.0 hr, P = 0.36). There was no difference in mean LOS, mean LOS in ICU, or 30-day mortality.ConclusionShorter duration of unnecessary vancomycin for CoNS bacteremia after BCID implementation and provision of an interpretation guide may have been driven in part by more frequent ID consultation.Disclosures All authors: No reported disclosures.

Shock and Early Death in Hematologic Patients with Febrile Neutropenia.

Empirical antibiotic therapy with a beta-lactam is the standard of care in febrile neutropenia (FN) and is given to prevent early death. The addition of vancomycin is recommended in certain circumstances, but the quality of evidence is low, reflecting the lack of clinical data. In order to characterize the epidemiology of early death and shock in FN, we reviewed all episodes of FN from 2003 to 2017 at University Hospital, Federal University of Rio de Janeiro, and looked at factors associated with shock at first fever and early death (within 3 days from first fever) by univariate and multivariate analyses. Among 1,305 episodes of FN, shock occurred in 42 episodes (3.2%) and early death in 15 (1.1%). Predictors of shock were bacteremia due to Escherichia coli (odds ratio [OR], 8.47; 95% confidence interval [95% CI], 4.08 to 17.55; P < 0.001), Enterobacter sp. (OR, 7.53; 95% CI, 1.60 to 35.33; P = 0.01), and Acinetobacter sp. (OR, 6.95; 95% CI, 1.49 to 32.36; P = 0.01). Factors associated with early death were non-Hodgkin's lymphoma (OR, 3.57; 95% CI, 1.18 to 10.73; P = 0.02), pneumonia (OR, 21.36; 95% CI, 5.72 to 79.72; P < 0.001), shock (OR, 11.64: 95% CI, 2.77 to 48.86; P = 0.01), and bacteremia due to Klebsiella pneumoniae (OR, 5.91; 95% CI, 1.11 to 31.47; P = 0.03). Adequate empirical antibiotic therapy was protective (OR, 0.23; 95% CI, 0.07 to 0.81; P = 0.02). Shock or early death was not associated with Gram-positive bacteremia; catheter-related, skin, or soft tissue infection; or inadequate Gram-positive coverage. These data challenge guideline recommendations for the empirical use of vancomycin at first fever in neutropenic patients.

Pilot Study of De-Implementation of Empiric Vancomycin Use in Surgical Inpatients

Chisholm, Leah; Robles, Jennifer MD; Marshall, Matthew PharmD; Nelson, George MD; Barocas, Daniel MD, MPH, FACS Author Information

First case report of bacteremia caused by Solobacterium moorei in China, and literature review

BackgroundSolobacterium moorei, the only species in the genus Solobacterium, is a Gram-positive, non-spore-forming, strict anaerobic, short to long bacillus. It has rarely been documented to cause blood stream infections. Here we report the first case of bacteremia caused by S.moorei in China.Case presentationA 61-year-old male presented to Peking Union Medical College Hospital (Beijing) with thrombotic thrombocytopenic purpura (TTP) and several other underlying diseases. He also had persistent coma accompanied by intermittent convulsions, halitosis, and intermittent fever. Blood cultures taken when the patient had a high fever were positive, with the anaerobic bottle yielding an organism identified as S.moorei by 16S rRNA gene sequencing, whilst the aerobic bottle grew Streptococcus mitis. After replacement of venous pipeline, and empirical use of vancomycin and meropenem, the patient’s body temperature and white blood cell count returned to normal. Unfortunately, the patient died of severe TTP.ConclusionThis is the first case report of S. moorei isolation from blood stream in China. 16S rRNA gene sequencing is the only method that can identify S. moorei. Blood cultures must be taken before administration of antibiotics, and anaerobic culture should be considered for such rare pathogens in patients with oral diseases and immune deficiency.

Effective vancomycin concentrations in children: a cross-sectional study.

