Prophylactic Use Of Vancomycin Research Articles

In at-risk patients, does the use of prophylactic vancomycin decrease the rate of Clostridium difficile infections?

In at-risk patients, does the use of prophylactic vancomycin decrease the rate of Clostridium difficile infections?

Vancomycin Concentrations in Paraspinal Muscles During Posterior Spinal Fusions for Neuromuscular Scoliosis

Study DesignProspective consecutively enrolled cohort. ObjectivesTo evaluate paraspinal muscle concentration of intravenously administered vancomycin, at predetermined time points, during posterior spinal fusion (PSF) with instrumentation in neuromuscular scoliosis (NMS). SummarySurgical site infection (SSI) after PSF for NMS can be a devastating complication, which may lead to prolonged antibiotic use, multiple additional surgical procedures, pseudarthroses, and sepsis. Because of significant morbidity of SSIs in NMS, the prophylactic use of vancomycin has been adopted at our institution as standard wound prophylaxis, despite any high-level evidence of its efficacy. MethodsA prospective study of 20 patients who underwent definitive PSF for NMS and received vancomycin infusion preoperatively per institutional protocol. Serum levels were obtained immediately after infusion, at surgical incision, and then at 1, 2, and 4 hours post incision. Muscle tissue samples were simultaneously obtained at incision and at 1, 2, and 4 hours post incision. Samples were analyzed by a validated liquid chromatography–tandem mass spectrometry method. Results10 males and 10 females with a mean age of 14+11 years (9–20 years) received a mean infusion of 15.0 mg/kg vancomycin. Mean serum levels were 26.7 μg/mL after infusion, 18.1 at incision, 13.2 at 1 hour, 11.8 at 2 hours, and 7.6 at 4 hours post infusion. Mean muscle levels were 0.5 μg/mL at incision, 0.6 at 1 hour, 0.5 at 2 hours, and 0.7 at 4 hours post infusion. Mean serum levels reached minimum inhibitory concentration (MIC) for Staphylococcus aureus at incision and at all timepoints during surgery. Mean muscle vancomycin levels never reached MIC. No patients had any cardiac or kidney disease, and all patients had normal kidney function according to their preoperative laboratory values. ConclusionsUsing accepted guidelines for the administration of intravenous vancomycin preoperatively, serum levels reached MIC at incision and at all timepoints tested during PSF for neuromuscular scoliosis. At no timepoint tested did muscle levels reach MIC. Level of EvidenceLevel II.

In vitro susceptibility of Propionibacterium acnes to simulated intrawound vancomycin concentrations

BackgroundThere is convincing evidence supporting the prophylactic use of intrawound vancomycin powder in spinal fusion surgery and mounting evidence in the arthroplasty literature suggesting that it can reduce surgical site infections. As a result, a number of shoulder arthroplasty surgeons have adopted this practice, despite a paucity of evidence and the presence of a pathogen that is, for the most part, unique to this area of the body—Propionibacterium acnes. The purpose of this study was to evaluate the efficacy of vancomycin against planktonic P. acnes in vitro, using time-dependent concentrations one would expect in vivo after intra-articular application.MethodsIntrawound vancomycin concentrations were interpolated and extrapolated from existing in vivo data. Planktonic P. acnes was then subjected to a time-kill analysis during 96 hours. At each time point, the inoculum was centrifuged into pellet form and then reconstituted for serial drop counts onto blood agar plates. After anaerobic incubation, colony-forming units were counted, and log10 colony-forming units per milliliter were determined.ResultsEarly time points grew to confluence, and thus colony-forming units per milliliter were not calculated. However, at 12 hours of vancomycin treatment, distinct colonies were appreciated. Notably, there was a 3 × log10 reduction in colony-forming units per milliliter between 12 and 48 hours, denoting bactericidal activity. In addition, P. acnes was completely eradicated after 3 days of treatment.ConclusionWhen administered in a fashion meant to simulate time-dependent in vivo intrawound concentrations, vancomycin exhibited bactericidal activity against P. acnes. This may lend credence to the prophylactic use of vancomycin in shoulder surgery.

