Vancomycin Utilization Research Articles

Efficacy of Oral Vancomycin, Oral Metronidazole, or IV Metronidazole Prophylaxis at Reducing the Risk of Clostridium difficile Recurrence

BackgroundSecondary prophylaxis (SP) for Clostridium difficile infection (CDI) with oral vancomycin or oral/IV metronidazole when initiating antibiotics is common, though few studies are available to support this practice. The purpose of this study was to assess the efficacy of prophylaxis within a year of index CDI.MethodsThis retrospective chart review looks at subsequent courses of antibiotics and CDI in patients with initial positive CDI testing in 2013–16. A positive CDI test within 90 days of antibiotics was a recurrence. The use of antibiotics for SP was noted, along with other factors associated with CDI relapse. Non-parametric and exact tests were used for univariate analysis. These variables were included in a multivariate proportional hazards model.ResultsWe found 597 antibiotic episodes in 230 patients. 130 episodes (21.8%) received SP. The difference of recurrence rates with and without antibiotics, 9.2 % vs 10.7%, was not statistically significant. No difference was seen when metronidazole was used, but vancomycin SP reduced the rate to 7.5% (6/80, P = 0.45). Probiotics were associated with a higher rate of recurrence (16.7 vs. 8.9%, P = 0.025). Proton pump inhibitors were also associated with a slightly higher rate of CDI recurrence (13.0% vs. 8.4%). The rate of relapse fell significantly with increasing time since the index case of CDI by logistic regression (P = 0.011). In multivariate regression, relapse was associated with shorter time from index CDI, shorter durations of antibiotics, and the use of probiotics.ConclusionThis retrospective study does not support the routine use of metronidazole in subsequent antibiotic courses following CDI. The use of probiotics paradoxically increased the rate of CDI relapse in this study. The limitations of this retrospective study do not eliminate the possibility of utility of vancomycin as prophylaxis, but this requires further evaluation.Disclosures All authors: No reported disclosures.

Vancomycin levels are frequently subtherapeutic in critically ill patients: a prospective observational study.

BackgroundAppropriate utilization of vancomycin is important to attain therapeutic targets while avoiding clinical failure and the development of antimicrobial resistance. Our aim was to observe the use of vancomycin in an intensive care population, with the main focus on achievement of therapeutic serum concentrations (15–20 mg/l) and to evaluate how this was influenced by dose regimens, use of guidelines and therapeutic drug monitoring.MethodsA prospective observational study was carried out in the intensive care units at two tertiary hospitals in Norway. Data were collected from 83 patients who received vancomycin therapy, half of these received continuous renal replacement therapy. Patients were followed for 72 h after initiation of therapy. Blood samples were drawn for analysis of trough serum concentrations. Urine was collected for calculations of creatinine clearance. Information was gathered from medical records and electronic health records.ResultsLess than 40% of the patients attained therapeutic trough serum concentrations during the first 3 days of therapy. Patients with augmented renal clearance had lower serum trough concentrations despite receiving higher maintenance doses and more loading doses. When trough serum concentrations were outside of therapeutic range, dose adjustments in accordance to therapeutic drug monitoring were made to less than half.ConclusionThe present study reveals significant challenges in the utilization of vancomycin in critically ill patients. There is a need for clearer guidelines regarding dosing and therapeutic drug monitoring of vancomycin for patient subgroups.

Strategies for Optimizing the Diagnostic Predictive Value of Clostridium difficile Molecular Diagnostics.

Because nucleic acid amplification tests (NAATs) do not distinguish Clostridium difficile infection (CDI) and asymptomatic C. difficile carriage, the diagnostic predictive value of NAATs is limited when used in patients with a low probability of CDI. In this issue of the Journal of Clinical Microbiology, Truong et al. (J. Clin. Microbiol., 55:1276-1284, 2017, https://doi.org/10.1128/JCM.02319-16) report significant reductions in hospital-onset CDI and oral vancomycin utilization at their institution following implementation of a novel intervention that leveraged their clinical bioinformatics resources to prevent C. difficile testing of stools from patients without clinically significant diarrhea and in patients with recent laxative use.