ABSTRACTObjective Analyze the microbiological effectiveness, based on the pharmacokinetics/pharmacodynamics correlation of vancomycin in pediatric patients, and to propose dose adjustment.Methods This is an observational, cross-sectional study, conducted in a pediatric hospital, over a 1-year period (2016 to 2017). Children of both sexes, aged 2 to 12 years, were included in the study; burn children, and children in renal replacement therapy were excluded. For the pharmacokinetic analysis, two samples of 2mL of whole blood were collected, respecting the 2-hour interval between each withdrawal.Results Ten pediatric patients with median age of 5.5 years and interquartile range (IQR) of 3.2-9.0 years, median weight of 21kg (IQR: 15.5-24.0kg) and median height of 112.5cm (IQR: 95-133cm), were included. Only one child achieved trough concentrations between 10µg/mL and 15µg/mL.Conclusion The empirical use of vancomycin in the children studied did not achieve the therapeutic pharmacokinetic/pharmacodynamic target for minimum inhibitory concentration of 1µg/mL.

Vancomycin Should Be Part of Empiric Therapy for Suspected Bacterial Meningitis.

The use of empiric vancomycin plus a third-generation cephalosporin for suspected bacterial meningitis has been recommended since 1997. Although the prevalence of ceftriaxone-nonsusceptible pneumococcal meningitis has decreased, vancomycin should still be included as empiric therapy for bacterial meningitis.

329. Impact of the Biofire® Film Array (FA) Meningitis Encephalitis (ME) Panel in Colombia

BackgroundCentral nervous system (CNS) infections are associated with significant adverse clinical outcomes. Approximately 50% of all CNS infections are idiopathic. The impact of the Biofire® FAME in Colombia is unknown.MethodsA retrospective study of all adults with CNS infections in one tertiary hospital in Colombia. The cohort was divided into two time periods: before and after the implementation of the Biofire® FAME panel in May 2016. Etiologies, management decisions, and outcomes were compared between both groups. Data analysis was done with Stata® version 14.ResultsA total of 76 patients were enrolled. The majority of the patients (72.4%) were male with a median age of 40.9 years. The most common comorbidity was Human immunodeficiency virus (HIV) infection (47.4%); 54% were admitted to the intensive care unit (ICU) and 29% died. Out of the 76 patients, 33 and 43 were enrolled in the pre- and post-Biofire FAME testing periods, respectively. A diagnosis was made more commonly in the post-Biofire time period (13/33;39% vs. 27/43;63%, P < 0.05). The etiologies in the pre-Biofire group were Cryptococcus neoformans (6); bacterial meningitis (5) and tuberculosis (1) and varicella zoster (1); and the etiologies in the post-Biofire group were Cryptococcus neoformans (7), cytomegalovirus (CMV) (4); bacterial meningitis (4), tuberculosis (3), syphilis (3), ADEM (3), CNS vasculitis (1), and neurocysticercosis (1). The Biofire FAME panel was positive in 14 patients: C. neoformans (6), CMV (3), S. pneumoniae (2), Herpes simplex virus type 2 (2), H. influenzae (1) and N. meningitidis (1). In 12 out of those 14 patient (85%), a change in therapy occurred due to the FAME results (5 started therapy, four stopped therapy and threehad a change in therapy). Furthermore, patients in the post-Biofire FAME period had a reduction in the empirical use of vancomycin, meropenem and cefepime (P < 0.05). The Biofire FAME panel missed identifying one patient with Cryptococcus neoformans and one with CMV.ConclusionThe introduction of the Biofire FAME panel in a hospital with high HIV prevalence in Colombia has increased the yield of pathogens identified and have reduced the use of empirical antibiotic therapy. The Biofire FAME failed to identify one case of Cryptococcus neoformans and one due to CMV.Disclosures R. Hasbun, Biofire: Speaker’s Bureau, Speaker honorariumBiomeriaux: Consultant, Consulting fee.

Reducing inappropriate empiric vancomycin use in neutropenic fever.