Impact of Vancomycin Surgical Antibiotic Prophylaxis on the Development of Methicillin-Sensitive Staphylococcus aureus Surgical Site Infections

To compare risks for developing surgical site infection (SSI) due to Staphylococcus aureus when vancomycin is used for antibiotic prophylaxis with risks when a β-lactam antibiotic is administered for prophylaxis. Vancomycin is often used as surgical antibiotic prophylaxis for major surgery. In nonsurgical populations, there is evidence that vancomycin is less effective for prevention and treatment of methicillin-sensitive Staphylococcus aureus (MSSA) infections. Since 2002, the Victorian Healthcare Associated Surveillance System (VICNISS) has used standardized methods for infection surveillance in Australia, including any prophylactic antibiotic agent administered before surgical procedures. Surveillance records were obtained for patients undergoing 4 clean surgical procedures during the period of November 2002 to June 2009. Logistic regression analysis was used to examine risk factors for infection, including age, procedure duration, American Society of Anesthesiologists score, and choice and timing of antibiotic prophylaxis. The data set consisted of 22,549 procedures, including cardiac bypass and hip and knee arthroplasty procedures. Vancomycin prophylaxis was administered in 1610 cases and a β-lactam antibiotic for 20,939 cases. A total of 754 SSIs were recorded. The most frequent pathogens were MSSA, methicillin-resistant Staphylococcus aureus, and Pseudomonas species. The adjusted odds ratio (OR) for an SSI with MSSA was 2.79, where vancomycin prophylaxis was administered (P < 0.001). For methicillin-resistant Staphylococcus aureus infection, the adjusted OR for vancomycin was 0.44 (P = 0.05), whereas for Pseudomonas infection, it was 0.96 (P = 0.95). In a large Australian study population, prophylaxis with vancomycin was found to be associated with an increased risk of SSI due to MSSA when compared with prophylaxis with a β-lactam antibiotic. Given the potential for poorer surgical outcomes in the setting of indiscriminate prophylactic vancomycin use, measures to improve adherence to guidelines for restricted administration of prophylactic vancomycin are supported.

Antibiotic prophylaxis for cardiac surgery in Australia

To evaluate national practice for antibiotic prophylaxis in cardiac surgery with respect to the use of protocols, agent selection and duration of administration. Two point-prevalence surveys of intensive care units in 24 public and 27 private hospitals performing cardiac surgery in Australia, conducted in 2004 and 2008, using a structured telephone questionnaire of the attending senior intensive care clinician in each unit. Existence of a protocol in the unit for antibiotic prophylaxis, specific antibiotic agents used and their duration of administration. Between 2004 and 2008, reported protocol use increased from 58% to 80% (P = 0.02), while concordance with version 13 of the Australian Therapeutic guidelines: antibiotic for both choice of agent and timing (duration of administration) remained around 10%. Use of multiple agents was common, as was continued antibiotic administration after completion of surgery. Over 4 years, the proportion of cardiac surgical units reporting vancomycin administration for routine valve surgery prophylaxis doubled to 62% (P < 0.001). Despite an increase in reported protocol use for antibiotic prophylaxis in cardiac surgery, concordance with national antibiotic guidelines remained low, with duration of antibiotic administration deviating most from recommendations. Prophylactic vancomycin use appears to have increased substantially in recent years. Clinical implementation of recommended perioperative cardiac surgical antibiotic prophylaxis may not occur until supported by evidence from either a large prospective randomised study or standardised national surveillance of cardiac surgical site infection rates.

Prophylactic use of vancomycin in adult cardiology and cardiac surgery.

The recent appearance of Staphylococcus aureus and Staphylococcus epidermidis strains that have reduced susceptibility to vancomycin, and the spread of vancomycin-resistant enterococci, raise the specter of endovascular infections that will be difficult or impossible to cure with available drugs. We review issues concerning the prophylactic use of vancomycin in adult cardiology and cardiac surgery with special attention to dosing and indications. There is no indication for the routine use of prophylactic vancomycin in pacemaker implantations, cardiac catheterization, and transesophageal echocardiography. In institutions with a high incidence of methicillin-resistant S. aureus and S. epidermidis, vancomycin may be used for antibiotic prophylaxis in place of cephalosporins for pacemaker or defibrillator implantation. The strongest evidence in support of the prophylactic use of vancomycin is during cardiac surgeries, particularly valvular surgeries in institutions with a high prevalence of methicillin-resistant S. aureus and S. epidermidis. When vancomycin is used prior to open heart surgery, the dose should be 15 mg/kg rather than the standard 1 g dose that is often recommended in the literature and used by 85% of institutional pharmacists who responded to our survey. Cardiologists and cardiac surgeons should assume leadership roles in promoting its responsible use.

Vancomycin usage in central venous catheters in a neonatal intensive care unit.

