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Published on: August 30, 2018
Improving Vancomycin Stewardship in Critically Ill Children
Kathleen Chiotos1,2,3,4,5, Julie C Fitzgerald1,4,5, Molly Hayes3
1Division of Critical Care Medicine, Department of Anesthesiology and Critical Care.
Background And Objectives:
Inappropriate vancomycin use is common in children's hospitals. We report a quality improvement (QI) intervention to reduce vancomycin use in our tertiary care PICU.
Methods:
We retrospectively quantified the prevalence of infections caused by organisms requiring vancomycin therapy, including methicillin-resistant Staphylococcus aureus (MRSA), among patients with suspected bacterial infections. Guided by these data, we performed 3 QI interventions over a 3-year period, including (1) stakeholder education, (2) generation of a consensus-based guideline for empiric vancomycin use, and (3) implementation of this guideline through clinical decision support. Vancomycin use in days of therapy (DOT) per 1000 patient days was measured by using statistical process control charts. Balancing measures included frequency of bacteremia due to an organism requiring vancomycin not covered with empiric therapy, 30-day mortality, and cardiovascular, respiratory, and renal organ dysfunction.
Results:
Among 1276 episodes of suspected bacterial infection, a total of 19 cases of bacteremia (1.5%) due to organisms requiring vancomycin therapy were identified, including 6 MRSA bacteremias (0.5%). During the 3-year QI project, overall vancomycin DOT per 1000 patient days in the PICU decreased from a baseline mean of 182 DOT per 1000 patient days to 109 DOT per 1000 patient days (a 40% reduction). All balancing measures were unchanged, and all cases of MRSA bacteremia were treated empirically with vancomycin.
Conclusion:
Our interventions reduced overall vancomycin use in the PICU without evidence of harm. Provider education and consensus building surrounding indications for empiric vancomycin use were key strategies.
Insights
Quality improvement initiatives successfully reduced vancomycin use in a pediatric intensive care unit (PICU). This intervention decreased vancomycin days of therapy by 40% without increasing harm, demonstrating effective antibiotic stewardship.
Area of Science:
- Pediatric Intensive Care
- Infectious Diseases
- Quality Improvement
Background:
- Inappropriate vancomycin use is a recognized issue in pediatric healthcare settings.
- A quality improvement (QI) initiative was designed to address and reduce vancomycin utilization within a tertiary care Pediatric Intensive Care Unit (PICU).
Purpose of the Study:
- To quantify the prevalence of infections requiring vancomycin, including methicillin-resistant Staphylococcus aureus (MRSA).
- To implement and evaluate a multi-faceted QI intervention aimed at reducing vancomycin use in the PICU.
- To assess the impact of interventions on vancomycin Days of Therapy (DOT) and key safety indicators.
Main Methods:
- Retrospective analysis of infections requiring vancomycin therapy.
- Implementation of three QI interventions: stakeholder education, guideline development, and clinical decision support.
- Measurement of vancomycin DOT using statistical process control charts.
- Monitoring of balancing measures including bacteremia rates, mortality, and organ dysfunction.
Main Results:
- A 40% reduction in vancomycin DOT per 1000 patient days was observed over the 3-year QI project (from 182 to 109).
- Prevalence of infections requiring vancomycin was low (1.5%), with MRSA bacteremia at 0.5%.
- No significant changes were noted in balancing measures, indicating no increase in harm.
Conclusions:
- QI interventions effectively decreased vancomycin use in the PICU without adverse effects.
- Provider education and consensus-based guidelines were critical components for successful implementation.
- The study highlights the feasibility and safety of reducing vancomycin use through targeted QI strategies.
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