290 Background: Neutropenic fever is an oncologic emergency associated with high morbidity and mortality, requiring prompt antibiotic initiation. National infectious disease and oncology guidelines do not recommend vancomycin for standard empiric therapy, unless used for certain evidence-based indications. At our institution, we observed inappropriate use of vancomycin for neutropenic fever and implemented an intervention to educate providers regarding appropriate indications. Methods: We conducted a series of educational sessions focused on the evidence-based indications for vancomycin use in neutropenic fever with residents, nurse practitioners, fellows, and attending physicians. We also displayed educational posters in work rooms and patient units. We conducted a retrospective chart review to assess the impact on vancomycin prescribing practices and patient outcomes pre-intervention (9/1/17 - 2/28/18) and post-intervention (3/1/18 - 5/24/18). We used descriptive statistics and chi-square tests to assess differences. Results: Vancomycin was frequently prescribed without an appropriate indication in the pre-intervention period. Both the overall use and the inappropriate use of vancomycin decreased significantly in the post-intervention period (Table 1). There was no significant difference in mean duration of fever (2.7 vs 2.1 days, p = 0.06) or length of stay (30 vs 34 days, p = 0.58) between the pre- and post-intervention groups, respectively, despite the reduction in vancomycin use. Conclusions: Multidisciplinary educational sessions reduced unnecessary vancomycin use as empiric treatment for neutropenic fever without adverse patient outcomes. This is a low resource intervention that can be applied to other healthcare settings. Future work will evaluate the effect on cost.[Table: see text]

Prospective Cohort Study of the Tolerability of Prosthetic Joint Infection Empirical Antimicrobial Therapy.

The empirical use of vancomycin in combination with a broad-spectrum beta-lactam is currently recommended after the initial surgery of prosthetic joint infection (PJI). However, the tolerability of such high-dose intravenous regimens is poorly known. Adult patients receiving an empirical antimicrobial therapy (EAT) for a PJI were enrolled in a prospective cohort study (2011 to 2016). EAT-related adverse events (AE) were described according to the common terminology criteria for AE (CTCAE), and their determinants were assessed by logistic regression and Kaplan-Meier curve analysis. The EAT of the 333 included patients (median age, 69.8 years; interquartile range [IQR], 59.3 to 79.1 years) mostly relies on vancomycin (n = 229, 68.8%), piperacillin-tazobactam (n = 131, 39.3%), and/or third-generation cephalosporins (n = 50, 15%). Forty-two patients (12.6%) experienced an EAT-related AE. Ten (20.4%) AE were severe (CTCAE grade ≥ 3). The use of vancomycin (odds ratio [OR], 6.9; 95% confidence interval [95%CI], 2.1 to 22.9), piperacillin-tazobactam (OR, 3.7; 95%CI, 1.8 to 7.2), or the combination of both (OR, 4.1; 95%CI, 2.1 to 8.2) were the only AE predictors. Acute kidney injury (AKI) was the most common AE (n = 25; 51.0% of AE) and was also associated with the use of the vancomycin and piperacillin-tazobactam combination (OR, 6.7; 95%CI, 2.6 to 17.3). A vancomycin plasma overexposure was noted in nine (37.5%) of the vancomycin-related AKIs only. Other vancomycin-based therapies were significantly less at risk for AE and AKI. The EAT of PJI is associated with an important rate of AE, linked with the use of the vancomycin and the piperacillin-tazobactam combination. These results corroborate recent findings suggesting a synergic toxicity of these drugs in comparison to vancomycin-cefepime, which remains to be evaluated in PJI. (This study has been registered at ClinicalTrials.gov under identifier NCT03010293.).

Decreasing Empiric Use of Vancomycin in Late Onset Sepsis: Adherence to Guidelines and Quality Improvement

Decreasing Empiric Use of Vancomycin in Late Onset Sepsis: Adherence to Guidelines and Quality Improvement

Effect of an intervention targeting inappropriate continued empirical parenteral vancomycin use: a quasi-experimental study in a region of high MRSA prevalence

BackgroundDespite vancomycin use is a major risk factor for the emergence of vancomycin resistance, it is frequently inappropriately prescribed, especially as empirical treatment. We evaluated the effect of an antimicrobial stewardship intervention targeting for inappropriate continued empirical vancomycin use.MethodsThis was a quasi-experimental study comparing vancomycin use in a 6-month pre-intervention and 6-month intervention period. If empirical vancomycin was continued for more than 96 h without documentation of beta-lactam-resistant gram-positive microorganisms, it was considered inappropriate continued empirical vancomycin use. The intervention consisted of the monitoring of appropriateness by a pharmacist and direct discussion with the prescribing physicians by infectious disease specialists when empirical vancomycin was continued inappropriately. An interrupted time series analysis was used to compare vancomycin use before and during the intervention.ResultsFollowing implementation of the intervention, overall vancomycin consumption decreased by 14.6%, from 37.6 defined daily doses (DDDs)/1000 patient-days in the pre-intervention period to 32.1 DDDs/1000 patient-days in the intervention period (P < 0.001). The inappropriate consumption of vancomycin also declined from 8.0 DDDs/1000 patient-days to 5.8 DDDs/1000 patient-days (P = 0.009).ConclusionInterventions such as direct communication with prescribing physicians and infectious disease clinicians can help reduce the inappropriate continued use of vancomycin.

