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Published on: November 9, 2016
Vancomycin Use in Patients Discharged From the Emergency Department: A Retrospective Observational Cohort Study
Kristen Mueller1, Craig McCammon2, Lee Skrupky2
1Division of Emergency Medicine, Washington University School of Medicine and Barnes Jewish Hospital, Saint Louis, Missouri.
Background:
Infections due to methicillin-resistant Staphylococcus aureus (MRSA) are associated with significant morbidity and mortality and are typically treated with intravenous vancomycin. Given vancomycin's time-dependent mechanism of action, it is unlikely that vancomycin administration in the emergency department (ED) prior to disposition home could be beneficial.
Study Objectives:
To characterize the indications, dosing, and appropriateness of vancomycin use in patients discharged from the ED.
Methods:
This is a single-center retrospective observational cohort study of patients who received vancomycin in an urban, academic, tertiary care ED. The subjects were consecutive adult patients administered intravenous vancomycin in the ED and then discharged home over an 18-month period. Outcomes were measured 1) to characterize patients receiving vancomycin prior to discharge home from the ED; and 2) to identify patients that did not meet indications for appropriate use based on the 2011 Infectious Diseases Society of America guidelines for treating MRSA infections.
Results:
There were 526 patients that received vancomycin in the ED prior to discharge during the study period. In this cohort, 368 (70%) patients were diagnosed with skin and soft tissue infections. A MRSA risk factor was present in 396 (75%) patients. Prior to discharge, one dose of vancomycin was administered to 357 (68%) patients. Underdosing of vancomycin occurred in 239 (73%) patients.
Conclusions:
Vancomycin was given frequently to patients discharged home from the ED, most commonly for conditions where vancomycin was not indicated, such as skin and soft tissue infections. The majority of these patients received a vancomycin dosing strategy that is not only unlikely to lead to clinical improvement, but also has the potential to contribute adversely to the development of antibiotic resistance. Further investigation is needed into the impact of vancomycin use, the emergence of vancomycin resistance, and the role of ED-based antibiotic stewardship.
Insights
Vancomycin was frequently administered to patients discharged from the emergency department (ED), often for inappropriate indications like skin infections, and frequently underdosed, potentially worsening antibiotic resistance.
Area of Science:
- Infectious Diseases
- Pharmacology
- Antibiotic Stewardship
Background:
- Methicillin-resistant Staphylococcus aureus (MRSA) infections cause significant illness and death.
- Intravenous vancomycin is the standard treatment for MRSA.
- Vancomycin's efficacy is time-dependent, questioning its utility when given in the ED before discharge.
Purpose of the Study:
- To analyze the reasons for vancomycin use in patients discharged from the ED.
- To evaluate the appropriateness of vancomycin dosing and indications.
- To assess the impact on antibiotic resistance and inform stewardship.
Main Methods:
- Retrospective observational cohort study in an urban academic tertiary care ED.
- Included adult patients receiving IV vancomycin and discharged home over 18 months.
- Assessed indications against 2011 IDSA MRSA guidelines.
Main Results:
- 526 patients received vancomycin before ED discharge.
- 70% had skin and soft tissue infections; 75% had MRSA risk factors.
- 68% received one dose; 73% were underdosed.
Conclusions:
- Vancomycin use in discharged ED patients was common, often for non-indicated conditions.
- Inappropriate dosing and indications may not improve outcomes and risk resistance.
- Further research on vancomycin's ED impact and stewardship is necessary.