We previously reported that vancomycin in hyperalimentation solution reduces catheter-related infections in the neonatal intensive care unit. Since June 1993 vancomycin (25 microg/ml) was routinely added to central venous catheter solutions, primarily hyperalimentation solution. Because the prophylactic use of vancomycin could lead to the emergence of resistant organisms, the decision to discontinue this practice was made in April of 1999. The use of vancomycin was reserved for documented infections with vancomycin-susceptible organisms. To compare catheter longevity, rate of laboratory-confirmed blood stream infections and total vancomycin exposure between two 18-month periods before and after the cessation of prophylactic vancomycin use. Data were evaluated for every neonate in whom a percutaneous central venous catheter was placed. There were 394 neonates enrolled. No statistically significant difference was identified between the two periods regarding the mean catheter days or number of catheters per patient. There was a higher rate of Gram-negative laboratory-confirmed blood stream infections during Period I in patients with percutaneous central venous catheters in place. There were more isolates of coagulase-negative staphylococci in Period II, resulting in more frequent vancomycin therapy institution and thus an overall increase in the amount of vancomycin used in that period Discontinuing the use of prophylactic vancomycin resulted in exposure of fewer neonates to vancomycin but a higher total amount of vancomycin used. The impact of low dose widespread exposure to vancomycin vs. high dose limited exposure on the microbiologic flora in the neonatal intensive care unit should be further examined.

Effect of prophylactic antibiotics on antimicrobial resistance of viridans streptococci in the normal flora of cataract surgery patients

Purpose: To evaluate the effect of prophylactic treatment including vancomycin in the irrigating solution and topical chloramphenicol on antimicrobial resistance in viridans-group streptococci in the normal flora of patients having cataract surgery. Setting: Department of Ophthalmology, Turku University Central Hospital and Antimicrobial Research Laboratory, National Public Health Institute, Turku, Finland. Methods: Minimal inhibitory concentrations (MICs) of 15 antimicrobials were determined for 529 viridans streptococci isolated from throat, nasopharyngeal, and conjunctival swabs of 23 patients on 4 sampling occasions: before cataract surgery and 1 day, 1 month, and 3 months after surgery. Resistance mechanisms of erythromycin-resistant isolates were studied by the double-disk test and polymerase chain reaction of resistance genes. Results: No statistically significant changes occurred in the proportions of isolates with elevated MICs between different sampling occasions. Resistance to vancomycin or chloramphenicol was not found. Resistance to tetracycline, erythromycin, penicillin, quinupristin–dalfopristin, clindamycin, levofloxacin, and moxifloxacin was found on different sampling occasions in 27.9% to 38.7%, 13.1% to 21.8%, 11.5% to 19.4%, 8.9% to 16.9%, 2.3% to 5.6%, 0% to 2.4%, and 0% to 2.2% of the isolates, respectively. Of the erythromycin-resistant isolates, 80.8% had the M phenotype and mefA gene and 19.2% has the macrolide–lincosamide–streptogramin B phenotype and ermB gene. Conclusions: Development of resistance of viridans streptococci in the normal flora to vancomycin and chloramphenicol during prophylactic use with uneventful cataract surgery is unlikely; the effect on resistance patterns of other antimicrobials is minor. Routine use of prophylactic vancomycin is discouraged, however, because of the lack of scientific proof of its efficacy in preventing postoperative endophthalmitis.

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.

Gram positive infection in trauma patients: new strategies to decrease emerging Gram-positive resistance and vancomycin toxicity

Bacterial resistance to antibiotics has become a serious problem in medicine. Particularly worrisome is the increasing incidence of multi-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). Not surprisingly, in view of the high incidence of life-threatening infections and heavy antibiotic use, resistance has become very frequent and problematic in intensive care units. The standard approach for the treatment of MRSA is vancomycin or teicoplanin. Long-term therapeutic and unrestricted prophylactic use of vancomycin has given rise to VRE which in turn may lead to the emergence of vancomycin-resistant S. aureus (VRSA) through plasmid mediated transmission. In order to reduce the incidence of VRE and to avoid the emergence of VRSA, vancomycin use should be restricted and alternative antibiotic strategies should be developed. Using those antibiotics to which MRSA are still generally sensitive, perhaps in combination with new ones, such as, quinupristin/dalfopristin, should be entertained. We performed a retrospective review of the Gram-positive infections in our Level 1 Trauma Center Intensive Care Unit, and an analysis of the resistance patterns of the NMSA infections showed that additional resistance rarely develops within less than 5 days. We then designed a new strategy for the treatment of MRSA infections. This strategy consists of the sequential use of a range of antibiotics with activity against MRSA in short 5–7 day pulses until the full clinical course is completed. Studies validating the benefit of this approach are currently in preparation.

