Background
Vancomycin has been considered the standard of therapy for infections caused by methicillin-resistant Staphylococcus aureus (MRSA) for decades. The aims of this study were to describe the clinical outcomes of patients with infections caused by MRSA with a vancomycin minimum inhibitory concentration (MIC) of 2 mcg/mL and determine whether achievement of a high vancomycin trough concentration affected outcomes.
Methods
A retrospective analysis was conducted on data from a single medical center from 2003 through 2007. The study included patients with a culture positive for MRSA with a vancomycin MIC of 2 mcg/mL who received vancomycin therapy. Treatment groups were determined by weighted average vancomycin trough concentration. Subjects were assigned to either the conventional (less than 15 mcg/mL) or high (15 mcg/mL or higher) trough group. Outcome measures included attainment of clinical cure, all-cause mortality, and occurrence of nephrotoxicity.
Results
Of the 79 patients included in the study, 50 (63.3%) attained clinical cure. Rate of clinical cure was similar between the conventional and high trough groups (64.7% vs 60.7%, P = 0.7). Treatment arms were similar in regard to all-cause mortality and other secondary endpoints. Patients demonstrating clinical response at 72 hours were significantly more likely to progress to clinical cure than those continuing to show signs of infection (77.8% vs 32.5, P < 0.001).
Conclusions
Use of vancomycin for the treatment of MRSA with a vancomycin MIC of 2 mcg/mL resulted in a low rate of clinical cure. Data from this study suggest that achieving higher vancomycin trough concentrations is not a sufficient strategy for enhancing efficacy in these challenging infections.
Early warning scores are algorithms designed to identify clinical deterioration. Current literature is predominantly in non-Veteran populations. Studies in Veterans are lacking. This study was a prospective quality improvement project deploying and assessing the National Early Warning Score (NEWS) at Kansas City VA Medical Center. Performance of NEWS was assessed as follows: discrimination for predicting a composite outcome of intensive care unit transfer or mortality within 24 hours via area under the receiver operating curve. A total of 4781 Veterans with 142 375 NEWS values were included. The NEWS area under the receiver operating curve for the composite outcome was 0.72 (95% CI, 0.71-0.74), indicating acceptable predictive accuracy. A NEWS of ≥7 was more likely associated with the composite outcome versus <7 (13.6% vs 0.8%; P < 0.001). This is one of the first studies to demonstrate successful deployment of NEWS in a Veteran population, with resultant important implications across the Veterans Health Administration.
186Applied Clinical Informatics M.E. Patterson et al.: Associations between the concurrent use of clinical decision support and computerized provider order entry and the rates of appropriate prescribing at discharge
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