Vancomycin prescribing patterns for patients admitted to intensive care units
CCCF ePoster library. Goodliffe L. Oct 26, 2015; 117378; P29
Ms. Laura Goodliffe
Ms. Laura Goodliffe
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Abstract
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P29


Topic: Quality Assurance/Quality Improvement Project


Vancomycin prescribing patterns for patients admitted to intensive care units



Laura Goodliffe, M. Haaland, J. Muscedere

Department of Medicine, Queen's University, Kitchener, Canada | Department of Medicine, Queen's University, Kingston, Canada | Department of Medicine, Queen's University, Kingston, Canada

Introduction:

Vancomycin continues to be the antibiotic of choice for MRSA infections. Although guidelines exist that aim to guide clinicians in selecting appropriate indications for vancomycin therapy, their adoption into clinical practice in the Intensive Care Unit (ICU) are unknown.



Objectives: To characterize vancomycin use in a tertiary critical care settings and determine the concordance with existing guidelines for vancomycin utilization.

Methods:

Retrospective study of all adult patients (> 18 years old) admitted to the medical surgical ICUs of Kingston General Hospital for > 48 hours, from March 1, 2015, to May 31, 2015, who were prescribed intravenous vancomycin during their ICU admission. Information on patient demographics, comorbidities and allergies, reason for admission, vancomycin prescription information and appropriateness of indication according to guidelines, culture results and patient outcomes were collected and summarized. Recommendations by the Hospital Infection Control Practices Advisory Committee (HICPAC) and the Infectious Diseases Society of America (IDSA) clinical practice guidelines for the treatment of MRSA infections were used to categorize appropriateness. [1,2]



Results: 95 of 545 patients admitted for > 48 hours (18%) received at least one dose of intravenous vancomycin during their critical care admission. The majority of prescriptions were initiated in the ICU (n=70/95, 74%). The median duration of therapy was 4 days (range 1 to 60). At the time of admission, 47 (49%) patients had one or more risk factors for MRSA; the median number of risk factors was 1 (range 1-5). Of the patients who received vancomycin 13 (14% of 90 tested) were colonized with MRSA according to ICU admission screening.

From information available in patient charts, 37 prescriptions were appropriate according to IDSA and/or CDC guidelines (39%). The most common appropriate indication for vancomycin therapy was empiric treatment of severe, community acquired pneumonia requiring ICU admission (n=22); empiric treatment of complicated skin & soft tissue infections was the second most common appropriate indication (n=4). Empiric treatment of bacteremia/sepsis accounted for 26 of the 58 prescriptions that did not fall into an “appropriate use” category (45%); empiric treatment of healthcare-associated pneumonia accounted for another 13 of these prescriptions.

91% of patients had blood cultures drawn (n=86), with a respiratory source most commonly suspected (36 of 86, 42%); other common cultures sites included respiratory (n=41, 44%), urinary (n=38, 40%), and skin/soft tissue (n=9, 9%). 60 (63%) patients had one or more positive cultures; 23 (27%) blood cultures were positive for a Staphylococcus organism. Methicillin-susceptible S. aureus (MSSA) was detected in 10 patients, cloxacillin-resistant S. epidermidis was detected in 4 patients and cloxacillin-resistant S. hominis was detected in 1 patient. MRSA was detected in cultures from 9 (9%) patients. After treatment with a course of vancomycin, 6 patients subsequently tested positive for MRSA (6%) and one developed vancomycin-resistant enterococci (VRE) bacteremia (1%).

Conclusion: A significant proportion of patients in ICU receive at least one dose of vancomycin during their admission, of which only 39% indication were appropriate according to existing guidelines. Vancomycin is most commonly prescribed empirically, and most commonly for suspected pneumonia requiring ICU admission. Few patients prescribed vancomycin tested positive for MRSA.

References: [1] The Hospital Infection Control Practices Advisory Committee (HICPAC). (1995). Recommendations for preventing the spread of vancomycin resistance. MMWR Recomm Resp, 22:44(RR-12):1-13.
[2] Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, et al. (2011). Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureaus infections in adults and children. Clin Infect Dis, 1;53(3):285-92
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