Reduction of Vancomycin Use in Orthopedic Patients With a History of Antibiotic Allergy

To reduce prophylactic vancomycin use in patients with a history of penicillin or cephalosporin allergy undergoing elective orthopedic surgery by using a targeted allergy consultation and penicillin allergy skin testing. The participants in this practice improvement study were patients with a history of penicillin or cephalosporin allergy who were scheduled for elective orthopedic surgery and referred by orthopedic surgeons for allergy consultation and penicillin allergy skin testing between September 22, 1998, and April 15, 1999. The primary outcome measure was the percentage of participants who received prophylactic cefazolin during the study period compared with historical controls. Of the 60 study patients, 59 received a penicillin allergy skin test, 58 underwent orthopedic surgery, and 55 received antibiotic prophylaxis. Fifty-five patients had a history of allergy to penicillin, a cephalosporin, or both, and 5 had a history of nonspecific antibiotic allergy. Of the 59 patients, 55 (93%) had negative penicillin allergy skin test results. Fifty-four (90%) of the 60 patients were given clearance by the allergist to receive cefazolin. Of the 55 study patients who received antibiotic prophylaxis, 6 (11%) received vancomycin compared with 38 (30%) of 127 historical controls (P < or = .05). None of the study patients had an immediate reaction to cefazolin or to vancomycin. Prophylactic vancomycin use in patients with a history of penicillin or cephalosporin allergy undergoing elective orthopedic surgery can be reduced by a targeted allergy consultation and penicillin allergy skin testing.

Vancomycin for prophylaxis against sepsis in preterm neonates.

Nosocomial, late onset sepsis occurs in up to 50% of infants of less than 1000gm at birth. The commonest organism isolated is coagulase negative staphylococcus (CoNS). A number of studies have evaluated the efficacy or prophylactic low dose vancomycin given either as a continuous infusion added to the infant's hyperalimentation fluid or by intermittent intravenous administration and these studies in very low birth weight infants are the subject of this review. To evaluate the safety and efficacy of vancomycin prophylaxis for the prevention of late-onset sepsis, coagulase negative staphylococcal sepsis, mortality, and effects on length of stay, total vancomycin exposure, evidence of vancomycin toxicity, and the development of vancomycin resistant organisms in the preterm neonate. Searches were made of Medline, (MeSH terms: Vancomycin and Sepsis; limits: age groups, newborn infants), HealthStar and EMBase, electronic abstracts, personal files and conference proceedings. Randomized controlled trials which compared the incidence of sepsis and mortality in preterm neonates receiving vancomycin prophylaxis versus a control group receiving no prophylaxis. Data regarding clinical outcomes including the overall incidence of sepsis, the incidence of coagulase negative staphylococcal sepsis, mortality, length of stay, total vancomycin exposure, evidence of vancomycin toxicity, and the development of vancomycin resistant organisms were excerpted from previous clinical trials. Data analysis was done in accordance with the standards of the Cochrane Neonatal Review Group. The administration of prophylactic vancomycin reduced the incidence of both total neonatal nosocomial sepsis and coagulase negative staphylococcal sepsis in eligible preterm infants. Mortality, length of stay, and evidence of vancomycin toxicity were not significantly different between the two groups. There was insufficient evidence to ascertain the risks of development of vancomycin resistant organisms in the nurseries involved in these trials. The use of prophylactic vancomycin in low doses reduces the incidence of nosocomial sepsis in the neonate. The methodologies of these studies may have contributed to the low rate of sepsis in the treated groups, as the blood cultures drawn from central lines may have failed to grow due to the low levels of vancomycin in the infusate. Although there is a theoretical concern regarding the development of resistant organisms with the administration of prophylactic antibiotic, there is insufficient evidence to ascertain the risks of development of vancomycin resistant organisms. Few clinically important benefits have been demonstrated for very low birth weight infants treated with prophylactic vancomycin. It therefore appears that routine prophylaxis with vancomycin should not be undertaken at present.

Low-dosage prophylactic vancomycin in central-venous catheters for neonates.

Neonatal infectious pathology remains one of the main causes of morbidity and mortality in this age group. The introduction of plasticized catheters for the administration of medication, fluidotherapy and parenteral nutrition was a significant advance in treatment of patients at risk, but also led to the appearance of infectious complications. Negative coagulase staphylococcus is the principal pathogen in most neonatal intensive care units. Recent studies have examined the prophylactic use of vancomycin in preterm babies receiving parenteral nutrition. We have evaluated the efficacy of this procedure, applied via the central venous catheters employed for all neonates, within the intensive care unit over a period of one year. Prophylactic vancomycin administered via the catheters significantly reduced the incidence of Gram-positive infections, despite the presence within this group of a greater number of septic risk factors than in the control group.

Coagulase-negative Staphylococcus Endophthalmitis After Cataract Surgery With Intraocular Vancomycin

We studied a case of postoperative coagulase-negative Staphylococcus endophthalmitis in a 79-year-old man who had undergone cataract extraction in which vancomycin had been used intraoperatively in the infusion fluid. The medical records were reviewed for the clinical history, ocular findings, and the vitreous and anterior chamber culture results. Acute, postoperative coagulase-negative Staphylococcus endophthalmitis developed in the patient in whom vancomycin had been used intraoperatively in the infusion fluid. Restraint is urged in the prophylactic use of vancomycin in the infusion fluids.