Real-Time Electronic Tracking of Diarrheal Episodes and Laxative Therapy Enables Verification of Clostridium difficile Clinical Testing Criteria and Reduction of Clostridium difficile Infection Rates.

Health care-onset health care facility-associated Clostridium difficile infection (HO-CDI) is overdiagnosed for several reasons, including the high prevalence of C. difficile colonization and the inability of hospitals to limit testing to patients with clinically significant diarrhea. We conducted a quasiexperimental study from 22 June 2015 to 30 June 2016 on consecutive inpatients with C. difficile test orders at an academic hospital. Real-time electronic patient data tracking was used by the laboratory to enforce testing criteria (defined as the presence of diarrhea [≥3 unformed stools in 24 h] and absence of laxative intake in the prior 48 h). Outcome measures included C. difficile test utilization, HO-CDI incidence, oral vancomycin utilization, and clinical complications. During the intervention, 7.1% (164) and 9.1% (211) of 2,321 C. difficile test orders were canceled due to absence of diarrhea and receipt of laxative therapy, respectively. C. difficile test utilization decreased upon implementation from an average of 208.8 tests to 143.0 tests per 10,000 patient-days (P < 0.001). HO-CDI incidence rate decreased from an average of 13.0 cases to 9.7 cases per 10,000 patient-days (P = 0.008). Oral vancomycin days of therapy decreased from an average of 13.8 days to 9.4 days per 1,000 patient-days (P = 0.009). Clinical complication rates were not significantly different in patients with 375 canceled orders compared with 869 episodes with diarrhea but negative C. difficile results. Real-time electronic clinical data tracking is an effective tool for verification of C. difficile clinical testing criteria and safe reduction of inflated HO-CDI rates.

Adherence to Institutional Guidelines for Community and Nosocomial Pneumonia and Its Impact on In-hospital Mortality and 30-day Readmission in a Community Health System

BackgroundAntimicrobial stewardship committee at Kennedy Health created novel pneumonia guidelines in 2016 which were based on local antibiogram and multi-drug resistant organism risk factors. The purpose of this study was to measure adherence to institutional treatment guidelines (ITG) and its impact on mortality and 30-day readmissions.MethodsAn IRB approved retrospective chart review was conducted on patients admitted for > 24 hours with a confirmed diagnosis of bacterial pneumonia. Patients were included if they were ≥18 years old and diagnosed with community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP) between April and September 2016. The primary objective of the study was to measure the adherence to ITG for CAP and HAP. The secondary objectives were to measure the in-hospital mortality and 30-day readmission rate between the adherent and non-adherent groups. A pre and post implementation analysis was performed focusing on rates of hospital acquired respiratory infection (HARI) rates, and overall antibiotic utilization.ResultsThere were 216 patients included in the study with CAP (n = 128) and HAP (n = 88). The rate of adherence to ITG was higher in CAP vs.. HAP (73.4% vs. 45.5%, P < 0.001). Although there was no difference observed in mortality between CAP and HAP (0.8% vs. 0.0%, P = 1.0), the rate of 30-day readmissions was lower in CAP vs. HAP (4.7% vs. 29.5%, P < 0.001). When comparing adherent and non-adherent groups, there was no difference in 30-day readmissions in patients with CAP (4.3% vs. 5.9%, P = 0.656) and HAP (30.9% vs. 26.1%, P = 0.613). There was a 32.1% decrease in anti-pseudomonal β-lactam usage in 2016 vs. 2015 (53.6 vs. 79 DOT/1000PD, P = 0.008). Fluoroquinolone utilization was decreased by 55.8% in 2016 vs. 2015 (39.6 vs. 89.6 DOT/1000PD, P < 0.001). Vancomycin utilization decreased by 28.4% in 2016 compared with 2015 (67.9 vs. 94.9, DOT/1000PD, P = 0.009). Comparing 2016 vs. 2015, we noticed a decrease in pseudomonas HARI rates (2% vs. 3%) however, an increase in MRSA HARI rates (1% vs. 0.2%).ConclusionAdherence to ITG was shown to be higher for CAP compared with HAP. Although there was no difference seen in mortality between CAP and HAP, there was significantly lower 30-day readmissions in patients with CAP compared with HAP. Overall, antipseudomonal and anti-MRSA antibiotic utilization was decreased after ITG implementation.Disclosures All authors: No reported disclosures.

