ICPs still seek solutions to prescription problems
Limiting vancomycin use difficult
Despite growing use of Centers for Disease Control and Prevention guidelines on preventing vancomycin-resistant enterococci (VRE), inappropriate physician prescribing continues to be a problem, say infection control practitioners and pharmacists.
Some hospitals, in fact, are going so far as to restrict vancomycin use to infectious disease physicians, and others are seeking to educate physicians both in written form and one on one.
At St. Charles Hospital in Oregon, OH, an antimicrobial subcommittee of the pharmacy and therapeutics committee was formed in 1995 soon after the CDC guidelines were published1, says Lauryl Hanf-Kristufek, PharmD, clinical pharmacy coordinator. The subcommittee included an infection control practitioner and infectious disease physician, as well as other physicians and representatives from the laboratory and pharmacy. One of the subcommittee’s main goals was to improve physician prescribing of vancomycin.
These are measures that were developed by the subcommittee to improve the use of vancomycin:
• The laboratory notifies the infection disease physician of any VRE isolates that occur at the institution (to date, only two isolates have been detected).
• Standard infection control protocols are in place for patients with VRE, including the use of gowns, gloves, and masks when necessary.
• A vancomycin drug-use evaluation (DUE) was to be performed by pharmacists to examine vancomycin use at the facility.
"A DUE would [give] the committee a more accurate picture of problems, if any, with vancomycin use at our institution," Hanf-Kristufek says. "This would allow more appropriate measures to be taken to correct problems identified."
In a retrospective review of vancomycin in 49 hospital patients in 1996, which represented half of patients placed on vancomycin over a three-month period, 39 were on parenteral vancomycin and 10 were on oral vancomycin. Only one patient (10%) on oral vancomycin was on the drug for an appropriate indication. The remaining nine patients were receiving the drug for antibiotic-associated colitis, either as primary or empirical treatment.
Of the 39 patients on parenteral therapy, 51% (16) were on the drug for an appropriate indication such as for methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-susceptible S. aureus (MSSA) with penicillin allergy. Inappropriate uses were routine surgical prophylaxis (five patients), empiric treatment without positive cultures (12 patients), MSSA without a penicillin allergy (four patients), and a single positive coagulase-negative S. aureus blood culture (two patients). Overall, patients on oral or parenteral therapy received vancomycin appropriately only 35% of the time.
The subcommittee then took the following steps to improve vancomycin use:
• Medical staff were educated on the CDC guidelines at medical staff meetings and through letters, and they regularly receive lists of micro-organism sensitivities specific to the institution.
• Pharmacy receives daily culture and sensitivity reports from the lab, and reviews patients’ medication profiles to make sure they are receiving appropriate antibiotic therapy. If the patient is receiving vancomycin (or other antibiotics) inappropriately, the pharmacist contacts the physician and recommends a more appropriate therapy.
• Pharmacy also receives a report listing all cultures for Clostridium difficile. If the culture is negative, the pharmacist checks to see if the patient is on oral metronidazole or vancomycin, and recommends that they be discontinued. If the patient has a positive culture, the pharmacist recommends oral metronidazole as the treatment of choice.
• Pharmacy receives a report of all patients receiving vancomycin. "The pharmacist verifies that vancomycin use is in compliance with the appropriate guidelines set forth by the CDC," says Hanf-Kristufek. "If the use of vancomycin does not fit the accepted guidelines, the pharmacist contacts the physician regarding other options of therapy."
Apparently, those methods have worked, because a follow-up DUE performed four months after the first study indicated that of 40 patients receiving oral or parenteral vancomycin, 66% of patients on oral vancomycin and 75% of patients on parenteral vancomycin were receiving it appropriately.
At LeBonheur Children’s Medical Center in Memphis, TN, Kelley R. Lee, PharmD, clinical pharmacy coordinator, and colleagues have also studied vancomycin use related to the CDC guidelines. In a six-month review of 118 pediatric patients, 64 (54%) received the drug inappropriately.2 Pharmacists evaluated all inpatients receiving vancomycin during the second week of each month from September 1995 until March 1996, and followed them until their therapy was completed. Vancomycin use was classified as appropriate or inappropriate based on the CDC guidelines. (The guidelines were modified to include patients such as those with presumed central line infections, for example.) Twenty-four patients received vancomycin for surgical prophylaxis, and 11 received it 96 hours after cultures were negative for B-lactam-resistant gram-positive organisms. The remaining patients received vancomycin for empiric treatment of febrile neutropenia, eradication of MRSA colonization, and other inappropriate reasons.
