Empiric Vancomycin Reduction in a Pediatric Intensive Care Unit

Lanata, Mariana; Díaz, Alejandro; Hecht, Shaina; Katragkou, Aspasia; Gallup, Nathaniel; Buckingham, Don; Tansmore, Jessica; Sargel, Cheryl; Watson, Joshua R.; Karsies, Todd

doi:10.1542/peds.2020-009142

Cited by 4 publications

(9 citation statements)

References 30 publications

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“…Vancomycin was mainly prescribed empirically, with only 4.1% of all admissions receiving culture‐guided vancomycin treatment. This practice was reported in both adult and paediatric wards, in developed countries such as the United States and developing countries such as Iran 6,20,21 . For instance, Keyserling et al 22 reported that 84% of vancomycin prescription in neonatology wards is empiric.…”

Section: Discussionmentioning

confidence: 97%

“…This practice was reported in both adult and paediatric wards, in developed countries such as the United States and developing countries such as Iran. 6,20,21 For instance, Keyserling et al 22 reported that 84% of vancomycin prescription in neonatology wards is empiric. The high empiric use of vancomycin at JUH is alarming.…”

Section: Discussionmentioning

confidence: 99%

“…4 Unfortunately, many centres report suboptimal practice in terms of underdosing, 5 excessive empiric use, and prolonged administration of empirically prescribed vancomycin in the absence of supporting cultures. [6][7][8] To limit the risks of excessive vancomycin prescription, the Paediatric Infectious Disease Society and the American Academy of Pediatrics recommend via their "Choosing Wisely" campaign to restrict the empirical prescription of vancomycin in newborns, unless there is a known risk of resistance to alternative antibiotics. 9 Imposing such restrictions and optimizing initial maintenance doses based on local guidelines, as shown in Appendix A, and the duration of therapy require a well-structured stewardship program.…”

Section: Introductionmentioning

confidence: 99%

“…Furthermore, inappropriate empiric and prolonged use can result in resistance and increased morbidity in preterm neonates 4 . Unfortunately, many centres report suboptimal practice in terms of underdosing, 5 excessive empiric use, and prolonged administration of empirically prescribed vancomycin in the absence of supporting cultures 6–8 …”

Section: Introductionmentioning

confidence: 99%

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Vancomycin audit in the paediatric population: Patterns of use and appropriateness of therapeutic drug monitoring

Jalil

Khaled

Qaryouti

et al. 2023

Basic Clin Pharma Tox

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Aims: This study aims to investigate prescribing and therapeutic drug monitoring (TDM) practices for vancomycin in paediatrics at the Jordan University Hospital and to determine the impact of inaccuracies in TDM data on dosing decisions.Methods: Patterns of vancomycin prescriptions, appropriateness of vancomycin dosing, duration, TDM, and the accuracy of the recorded dosing/sampling times were determined prospectively based on prespecified criteria. Finally, Monte Carlo simulations were undertaken using the mrgsolve-package in R to assess the effect of inaccuracies in recording dosing/sampling times on subsequent dose adjustments.Results: Four hundred forty-two vancomycin courses were analysed. Vancomycin prescriptions were mainly empirical (77.4%). Initial vancomycin doses were appropriate in 73.1% of vancomycin courses. Prolonged use (>5 days) was found in 45.7% of admissions with negative cultures; this was related to the diagnosis of suspected sepsis unadjusted-OR: 1.8 (1.1-2.9). TDM was appropriately ordered in 90.7% of concentrations. Discrepancies between the recorded and actual times were noted in 83.9% and 82.7% of audited times of dose administration and sample collection, respectively. Based on simulations, these discrepancies were predicted to result in inappropriate dose adjustment in 37.9% of patients. Conclusions: Inappropriate empirical and prolonged vancomycin use and inaccuracies in recording dosing/sampling times are important areas of improvement in the current clinical practice.

