Research shows benefits of timing Vancomycin
Study looked at coronary artery bypass patients
Health care institutions and pharmacists continually look for ways to prevent post-operative infections through more sterile practices and better antibacterial prophylaxis.
A recent study shows that for patients undergoing a coronary artery bypass graft (CABG) and/or valve replacement surgery there is an optimal time period of 16-120 minutes for administering vancomycin before incision.1
Historically, the antibiotics chosen for such patients are cefazolin and cefuroxime, but these have become susceptible to methicillin-sensitive Staph species, says Kevin Garey, PharmD, MS, an associate professor and chair of the department of clinical sciences and administration at the University of Houston College of Pharmacy in Houston, TX.
"Especially in the 2000s, there has been a huge increase of methicillin-resistant staph infections," Garey says. "So some institutions, including ours, that have high rates of MRSA use vancomycin as a prophylaxis."
This is a big change since vancomycin historically has been reserved for patients with severe infections that are suspicious of MRSA, he notes.
Several years ago, Garey and co-investigators studied how well cardiac surgery patients tolerated vancomycin for surgical prophylaxis and found that it was reasonably well-tolerated with only a 4% incidence of vancomycin-resistant Enterococcus (VRE).2
For institutions that have high rates of MRSA infections, the next question is how to time vancomycin use to obtain the best impact.
Research dating back to the 1990s has shown that there is a specific window of opportunity and specific time for when antibiotic prophylaxis provides the most benefit, Garey explains.
Based on the earlier research, the guidelines were developed to recommend that the antibiotic prophylaxis be administered from 15 minutes to one hour before surgery begins, Garey says.
"Because vancomycin had not been used previously for surgical prophylaxis, we didn't know if the guidelines would be appropriate for vancomycin," Garey says. "It has as longer half-life, so you would potentially think you could give it for a longer period of time."
The trouble is that the antibiotic should be given for one hour as an infusion to prevent toxicities, he notes.
Previous research has shown that the same timing used in administering cefuroxime prophylaxis also works well for administering vancomycin prophylaxis.3
So Garey and co-investigators went a step further to look at the economic outcomes tied to timing of a vancomycin prophylaxis.
"We had a large study with over 1,600 patients, and we divided these patients into those having received the appropriate prophylaxis, meaning it was administered over the correct time period, or an inappropriate prophylaxis, meaning they got it in the incorrect time period," Garey says. "The length of total hospitalization and length of intensive care unit days were lower in patients who received the appropriate timing of antibiotic prophylaxis."
About 60% of the patients received the vancomycin prophylaxis appropriately, he adds.
"It's difficult to get the timing correct because of the delays in going into surgery," Garey says. "You set up protocols to do this as well as possible, but sometimes things get delayed."
The chief reason why the time between antibiotic infusion and start of surgery often is too long is because the surgery is held up when the preceding surgery takes longer than expected, Garey says.
"It's very difficult to change that factor because most hospitals have an active OR with no extra suites open," he explains.
The study showed that patients receiving the vancomycin prophylaxis within an appropriate timeframe had significantly reduced patient hospitalization duration and total hospital costs.1
"What this shows is that you should devote quite a bit of energy and attention to making sure you're getting the antibiotic prophylaxis in an appropriate time period," Garey says. "It prevents surgical infections, prevents morbidity and mortality, which is most important, and, secondly, it saves a lot of money."
This means that any resources health care organizations put into improving the prophylaxis timing will be money that is returned from reduced hospital costs, he adds.
"We established a task force that was specifically devoted to timing and choice of antibiotic prophylaxis," Garey says. "This group was composed of operating room personnel and nurses, the ones who are on the front lines and have to understand how to give this antibiotic and the importance of timing."
The group also had infection disease physicians, infection control professionals, and pharmacy professionals.
"In every order set of patients going to surgery there would be instructions of how to appropriately give the antibiotic prophylaxis," Garey says. "What we've recently done is put in every surgery a time-out period and recheck of the most important variables going into the surgery."
For instance, one variable is having someone check his watch and compare the current time to the time the antibiotic was given, and if the timing is inappropriate, then the OR staff will give the patient another dose of an antibiotic, Garey says.
"Our decision was to give an antibiotic that you could infuse very rapidly, such as cefuroxime," Garey says. "We hope the vancomycin is still in the patient's body, and we're giving an additional antibiotic that's good against methicillin-sensitive bacteria."
References
- Garey KW, Amrutkar P, Dao-Tran TK, et al. Economic benefit of appropriate timing of vancomycin prophylaxis in patients undergoing cardiovascular surgery. Pharmacotherapy 2008;28:699-706.
- Kachroo S, Dao T, Zabaneh F, et al. Tolerance of vancomycin for surgical prophylaxis in patients undergoing cardiac surgery and incidence of vancomycin-resistant enterococcus colonization. Ann Pharmacother 2006;40:381-385.
- Garey KW, Lai D, Dao-Tran TK, et al. Interrupted time series analysis of vancomycin compared to cefuroxime for surgical prophylaxis in patients undergoing cardiac surgery. Antimicrob Agents Chemother 2008;52:446-451.
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