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.

Impact of a clinical pathway on appropriate empiric vancomycin use in cancer patients with febrile neutropenia.

Objectives Febrile neutropenia management guidelines recommend the use of vancomycin as part of an empiric antimicrobial regimen when specific criteria are met. Often, vancomycin use among patients with febrile neutropenia is not indicated and may be over utilized for this indication. We sought to evaluate the impact of implementing a febrile neutropenia clinical pathway on empiric vancomycin use for febrile neutropenia and to identify predictors of vancomycin use when not indicated. Methods Adult febrile neutropenia patients who received initial therapy with an anti-pseudomonal beta-lactam with or without vancomycin were identified before (June 2008 to November 2010) and after (June 2012 to June 2013) pathway implementation. Patients were assessed for appropriateness of therapy based on whether the patient received vancomycin consistent with guideline recommendations. Using a comorbidity index used for risk assessment in high risk hematology/oncology patients, we evaluated whether specific comorbidities are associated with inappropriate vancomycin use in the setting of febrile neutropenia. Results A total of 206 patients were included in the pre-pathway time period with 35.9% of patients receiving vancomycin therapy that was inconsistent with the pathway. A total of 131 patients were included in the post-pathway time period with 11.4% of patients receiving vancomycin inconsistent with the pathway ( p = 0.001). None of the comorbidities assessed, nor the comorbidity index score were found to be predictors of vancomycin use inconsistent with guideline recommendations. Conclusion Our study has demonstrated that implementation of a febrile neutropenia pathway can significantly improve adherence to national guideline recommendations with respect to empiric vancomycin utilization for febrile neutropenia.

Use of Intravenous Vancomycin and Cefepime in Preventing Endophthalmitis After Open Globe Injury.

The choice and route of antibiotic prophylaxis in the setting of open globe injury remains controversial. We investigated the utility of intravenous vancomycin and cefepime prophylaxis in preventing endopthalmitis after open globe injury. The charts of 224 patients who presented to Parkland Memorial Hospital and Children's Medical Center in Dallas, Texas, between June 1, 2009 and June 30, 2013, with open globe injury and who were treated with prophylactic intravenous vancomycin and cefepime were retrospectively reviewed. Data collection included time from injury to presentation, mechanism of injury, details of ophthalmological examination, timing of open globe repair, and length of follow-up. All patients were treated with intravenous vancomycin and cefepime for 48 h after presentation. The primary outcome measure was rate of endophthalmitis, and the secondary outcome measure was identification of risk factors for developing endophthalmitis. Out of 224 patients who presented after open globe injury, 3 patients had signs of endophthalmitis on initial exam before starting antibiotics, and 2 patients developed endophthalmitis after initiation of vancomycin and cefepime (0.9%). Delayed time from injury to presentation was a risk factor for post-traumatic endophthalmitis (P = 0.0002). The association between presence of intraocular foreign body and post-traumatic endophthalmitis was approaching significance (P = 0.064). When intravenous vancomycin and cefepime are used prophylactically after open globe injury, the rate of endophthalmitis is low.

CORR Insights(®): Is Vancomycin-only Prophylaxis for Patients With Penicillin Allergy Associated With Increased Risk of Infection After Arthroplasty?

