• This research was supported by the Oregon Clinical and Translational Research Institute funded by National Center for Advancing Translational Sciences (UL1TR000128).
• Further work is required to determine the impact of these findings on patientso Determine if excessive vancomycin use increased rates of adverse events or
treatment failure • Explore opportunities to reduce vancomycin use such as rapid intervention and de-
escalation of therapy
Vancomycin Use in Community-Acquired Pneumonia: Assessing Inappropriate TherapyTimothy G. Shan, BS1; Sara J. Gore, MD2; Caitlin M. McCracken, MA1; Gregory B. Tallman, PharmD MS
BCPS3; Haley K. Holmer, MPH4; David T. Bearden, PharmD FSIDP1,5; Jessina C. McGregor, PhD FSHEA1
INTRODUCTION
OBJECTIVES
RESULTS
ACKNOWLEDGEMENTS & DISCLOSURES
REFERENCES
CONCLUSIONS
• Empiric therapy with anti-methicillin-resistant Staphylococcus aureus (MRSA) agents for treatment of community-acquired pneumonia (CAP) is recommended only in high-risk patients1
• MRSA is a relatively rare causative pathogen of CAP, accounting for only 0.7% of cases in hospitalized patients2
• Vancomycin is the first line agent for empiric MRSA coverage in most inpatients and may often be used excessively
• There is limited data on duration of vancomycin use that is appropriate in hospitalized patients with CAP
• To evaluate the excess use of vancomycin among patients admitted for CAP
METHODSDesign & Setting• Retrospective, single-center cohort study of hospitalized adults with CAP• IRB approved study • Oregon Health & Science University (OHSU) hospital Inclusion Criteria• Inpatient adults ≥ 18 years old treated with IV vancomycin for CAP between 08/01/2017
and 07/31/2018• Pneumonia encounter ICD-9 diagnosis code • CAP defined as pneumonia acquired outside of the hospital Exclusion Criteria• Hospital acquired pneumonia (HAP)
o defined as pneumonia occurring 48 hours or more after admission, not associated with endotracheal intubation, and not incubating at time of admission
• Ventilator associated pneumonia (VAP)o defined as pneumonia occurring >48 hours or more after endotracheal intubation
Data Collection• Demographics, diagnostic codes, laboratory and pharmacy data were obtained from the
Pharmacy Research Repository • CAP patients, appropriateness, and duration of inappropriate therapy identified
through manual chart review Outcome• Inappropriate vancomycin use was determined as follows:
o Culture positive for gram negative organism, yeast, or funguso Narrower spectrum therapy available based on the lack of MRSA risk factors or
culture with methicillin susceptible Staphylococcus aureus o Duration of therapy exceeding the recommended duration set by IDSA guidelines for
CAP o Redundant therapy including more than one anti MRSA agent o Lack of infectious process
Analysis • Inappropriate vancomycin use was reported as days of therapy per patient-day • Patient characteristics and reasons for inappropriate use were summarized
• 52 patients were identified for inclusion o 11/52 (21%) patients had risk factors warranting empiric vancomycin therapy o 22/52 (42%) patients had sepsis at the time of admission
• Median duration of therapy was 2 days (interquartile range: 1-3) • 9/52 (17%) patients received inappropriate courses of vancomycin
o Median duration of inappropriate therapy was 1 day (IQR: 1-2.25)o 20/125 (16%) of vancomycin days of therapy were inappropriate o 7/9 (78%) patients had positive cultures
• 51/52 (98%) of patients had cultures performedo 23/52 (44%) grew no organism
Total Cohort (n=52)Age, mean (SD) 68 (17.5)Male 32 (61.5)Race
White 45 (86.5)Black/African American 1 (1.9)Asian/Pacific Islander 3 (5.8)More than one race 3 (5.8)
EthnicityHispanic or Latino 7 (13.5)Not Hispanic or Latino 45 (86.5)
Route of admissionClinic or physician 3 (5.8)Non-healthcare facility 30 (58)Transfer from hospital 17 (33)Transfer from SNF 2 (3.8)
Culture results 51 (98)No organism identified 23 (44)
Risk factorsHistory of MRSA 4 (7.7)History of IV drug use 3 (5.7)Recent IV antibiotics 4 (7.7)
Appropriate(n = 43)
Inappropriate(n = 9)
Route of admissionClinic or physician 3 (7) 0Non-healthcare facility 26 (60.5) 4 (44.4)Transfer from hospital 13 (30.2) 4 (44.4)Transfer from SNF 1 (2.3) 1 (11.1)
Average length of stay (d) 10 16Average length of therapy (d) 2.5 3.3
1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007;44(Supplement_2):S27-S72.
2. 1. Self WH, Wunderink RG, Williams DJ, et al. Staphylococcus aureus Community-acquired Pneumonia: Prevalence, Clinical Characteristics, and Outcomes. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2016;63(3):300-309.
Table 1: Patient characteristics
Table 2: Characteristics based on appropriateness
• CAP patients accounted for a small number of pneumonia patients who received vancomycin
• The median inappropriate DOT was short• Concomitant sepsis was the most common reason for appropriate empiric vancomycin
therapy• Continuation of vancomycin after organism identification from a culture was the most
frequent reason for inappropriate therapy• Admission from a non-healthcare facility or outside hospital accounted for the majority
of inappropriate therapy which may present as another opportunity for intervention • Rapid identification and intervention may help further reduce the duration of
inappropriate therapy
FUTURE OPPORTUNITIES
Total Inappropriate (n =9)Reason for Inappropriate therapy
Culture positive for gram negative organism, yeast, or fungus 6 (66.7)Narrower spectrum antibiotic therapy 2 (22.2)Longer treatment duration than indicated 1 (11.1)Redundant therapy 0Lack of infectious process 0
Entire course inappropriate 1 (11)Partial course inappropriate 8 (89)
Table 3: Reason for inappropriate therapy
Timothy Shan: [email protected]
