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Transpl Infect Dis. 2019 Apr;21(2):e13059. doi: 10.1111/tid.13059. Epub 2019 Feb 22.

The impact of a multimodal approach to vancomycin discontinuation in hematopoietic stem cell transplant recipients (HSCT) with febrile neutropenia (FN).

Author information

1
Department of Pharmacy Services, Yale-New Haven Hospital, New Haven, Connecticut.
2
Department of Internal Medicine, Section of Hematology, Yale-New Haven Hospital, New Haven, Connecticut.
3
Department of Internal Medicine, Section of Infectious Diseases, Yale-New Haven Hospital, New Haven, Connecticut.

Abstract

BACKGROUND:

Current guidelines recommend adding vancomycin to empiric treatment of FN in patients who meet specific criteria. After 48 hours, the guidelines recommend discontinuing vancomycin if resistant Gram-positive organisms are not identified. Based on these recommendations, a vancomycin stewardship team defined criteria for discontinuation of vancomycin at 48 hours and increased surveillance of vancomycin usage through a multimodal approach. The purpose of this retrospective analysis is to assess the impact of this multimodal approach on the discontinuation of empiric vancomycin at 48 hours in FN.

METHODS:

This retrospective analysis included a pre- and post-intervention cohort of 200 HSCT recipients with FN from 2015 to 2018. Criteria for continued vancomycin use beyond 48 hours included culture-documented resistant Gram-positive infection, positive Methicillin-Resistant S aureus (MRSA) nasal swab with evidence of pneumonia, or hemodynamic instability with concern for sepsis. The following patient characteristics were collected: previous MRSA infection, MRSA nasal swab collection and results, culture results, duration of vancomycin use, rationale for continuation of vancomycin beyond 48 hours, and re-initiation of vancomycin.

RESULTS:

In the post-intervention cohort, vancomycin discontinuation at 48 hours increased from 31% (95% CI 21.94-40.05) to 70% (95% CI 61.02-78.97; P < 0.0001). An additional 23% of vancomycin orders were discontinued at 72 hours. Off criteria vancomycin use decreased from 33% in pre to 1% in the post-implementation cohort.

CONCLUSION:

Establishing define criteria for vancomycin use in FN patients with a multimodal approach of physicians from hematology and infectious diseases, clinical pharmacists and the antibiotic stewardship team significantly improved vancomycin discontinuation.

KEYWORDS:

antibiotic stewardship; febrile neutropenia; vancomycin

PMID:
30737868
DOI:
10.1111/tid.13059
[Indexed for MEDLINE]

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