Evaluating guideline adherence regarding empirical vancomycin use in patients with neutropenic fever

ObjectiveThe purpose of this study was to evaluate the use of empirical vancomycin for patients with neutropenic fever (NF) with regard to adherence to treatment guidelines. MethodsAdult patients with a diagnosis of neutropenia, who met the definition of NF as per treatment guidelines, were identified. Use of vancomycin was evaluated as part of empirical therapy and again after 72h. Outcomes were assessed using descriptive statistics, the Chi-square or Fisher’s exact test, and univariate exact logistic regression analyses. ResultsSixty-four patients were included. Overall, inappropriate empirical vancomycin use was observed in more than 30% of patients. Of 35 patients with indications for empirical vancomycin, only 68% received it. At 72h, appropriate vancomycin continuation, de-escalation, or discontinuation occurred in 21 of 33 patients. On univariate regression, hematological malignancy was associated with appropriate empirical vancomycin prescribing, whether initiating or withholding (odds ratio 4.0, 95% confidence interval 1.31–12.1). No variable was independently associated with inappropriate continuation at 72h. ConclusionsThere is poor guideline adherence to vancomycin prescribing as empirical therapy and at 72-h reassessment in patients with NF. Further efforts are needed to foster a more rational use of vancomycin in patients with NF.

Empirical use of vancomycin in neonates. Risks greater than benefits

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Bacterial Keratitis in Toronto: A 16-Year Review of the Microorganisms Isolated and the Resistance Patterns Observed.

To review the incidence, distribution, current trends, and resistance patterns of bacterial keratitis isolates in Toronto over the past 16 years. Microbiology records of suspected bacterial keratitis that underwent a diagnostic corneal scraping and cultures from January 1, 2000, through December 31, 2015, were retrospectively reviewed. The distribution of the main isolated pathogens and in vitro laboratory minimum inhibitory concentration testing results were used to identify resistance patterns. A total of 2330 corneal scrapings were taken over 16 years. A pathogen was recovered in 1335 samples (57.3%), with bacterial keratitis accounting for 1189 of the positive cultures (86.0% of all isolates). The total number of gram-positive and gram-negative isolates was 963 and 324, respectively. Coagulase-negative Staphylococcus and Pseudomonas aeruginosa were the most common gram-positive and gram-negative bacteria isolates, respectively. A decreasing trend in the number of isolates in gram-positive bacteria (P = 0.01), specifically among Staphylococcus aureus (P < 0.0001) and Streptococcus species (P = 0.005), was identified. When analyzing the susceptibilities of gram-positive and gram-negative isolates, an increasing trend in antibiotic resistance was observed in erythromycin (P = 0.018), ceftazidime (P = 0.046), and piperacillin/tazobactam (P = 0.005). The susceptibility of tested gram-positive microorganisms to vancomycin was 99.6%. There has been a decreasing trend in the number of isolates in gram-positive microorganisms over the past 16 years. An increasing trend in resistance for various antibiotics against gram-negative and gram-positive isolates was identified. High susceptibility to vancomycin reinforced the empirical use of fortified tobramycin and vancomycin in the initial management of severe bacterial keratitis.

High burden of complicated skin and soft tissue infections in the Indigenous population of Central Australia due to dominant Panton Valentine leucocidin clones ST93-MRSA and CC121-MSSA