Where Are We Now? Deep prosthetic joint infections (PJI) following total joint arthroplasty (TJA) can be catastrophic. Timely administration of intravenous antibiotics prior to surgical incision is one of the most effective strategies to prevention of postoperative infections [6]. Currently, first- or second-generation cephalosporins are recommended for prophylaxis prior to routine THA and TKA [1]. However, in recent years, changes in patient demographics and increasing prevalence of resistant organisms in patients undergoing lower-extremity arthroplasty have raised the question of whether current recommendations are adequate. Combination therapies including the routine addition of vancomycin to the prophylactic antimicrobial regimen have shown only comparable efficacy to monotherapy in some studies, while increasing the risk of acute kidney injury in others [3, 8]. Furthermore, decolonization protocols have also been shown to be variable in terms of compliance and efficacy [10]. Therefore, the question remains: What is the correct approach to antibiotic prophylaxis prior to hip or knee replacement? In this article, Tan et al. present an interesting study on the use of vancomycin alone for prophylaxis in patients with penicillin allergies undergoing TJA. The authors found that administration of vancomycin alone did not increase the rate of deep surgical site infections, but decreased the risk for infections with Gram-positive organisms and antibiotic resistant organisms. Where Do We Need To Go? This work adds valuable information, but a number of questions remain. It would be important to validate these findings in other centers, and in prospective studies that permit tighter standardization of clinical practices. Of course, the endpoint we are most interested in—deep infection—requires much larger (and almost certainly multicenter) studies. The allure of widespread utilization of vancomycin as an effective agent to prevent infections with resistant organisms must be tempered by the potential risks, including renal toxicity, ototoxicity, and antimicrobial resistance. However, this is a common clinical scenario that not only affects arthroplasty surgeons, but all orthopaedic surgeons. Even though cross-reactivity and true anaphylaxis resulting from cephalosporin administration is only approximately 10% [2], most surgeons opt for antibiotic alternatives rather than “test-dosing” the patient under anesthesia to determine the presence or absence of true allergy. Vancomycin and clindamycin are commonly used alternatives in these situations, but concerns remain with regards to the efficacy of clindamycin and coverage of vancomycin as stand-alone agents [9]. Other studies have shown an increased risk of infections when only vancomycin is administered for routine prophylaxis [7]. Consequently, larger, prospective studies taking into account host factors, local antibiograms, and clinical practices such as decolonization protocols will be needed to definitively define the indications and efficacy for various antibiotic prophylactic protocols surrounding TJA. How Do We Get There? Many factors contribute to the risk of surgical site infections, and so to study the impact of antibiotics on infection properly, a multidisciplinary approach is called for. First, standardization of definitions and clinical practices will allow us to collaborate to find an answer to this problem without introducing confounding variables and bias. Today, there are established criteria for the work-up and diagnosis for infected TJA as well as clinical practice guidelines for the management of the infected TJA [5]. Second, a creation and contribution of surgical site infection and PJI data to various local and national registries will allow surveillance at a population level and the development of protocols based on specific antibiograms. Finally, and perhaps most challenging, is the need to define the “optimized” candidate for joint arthroplasty. Conditions such as diabetes, chronic kidney disease, obesity, and malnutrition have been shown to place patients at increased risk for development of infections postoperatively [4]. We need more studies that specifically ascertain at what point we should consider those sorts of conditions “well enough” managed that it is clinically reasonable to proceed with elective arthroplasty. Because of the increased risk, those studies also should help us to determine whether these higher-risk patients should be treated with different antibiotic approaches than low-risk patients? Identifying the correct antibiotic prophylaxis protocols can have profound and wide-reaching impact. The cost to prevent a single patient's infection must be counterbalanced against the risks in that patient of adverse effects, but also against societal costs, such as the development of antibiotic-resistant organisms. Orthopaedic surgeons, will be at the forefront of this dilemma and must play a part in practicing good, evidence-based, antibiotic stewardship.

A new approach to Vancomycin utilization evaluation: A cross-sectional study in intensive care unit.

Objective:The risk of methicillin-resistant Staphylococcus aureus infections in Intensive Care Unit (ICU) is increasing in recent years with high rate of morbidity and mortality. Therefore, in this study, we aimed to evaluate the rationale use of vancomycin in ICU patients.Methods:A total of 200 patients who received at least 48 h intravenous vancomycin were randomly selected from ICU wards, during 9 months. Vancomycin administration and related clinical and laboratory data were gathered from patients' charts and health information system to evaluate the appropriateness of different aspects of vancomycin use during all days which vancomycin were ordered.Findings:During the study, 15,230 ± 1216 mg (mean ± standard error of the mean [SEM]) vancomycin was administered for 200 patients in the mean period of 9.79 ± 0.64 (SEM) days of ICU stay, for prophylaxis and empiric therapy. Results showed the appropriateness of vancomycin uses were 30.5%, 9%, and 5.5% in the first 24 h, after 72 h and during the whole time of treatment, respectively. In addition, infectious consultation was the only significantly different parameter between appropriate and inappropriate vancomycin administration groups (P < 0.001).Conclusion:Although vancomycin utilization evaluation were mentioned in previous studies, but data related to ICU patients and during all days of vancomycin therapy are limited. High prevalence of inappropriate use of vancomycin in ICU is alarming for health systems and necessitates implementation of antibiotic policies.

