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

Appropriate use of vancomycin in a pediatric emergency department through the use of a standardized electronic guideline

OBJECTIVES

(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.

METHODS

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.

RESULTS

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.

CONCLUSION

There was no difference in vancomycin utilization and appropriateness of initiating therapy after STGOT implementation.

Prospective Evaluation of Colonization with Extended-Spectrum β-Lactamase (ESBL)–Producing Enterobacteriaceae Among Patients at Hospital Admission and of Subsequent Colonization with ESBL-Producing Enterobacteriaceae Among Patients During Hospitalization

Objective.

To determine the rates of and risk factors for carriage and acquisition of extended-spectrum (β-lactamase (ESBL)-producing Enterobacteriaceae during hospitalization.

Design.

Cohort study.

Setting.

Shaare Zedek Medical Center, a 550-bed teaching hospital.

Methods.

During a 5-month period (February 1-June 30, 2004), 167 (8%) of 1,985 newly admitted general medical patients were enrolled in our study. Nasal, oropharyngeal, and rectal swab specimens were obtained at admission and every 2-3 days until hospital discharge or death. Enterobacteriaceae isolates were tested for ESBL, andStaphylococcus aureusisolates were tested for methicillin resistance.

Results.

Of the 167 patients enrolled in our study, 15 (9%) were identified as nasal carriers of methicillin-resistantS. aureus(MRSA) at admission, and 13 (8%) were rectal carriers of ESBL-producing Enterobacteriaceae at admission. Univariate risk factors for rectal carriage of ESBL-producing Enterobacteriaceae included female sex (odds ratio [OR], 11 [95% confidence interval {CI}, 1.4—238];P< .05), nursing home residence (OR, 6.9 [95% CI, 1.8-27];P< .01), recent antibiotic treatment (OR, 9.8 [95% CI, 1.7-74];P< .05), and concomitant nasal carriage of MRSA and/or ESBL-producing Enterobacteriaceae (OR, 5.8 [95% CI, 1.2-26];P< .01). Multivariate risk factors were female sex and recent antibiotic treatment. During hospitalization, 35 (21%) of 167 patients had acquired rectal carriage of ESBL-producing Enterobacteriaceae (P= .002, for trend analysis). Of the 12 patients who were still in the hospital 2 weeks after admission, 4 (33%) were carriers of ESBL-producing Enterobacteriaceae. Univariate risk factors for acquisition included an age of older than 65 years (P< .005), nursing home residence (OR 2.6, [95% CI, 0.98-2.6]), impaired cognition (OR, 4.8 [95% CI, 1.9-12]), recent antibiotic treatment (OR, 2.7 [95% CI, 0.9-8.3]), respiratory assistance (OR, 4.2 [95% CI, 1.2-14]), and prolonged hospitalization. Multivariate risk factors were an age of older than 65 years and broad-spectrum antibiotic therapy.

Conclusions.

Rectal carriage of ESBL-producing Enterobacteriaceae occurred in 13 (8%) of 167 patients at admission to the medical departments of our hospital and in 4 (33%) of 12 patients still remaining in our hospital after 2 weeks.

Restricted use of glycopeptides in paediatric cancer patients with fever and neutropenia

Until now, studies confirming the safety of glycopeptide restriction in the empirical treatment of prolonged fever and neutropenia included only nine children. In an open-label observational study, the use of teicoplanin in paediatric oncology patients was investigated. A period of unrestricted use (2001-2003) was compared with a second period (2004) following implementation of a restrictive treatment guideline. Empirical first-line treatment consisted of piperacillin/tazobactam; in 2004, fosfomycin was added after 72 h as the second-line combination instead of teicoplanin. In total, 213 episodes (n=163 in 2001-2003; n=50 in 2004) managed with teicoplanin or fosfomycin (only 2004) were eligible. Empirical treatment of fever of unknown origin with teicoplanin was reduced by 97%. In 2004, the mean length of stay was 0.4 days shorter, no infection-related death occurred and no vancomycin-resistant enterococci were detected. Restriction of empirical glycopeptides is safe in paediatric cancer patients after first-line treatment with piperacillin/tazobactam. Fosfomycin appears to offer a feasible and cost-saving alternative in second-line combination therapy.

Diagnosis and treatment of catheter-related infections in paediatric oncology: an update

Otherwise unexplained clinical signs of infection in patients with long-term tunnelled or totally implanted central venous access devices (CVADs) are suspected to be CVAD-associated. Diagnostic methods include catheter swabs, blood cultures and cultures of the catheter tip or port reservoir. In the case of a suspected CVAD-related bloodstream infection in paediatric oncology patients, in-situ treatment without prompt removal of the device can be attempted. Removal of the CVAD should be considered if bacteraemia persists or relapses > or = 72 h after the initiation of (in-vitro effective) antibacterial therapy administered through the line. Timely removal of the device is also recommended if the patient suffers from a complicated infection, or if Staphylococcus aureus, Pseudomonas aeruginosa, multiresistant Acinetobacter baumannii or Candida spp. are isolated from blood cultures. Duration of therapy depends on the immunological recovery of the patient, the pathogen isolated and the presence of related complications, such as thrombosis, pneumonia, endocarditis and osteomyelitis. Antibiotic lock techniques in addition to systemic treatment are beneficial for Gram-positive infections. Although prospectively controlled studies are lacking, the concomitant use of urokinase locks and taurolidine secondary prophylaxis seem to favour catheter salvage.

Appropriateness of glycopeptide use in a hospital in Italy

The aims of this study were to quantify the rate of inappropriate glycopeptide use. The study was carried out by reviewing all medical records of patients who received a glycopeptide in a hospital located in Italy. A total of 452 patients received glycopeptides, with a rate of inappropriate use of 90.9%. Appropriateness of glycopeptide prescriptions was significantly higher in Intensive Care Units compared with surgical wards (odds ratio (OR) = 0.03; 95% confidence interval (CI) = 0.01-0.14), in younger patients (OR = 0.97; 95% CI = 0.95-0.99) and in those patients who received the prescription for therapy rather than prophylaxis (OR = 0.2; 95% CI = 0.06-0.66). Models were also developed to predict appropriateness of glycopeptide indications for therapy and prophylaxis. The information obtained in our audit may enable development of strategies to improve physician prescribing patterns.