BackgroundSuperficial skin and soft tissue infections (SSTIs) are common among the Indigenous population of the desert regions of Central Australia. However, the overall burden of disease and molecular epidemiology of Staphylococcus aureus complicated SSTIs has yet to be described in this unique population.MethodsAlice Springs Hospital (ASH) admission data was interrogated to establish the population incidence of SSTIs. A prospective observational study was conducted on a subset of S. aureus complicated SSTIs (carbuncles and furuncles requiring surgical intervention) presenting during a one month period to further characterize the clinical and molecular epidemiology. High resolution melting analysis was used for clonal complex discrimination. Real-time polymerase chain reaction identifying the lukF component of the Panton Valentine leucocidin (pvl) gene determined pvl status. Clinical and outcome data was obtained from the ASH medical and Northern Territory shared electronic health records.ResultsSSTIs represented 2.1% of ASH admissions during 2014. 82.6% occurred in Indigenous patients (n = 382) with an estimated incidence of 18.9 per 1, 000 people years compared to the non-Indigenous population of 2.9 per 1000, with an incident rate ratio of 6.6 (95% confidence interval 5.1–8.5). Clinical and molecular analysis was performed on 50 isolates from 47 patients. Community-associated methicillin-resistant S. aureus (CA-MRSA) predominated (57% of isolates). The high burden of SSTIs is partly explained by the prevalence of pvl positive strains of S. aureus (90% isolates) for both CA-MRSA and methicillin-susceptible S. aureus (MSSA). ST93-MRSA and CC121-MSSA were the most prevalent clones. SSTIs due to ST93-MRSA were more likely to require further debridement (p = 0.039), however they also more frequently received inactive antimicrobial therapy (p < 0.001).ConclusionsST93-MRSA and CC121-MSSA are the dominant causes of carbuncles and furuncles in Central Australia. Both of these virulent clones harbor pvl but the impact on clinical outcomes remains uncertain. The high prevalence of CA-MRSA supports empiric vancomycin use in this population when antimicrobial therapy is indicated. Prompt surgical intervention remains the cornerstone of treatment.

Empiric antibiotic regimens for neonatal sepsis in Australian and New Zealand neonatal intensive care units.

Neonatal sepsis remains an important cause of morbidity and mortality, and requires prompt empiric treatment. However, only a minority of babies who receive antibiotics for suspected sepsis have an infection. Antimicrobial exposure in infancy has important short- and long-term consequences. There is no consensus regarding empirical antimicrobial regimens. The study included a survey of empiric antimicrobial regimens in all tertiary neonatal intensive care units in Australia and New Zealand in 2013-2014. All 27 units responded. For early-onset sepsis, all units used a combination of gentamicin with either penicillin or ampicillin. For late-onset sepsis, the frequency of units using empiric vancomycin (41%) versus empiric flucloxacillin (48%) was similar. Gestational age or the presence of a central venous catheter had little influence on using vancomycin instead of flucloxacillin. For late-onset sepsis with meningitis there was marked variation in antimicrobial combinations, with 15 different regimens described. A total of 93% used a cefotaxime-based regimen, either as monotherapy (22%) or combined with a second (22%) or third (48%) agent. For suspected necrotising enterocolitis, 89% used an aminoglycoside, metronidazole and a penicillin. Historical outbreaks of multi-resistant organisms exerted long-term influence over regimen choice. There was limited use of broad-spectrum agents such as carbapenems or third-generation cephalosporins. In this region with low methicillin-resistant Staphylococcus aureus prevalence, empiric vancomycin use was common, selected for activity against coagulase-negative staphylococci. Empiric vancomycin is rarely necessary because coagulase-negative staphylococci are often contaminants and sepsis is rarely fulminant, occurring almost exclusively in extremely low birthweight infants. Implementation of appropriate, local antimicrobial policies is crucial to minimise antimicrobial exposure in this vulnerable population and halt the development of antimicrobial resistance.

Evaluation of a Second-Sign Process for Antimicrobial Prior Authorization.