Effects of Pharmacist Intervention on the Utilization of Vancomycin in a Teaching Hospital.

In order to investigate the effect of pharmacist intervention on vancomycin use, this study was performed on all patients receiving vancomycin in the intensive care unit (ICU) and hematology-oncology ward of Taleghani Educational Hospital in Tehran, Iran. Vancomycin use was assessed during a pre- and post-intervention period in accordance with the Center of Disease Control and prevention (CDC) and Infectious Diseases Society of America (IDSA) guidelines. Following the intervention, there was a significant change in appropriate initiation of vancomycin (P = 0.009) and no significant improvement was observed in adequate dosage and the duration of therapy (P = 0.15 and P = 0.54 respectively); however, informing the physician resulted in discontinuation of the drug in 50% of inappropriate cases and vancomycin dosage was adjustedin 31% of cases. Temperature charts, culture results and pre-treatment CBC tests changed significantly (P = 0.02, P = 0.009 and P = 0.04 respectively). The rate of infusion related adverse drug reactions did not decrease significantly (P = 0.06); yet in 100% of patients, these reactions were resolved after notifying the nursing team. After pharmacist intervention,vancomycin use improved in some aspects. A significant improvement in appropriate initiation of therapy was observed; however, treatments continued despite negative cultures. It is necessary to optimize the use of vancomycin by performing more educational interventions.

Comparison of Intrawound Vancomycin Utility in Posterior Instrumented Spine Surgeries Between Patients With Tumor and Nontumor Patients.

Retrospective cohort study of consecutive patients. To compare the efficacy of intrawound vancomycin to prevent postoperative surgical site infection (SSI) between patients with spinal tumor and nontumor spine patients. Recent studies have suggested that intrawound vancomycin is a promising method for reducing the SSI rate in spine surgery. However, the patient population in which it is most effective remains unknown. Medical records of a consecutive series of patients with tumor and nontumor spine patients who underwent open posterior instrumented surgeries at our institution between October 2011 and June 2014 were reviewed. 1 gram of vancomycin powder was evenly sprayed into the surgical site before drain placement. The SSI rates before and after vancomycin use were compared. Changes in SSI rates, which reflected the utility of vancomycin, were compared between patients with tumor and nontumor patients. A total of 334 patients were enrolled including 25 patients with tumor and 129 nontumor patients in the "before" period, and 27 patients with tumor and 153 nontumor patients in the "after" period. Baseline characteristics in both patients with tumor and nontumor patients did not differ between periods. The SSI rate of nontumor patients was significantly reduced with intrawound vancomycin application (7.0% [9/129] vs. 0.7% [1/153], P = 0.011). However, the SSI rate in patients with tumor was not reduced (8.0% [2/25] vs. 14.8% [4/27], P = 0.442). 3 of the 4 patients with tumor who developed SSI after vancomycin use had previous radiotherapy, whereas only 1 SSI occurred in 14 patients with tumor without radiotherapy in the same period. Intrawound vancomycin may be beneficial for nontumor spine patients who undergo open posterior instrumented surgeries, but may not for those with spinal tumors. The poor physical health status, major surgical trauma, and tumor-related adjuvant treatments of patients with spinal tumor may contribute to this disparity.

Decreasing vancomycin utilization in a neonatal intensive care unit

This study evaluated the efficacy of education versus audit and feedback in decreasing vancomycin utilization. Data were collected prospectively from October 1, 2012-April 30, 2014 over the following 3 periods: baseline, after education and introduction of a late-onset sepsis treatment guideline, and after prospective audit-feedback to physicians. Vancomycin utilization and administration duration >3days significantly decreased with education and guideline use, but it was not affected by addition of audit and feedback.