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Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Vancomycin audit in the paediatric population: Patterns of use and appropriateness of therapeutic drug monitoring

Jalil

Khaled

Qaryouti

et al. 2023

Basic Clin Pharma Tox

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“…Despite the identification of MRSA among only one in eight patients, vancomycin was used in over three-quarters of all patients. Excessive empiric use of vancomycin contributes to resistance, with minimum inhibitory concentration (MIC) “creep” widely reported in the literature [ 28 , 29 , 30 , 31 ]. The ability for rapid pathogen identification may preclude the prescription of irrelevant antibiotics, thereby removing the need to consider de-escalation in some cases.…”

Section: Discussionmentioning

confidence: 99%

Epidemiology and Economic Outcomes Associated with Timely versus Delayed Receipt of Appropriate Antibiotic Therapy among US Patients Hospitalized for Native Septic Arthritis: A Retrospective Cohort Study

et al. 2022

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Timely administration of appropriate antibiotic therapy is associated with better patient outcomes and lower costs of care compared to delayed appropriate therapy, yet initial treatment is often empiric since causal pathogens are typically unknown upon presentation. The challenge for clinicians is balancing selection of adequate coverage treatment regimens, adherence to antimicrobial stewardship principles to deter resistance, and financial constraints. This retrospective cohort study aimed to assess the magnitude and impact of delayed appropriate antibiotic therapy among patients hospitalized with septic arthritis (SA) in the U.S. from 2017 to 2019 using healthcare encounter data. Timely appropriate therapy was defined as the receipt of antibiotic(s) with in vitro activity against identified pathogens within two days of admission; all other patients were assumed to have received delayed appropriate therapy. Of the 517 patients admitted to hospital for SA who met all selection criteria, 26 (5.0%) received delayed appropriate therapy. In inverse-probability-treatment-weighting-adjusted analyses, the receipt of delayed appropriate therapy was associated with an additional 1.1 days of antibiotic therapy, 1.4 days in length of stay, and $3531 in hospital costs (all vs. timely appropriate therapy; all p ≤ 0.02). Timely appropriate therapy was associated with a twofold increased likelihood of antibiotic de-escalation during the SA admission.

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Antibiotic Indications and Appropriateness in the Pediatric Intensive Care Unit: A 10-Center Point Prevalence Study

Chiotos

Blumenthal

Boguniewicz

et al. 2022

Clinical Infectious Diseases

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Background Antibiotics are prescribed to most pediatric intensive care unit (PICU) patients, but data evaluating indications and appropriateness of antibiotic orders in this population are lacking. Methods We performed a multicenter point prevalence study including children admitted to 10 geographically diverse PICUs over four study days in 2019. Antibiotic orders were reviewed for indication, and appropriateness was assessed using a standardized rubric. Results Of 1462 patients admitted to participating PICUs, 843 (58%) had at least one antibiotic order. A total of 1277 antibiotic orders were reviewed. Common indications were empiric therapy for suspected bacterial infections without sepsis or septic shock (260 orders, 21%), non-operative prophylaxis (164 orders, 13%), empiric therapy for sepsis or septic shock (155 orders, 12%), community acquired pneumonia (CAP) (118 orders, 9%), and post-operative prophylaxis (94 orders, 8%). Appropriateness was assessed for 985 orders for which an evidence-based rubric for appropriateness could be created. Of these, 331 (34%) were classified as inappropriate. Indications with the most orders classified as inappropriate were empiric therapy for suspected bacterial infection without sepsis or septic shock (78 orders, 24%), sepsis or septic shock (55 orders, 17%), CAP (51 orders, 15%), ventilator-associated infections (47 orders, 14%), and post-operative prophylaxis (44 orders, 14%). The proportion of antibiotics classified as inappropriate varied across institutions (range: 19%-43%). Conclusions Most PICU patients receive antibiotics, and based on our study, we estimate that one-third of antibiotic orders are inappropriate. Improved antibiotic stewardship and research focused on strategies to optimize antibiotic use in critically ill children are needed.

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Empiric Vancomycin Reduction in a Pediatric Intensive Care Unit

Cited by 4 publications

References 30 publications

Vancomycin audit in the paediatric population: Patterns of use and appropriateness of therapeutic drug monitoring

Vancomycin audit in the paediatric population: Patterns of use and appropriateness of therapeutic drug monitoring

Epidemiology and Economic Outcomes Associated with Timely versus Delayed Receipt of Appropriate Antibiotic Therapy among US Patients Hospitalized for Native Septic Arthritis: A Retrospective Cohort Study

Antibiotic Indications and Appropriateness in the Pediatric Intensive Care Unit: A 10-Center Point Prevalence Study

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