A second-sign prospective restriction of select broad-spectrum antimicrobials was fully implemented in January 2015 as a pediatric antimicrobial stewardship program (ASP) initiative to help ensure the most appropriate empiric use of ceftaroline, cefepime, fidaxomicin, linezolid, and vancomycin (intravenous). The objective of this evaluation is to assess the effectiveness of a forced second-sign process in the electronic medical record as a pediatric ASP strategy. We anticipated that the second-sign process for antibiotics would increase the appropriateness of empiric antibiotic use, as defined by preapproved criteria, clinical pathways, national guidelines, and pediatric-specific infectious diseases reference texts, while not causing significant delay in the initial administration of antibiotic therapy. This was a retrospective before and after intervention chart review conducted from July 2014 to June 2015. The study was conducted at a 187-bed, freestanding teaching children's hospital that included the following: level-1 pediatric trauma center, 18-bed pediatric intensive care unit, and 32-bed neonatal intensive care unit. A total of 1178 orders were identified, and 389 met inclusion criteria. The vast majority of second-sign orders were for vancomycin (92%), 61% were written for males, and the median age was 6 years old. Appropriateness of second-sign restricted antibiotic use significantly increased after second-sign implementation (84.5% to 92.9%, P = .01). The secondary outcome of time from initial order entry to medication administration was not different between the before and after groups (median time, 184.5 [interquartile range, 110.25-280.75] vs 174 [interquartile range, 104-228] minutes; P = .342). The use of a second-sign approval process for antimicrobial restriction can lead to increased appropriateness of antibiotic use at a pediatric hospital, without causing a delay in administration.

Strategies to reduce infections and antibiotic use and its effects in a neonatal care unit

Late onset sepsis (LOS) remains an important cause of morbidity and mortality in neonatal intensive care units (NICU). The empirical use of vancomycin and other broad spectrum antibiotics is very frequent and is associated with the emergence of resistant agents, infection by gram-negative bacilli (GNB), fungal infections and increased morbidity and mortality. To evaluate the impact of 5 intervention protocols designed to reduce infections and promote the rational use of antibiotics (AB) in a single NICU. Retrospective analysis included all hospitalized patients before (year 2012) and after interventions (August 2013 through July 2014). All episodes of positive cultures (blood, urine, tracheal and spinal fluid) were considered as late onset infections. After intervention, a significant decrease of late onset infections was observed from 14.3 to 8.5 per 1,000 live births (p < 0.01); with a decrease in LOS from 5.7 to 2.9 per 1,000 live births, although no significant. There was a decrease in vancomycin and 3rd generation cephalosporin use without Candida spp infections in the intervention period. Mortality rates and length of hospital stay were similar in both study periods. After interventions, there was an important reduction in overall late onset infections and AB related costs.

Decreasing Vancomycin Utilization in the NICU by Optimizing Treatment Decisions in Suspected Late Onset Sepsis

BackgroundLate Onset Sepsis (LOS) is frequently suspected in NICU patients in the setting of nonspecific clinical symptoms. Based on institutional antibiogram data, empiric treatment of LOS in our NICU is vancomycin and amikacin with a plan to deescalate or discontinue based on culture results and symptomatology. Baseline data in our NICU revealed vancomycin overuse where vancomycin was continued past 48 hours of culture negativity, after Gram-negative urinary tract infection (UTI) was diagnosed, or for urine cultures reported with multiple organisms or < 10,000 CFU/mL. Our objective was to eliminate inappropriately prolonged empiric use of vancomycin for suspected LOS or UTI.MethodsTo institute timely discontinuation of vancomycin when cultures are negative at 48 hours, group education sessions were conducted for physicians, nurse practitioners, and nurses that included evidence-based criteria for diagnosing “true UTI”. Vancomycin indication for use and duration were added to the rounding script for the night shift.ResultsAt baseline over a 6 month period, extra vancomycin doses were administered in 39% of LOS courses, typically because late-night doses (past 48 hours culture negativity) preceded the decision to discontinue empiric therapy on morning rounds. After intervention, during a 6 month period, extra vancomycin doses were reduced to 3%. A baseline anonymous survey revealed that some prescribers advocated continuing vancomycin in the setting of urine cultures with < 10,000 CFU/mL (18%) or for Gram-negative UTI until sensitivities are reported (24%). After intervention, these were both reduced to 7%. At baseline over a 9 month review of UTI data, the use of vancomycin past 48 hours occurred in 86% of patients with negative or contaminated urine cultures (< 10,000 CFU/mL or > 1 organism) and in 48% of patients with Gram-negative UTI. In the post intervention phase, this occurred in 0% and 50% (N = 2) of cases respectively.ConclusionA high incidence of overtreatment with vancomycin was found to be related to inconsistent system processes and knowledge deficiencies. Through improved documentation, staff education and creation of evidence based guidelines for the diagnosis and management of UTI, we successfully minimized vancomycin overutilization for suspected LOS and UTI in the NICU.Disclosures All authors: No reported disclosures.