Su1263 Clostridium difficile Infection Remains an Independent Risk Factor for Mortality and Colectomy in Hospitalized Patients With Ulcerative Colitis

Background: Severe flares of ulcerative colitis (UC) requiring hospitalization are frequently associated with Clostridium difficile infection (CDI). Previous studies suggest an increase risk of colectomy (OR=2.5) and mortality (OR=4.7) in hospitalized patients with IBD and concomitant CDI (Inflamm Bowel Dis 2011; 17 and Gut 2008; 57). Over the past 5 years the utilization of vancomycin for CDI and biologics for UC has increased substantially. This study aimed to re-assess the relationship between UC and CDI using more recent data to identify whether outcomes have improved. Methods: We utilized the Nationwide Inpatient Sample, a database that collects discharge data from more than 7 million admissions annually from participating community hospitals. This data set represents 20 percent of the discharges from these hospitals. We identified patients hospitalized for the period 2007-2011. We restricted our analysis to patients aged 18 to 80, admitted under urgent or emergent conditions, with a diagnosis of ulcerative colitis with or without CDI, as indicated by ICD-9 coding. Rates of in-hospital mortality and colectomy were similarly ascertained. The study sample was weighted and analyzed using the Complex Samples Module of SPSS 22.0. Results: After weighting, 307,898 hospitalizations for UC were identified. Mean age was 51 ± 17.5 years; 53% female. There were 19,090 (6.2%) with concomitant CDI. The rate of colectomy in patients hospitalized with UC and CDI was 2.5%, compared with 0.6% in those without concomitant CDI (univariate odds ratio (OR) for colectomy 4.7, 95% CI= 4.2-5.1). In multivariate logistic regression, when adjusting for age, race, and gender, the OR remained highly significant at 5.1 (95% CI=4.5-5.8, p<0.001). The mortality rate in patients hospitalized with UC and CDI was 10.3%, compared with 1.5% in those without CDI (univariate OR for death 7.4 (95% CI=7.0-7.8, p<0.001). In multivariate logistic regression, when correcting for age, race, and gender, the OR similarly remained highly significant at 7.1 (95% CI=6.7-7.6, p<0.001). Conclusion: In this large, nationwide sample of patients hospitalized with ulcerative colitis, infection with CDI remains a highly significant independent risk factor for in-hospital mortality and colectomy. Our results are similar to previous reports indicating that there has been little change in outcomes despite advances in therapy for both diseases.

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.

Drug Utilization Evaluation of Vancomycin Among Hospitalized Patients in Internal Medicine Wards of Tikur Anbessa Specialized Hospital

Background: Vancomycin use is considered inappropriate in most hospitals. A particular concern is the recent emergence vancomycin-resistant enterococci (VRE) which is related to the potential for nosocomial transmission, the lack of antibiotics to treat infections caused by this organism, and the possibility that the vancomycin-resistant genes present in VRE can be transferred to other gram-positive microorganisms such as S. aureus. The objective of this study was to evaluate the utilization of vancomycin among hospitalized patients in internal medicine wards of Tikur Anbessa Specialized Hospital (TASH). Methods: A retrospective cross-sectional chart review was carried out to evaluate the utilization of vancomycin among hospitalized patients with vancomycin therapy between April 2012 to 2013. Results: One hundred twenty five patients were enrolled in the study, consisting of 60 males and 65 females. The age range was 13 to 80 years. Of all courses, 88.8% were considered to be initially appropriate, but this decreased to 6.4% after vancomycin initiation. Continued empiric use of vancomycin without further evidence of gram-positive infections accounted for the majority of inappropriate use. The major dosing regimen employed was 1g every 12 h in 99 (79.2%) of treatments. Vancomycin dose was not adjusted or adjusted inadequately for 62 (96.5%) of the patients with increased serum creatinine. Furosemide was the most frequently identified potentially interactive drug. Conclusion: Although the initial indication for vancomycin use was generally appropriate, failure to continue this antibiotic as per HICPAC criteria and inappropriate dosing adjustment based on MDRD CrCl level were common challenges identified.

Questioning the accuracy of trough concentrations as surrogates for area under the curve in determining vancomycin safety.

Questioning the accuracy of trough concentrations as surrogates for area under the curve in determining vancomycin safety.

