CDC VRE guidelines still relevant
Prevention, control require coordinated effort
The Hospital Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) in Atlanta published Recommendations for Preventing the Spread of Vancomycin Resistance a few years ago. (See key recommendations on p. 29.) The suggestions focus on vancomycin-resistant enterococci (VRE) and stress that the antibiotic should be reserved for treating patients who have severe allergies to other antibiotics or infections that resist other antibiotics. The entire document can be accessed on the Internet at http://www.cdc.gov/ncidod/vancom.htm."I know nothing new has come out from the CDC since then," says Paul J. Deziel, PA-C, MHA, a physician assistant in the division of infectious disease at The Grace Hospital, a division of Wayne State University School of Medicine in Detroit. "Those guidelines probably won’t be changed soon because they were written in anticipation of a resistance problem. That’s why they were issued." HICPAC specifically mentions a concern about vancomycin-resistant Staphylococcus aureus (VRSA) under the vancomycin usage section. The guidelines also discuss the fact that vancomycin use has been a risk factor for infection with VRE. "There’s not much else they can say," continues Deziel.
HICPAC’s recommendations emphasize that prevention and control of vancomycin resistance requires a coordinated, concerted effort among various hospital departments. HICPAC strongly encourages hospitals to develop institution-specific plans, which should stress the following elements:
• prudent vancomycin use by clinicians;
• education of hospital staff regarding vancomycin resistance;
• early detection and prompt reporting of VRE and resistance in other gram-positive micro organisms by the hospital microbiology laboratory;
• immediate implementation of appropriate infection-control measures to prevent person-to-person transmission of VRE.
The guidelines were developed with limited data, and further research is needed to find cost-effective ways to control the spread of the problem.
A recent study by the Health Care Financing Administration (HCFA) revealed that 63% of orders for vancomycin violated CDC guidelines. Researchers reviewed more than 7,000 patient records at 131 hospitals. HCFA officials said physicians tend to rely on the drug as a catch-all, rather than waiting up to 72 hours for a laboratory culture to more definitively determine its appropriateness.
Rob Stanton, PharmD, clinical pharmacist at Cabell Huntington Hospital in Huntington, WV, says his facility and surrounding hospitals ran a similar study and came up with "nowhere near that percentage." Their noncompliance figures were much lower. "I find it hard to believe that any hospital would have such a high noncompliance rate," says Stanton. "Those findings may be the result of garbage-in-garbage-out information."
Another study found that 44 out of 66 identified inappropriate vancomycin uses were due to empi ric treatment without obtaining cultures. The threat of methicillin-resistant S. aureus (MRSA) frequently was cited as a reason for vancomycin use, but the authors noted that a "a number of antibiotic agents were potentially useful alternatives, but were used rarely."1 The authors also noted that shortening the course of empiric therapy should decrease the amount of vancomycin used.
Programs targeted at inappropriate use of vancomycin have proven effective at some hospitals, particularly if the efforts are accepted by attending physicians. Examples include the following:
• At the University of Pennsylvania Health Systems in Philadelphia, vancomycin was used inappropriately in 65% of cases until 18 months ago, says Neil Fishman, director of antimicrobial management there. The organization launched an aggressive campaign that brought the figure down to about 10%.
• At Grace Hospital, when physicians want to prescribe restricted antibiotics, they must contact the infectious disease department. "Physicians can get some broad-spectrum anti biotics, but for only 24 hours," says Deziel. "Then the infectious disease department has to approve the order."
• A similar protocol exists at Strong Memorial Hospital at the University of Rochester (NY) Medical Center. "We provide a 24-hour window," says Gail Mowrer, RN, CIC, an infection control nurse there. "If a physician at Strong orders vancomycin, the pharmacy will issue it. But then the doctor needs to get approval from the infection control department for continuation. We don’t want to restrict the drug from getting to a patient who needs it quickly."
Reference
1. Evans ME, Kortas KJ. Vancomycin use in a university medical center: Comparison with Hospital Infection Control Practices Advisory Committee guidelines. Infect Control Hosp Epidemiol 1996; 17:356-359.
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