After the study had proceeded for two months, Lee says the pharmacy sent a letter to physicians outlining the results of the study up to that point and explaining the CDC guidelines. Although that letter appeared to have an "immediate" impact on prescribing with inappropriate use decreasing by 14% soon after the letter was sent out that result also appears to have been "short-lived," she says. During the month the letter was sent out (month three of the study), inappropriate use dropped to 37% from 64% in the previous month, but by the sixth month of the study, it had increased again to 54%.
"It made a short-term difference, but then it seemed to go back to the way it was," she notes.
Lee says pharmacy is now considering placing restrictions on vancomycin use at the hospital so it must be approved by the infectious disease physicians. "But we’ve been discussing probably letting [physicians] use it for up to 72 hours empirically, and after 72 hours, it becomes an automatic infectious disease consult," she adds.
Hanf-Kristufek says the hospital elected not to restrict vancomycin among physicians.
"It leads to some bad feelings, at least from what we’ve found, because the physicians feel as if they can’t make their own decisions," she notes.
Instead, Hanf-Kristufek says the hospital subcommittee elected to improve vancomycin use by having pharmacists notify physicians one-on-one about specific prescribing situations.
"When you just restrict [vancomycin], you’re not really educating them," she says. "A physician can go to another hospital or nursing home in the city where [vancomycin isn’t] restricted and do whatever [he or she] wants. Education works to change patterns. Even if they use it in another hospital, it can still affect us, because that patient can then come here if [he or she] has resistance develop. So just restricting them . . . is really just a quick fix."
At Good Samaritan Hospital in Downers Grove, IL, ICPs have worked with pharmacists and other clinicians as part of a continuous quality improvement (CQI) team to improve use of the CDC guidelines at the hospital. As part of their approach, the team developed a "mandatory vancomycin ordering form," and created policies and procedures to prevent the spread of VRE, such as using dedicated equipment for patients infected with VRE. (See sample form, p. 27.) Since the project was begun in late 1994, VRE cases have decreased from 17 in the first quarter of 1995 to seven cases by the final quarter of 1996, says Dorothy Thompson, RN, CIC, clinical epidemiologist, and Eileen Yaeger, MT, MPH, surveillance coordinator.
Although the ICPs say one of the main reasons VRE cases are down is because of improved prescribing, some physicians still are using vancomycin for the wrong indications. In fact, VRE may even be increasing again, says Yaeger.
"It seems that some of the ordering physicians have found some loopholes to get around the order system," she notes. "So if they have a spot that’s called empiric therapy, they can write something in, and it isn’t really flagged until after the fact. In the last few months, pharmacy has been looking more closely at those orders, because there seems to be a resurgence of VRE in the hospital. We’re attributing that a little bit to the practice of [inappropriate] vancomycin ordering."
Thompson says ICPs are natural partners with pharmacists, physicians, and other clinicians to improve vancomycin use in hospitals.
"We’re supposed to be looking at antibiotic utilization," she notes. "The [CDC] gives us a little meat to help us enforce these guidelines. In the past we haven’t had that."
Yaeger agrees. "A lot of this is up to us," she says. "We’ve got to bring it to everyone’s attention that there still is a problem and not let it get pushed aside. We have to be the ones on the forefront of this, because it is just back burner for everyone else."
References
1. Centers for Disease Control and Prevention. Recom men dations for preventing the spread of vancomycin resistance: Recommendations of the hospital infection control practices advisory committee. MMWR 1995; 44:(No. RR-12)1-13.
2. Logsdon BA, Lee KR, Luedtke G, et al. Evaluation of vancomycin use in a pediatric teaching hospital based on CDC criteria. Infect Control Hosp Epidemiol 1997; 18:780-782.
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