Outcomes associated with a thrice-weekly antimicrobial stewardship programme in a 253-bed community hospital

Antimicrobial stewardship programmes (ASPs) have been shown to decrease antimicrobial resistance, reduce hospital-acquired infections and decrease overall antimicrobial expenditures. At St. Joseph Medical Center in Bellingham, WA, a thrice-weekly ASP was initiated in 2010 with the goals of decreasing carbapenem, fluoroquinolone and vancomycin use and tailoring duration of therapy. Antibiotic use per 1000 patient-days and carbapenem, fluoroquinolone and vancomycin use were evaluated pre- and post-implementation of the ASP. Total antimicrobial expenditures were evaluated for the 3 years prior to ASP implementation and three years following implementation. Antimicrobial days of therapy per 1000 patient-days declined by 6·4% after implementation of our ASP. There was a 37% reduction in total antimicrobial expenditures after implementation. Carbapenems, vancomycin and levofloxacin use decreased considerably. Ciprofloxacin use increased during the same time period. A thrice-weekly, pharmacist-driven ASP can decrease antimicrobial expenditure, shorten duration of therapy and decrease the utilization of carbapenems, vancomycin and levofloxacin.

Analysis of Vancomycin Therapeutic Drug Monitoring Trends at Pediatric Hospitals

Vancomycin treatment failures in adults with methicillin-resistant Staphylococcus aureus bacteremia are well documented despite established therapeutic monitoring consensus recommendations. Vancomycin use in children has unique challenges, and consensus guidelines are lacking. We evaluated trends in vancomycin monitoring in children and estimated the impact of adult guidelines on patterns of vancomycin use. A retrospective, descriptive study was designed. Data were obtained from the Pediatric Health Information System from 40 not-for-profit, tertiary care pediatric hospitals in the United States. Patients receiving vancomycin during hospitalizations ending July 1, 2007 through June 30, 2011 were included, and the number of vancomycin monitoring determinations per course of therapy was queried. Vancomycin utilization and monitoring practices were evaluated across institutions, age groups and time intervals. A total of 104,586 patients met study criteria. The mean duration of vancomycin administration was 5 (median 3, range 1-257) days. A mean of 1 (median 1, range 0-186) serum vancomycin concentration was obtained per patient; 46% of patients had none. Eighty-one percent of those receiving vancomycin more than 3 days had monitoring performed at least once. Monitoring practices did not correlate with length of therapy (r² = 0.11). Monitoring frequency increased across all age groups (P < 0.05) after publication of adult guidelines in January 2009. Vancomycin monitoring practices are highly variable in children admitted to pediatric hospitals. The frequency with which serum vancomycin concentrations were monitored in children increased after the publication of the adult guidelines. Pediatric consensus guidelines should be developed to optimize patient care and resource utilization.

Does resistance in severe infections caused by methicillin-resistant Staphylococcus aureus give you the ‘creeps’?

The clinical implications of reduced vancomycin susceptibility amongst methicillin-resistant Staphylococcus aureus (MRSA) are controversial, and crossresistance to daptomycin amongst such strains has been reported. As a consequence of 'MIC creep', higher trough levels were recommended for serious infections. This review focusses on the new data published in the past 18 months that pertain to these issues. Heteroresistant vancomycin-intermediate Staphylococcus aureus reduces the clinical response rates to vancomycin in bacteraemic MRSA patients without impacting on mortality as opposed to 'MIC creep' with vancomycin minimum inhibitory concentration (MIC) levels of ≥1.5 mg/l that are significantly associated with mortality. Although daptomycin resistance is rare, 'concomitant MIC creep' amongst MRSA isolates with increasing vancomycin MICs may occur or exist concurrently amongst such strains. The aggressive vancomycin dosing regimens are still associated with unacceptable high microbiological failure rates and it is not currently possible to achieve probability of target attainment at higher vancomycin MICs of 2 mg/l. The nephrotoxic impact of high-dose vancomycin therapy has been confirmed. Continued monitoring of patients on aggressive vancomycin dosing schedules is advised. Unless alternative dosing strategies prove otherwise efficacious, an alternative antibiotic should be considered for severe MRSA infections with vancomycin MICs greater than 1 mg/l. The utility of vancomycin may be waning but will depend on the prevalence of resistant MRSA phenotypes in a specific ICU.