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Use of nares swab to de-escalate vancomycin for patients with suspected methicillin-resistant Staphylococcus aureus
Joshua Gentges1, Nadeem El-Kouri1, Tashrique Rahman2
1Department of Emergency Medicine, The University of Oklahoma School of Community Medicine (OUSCM), Tulsa, OK, USA.
Introduction:
According to the US Center for Disease Control and Prevention, 30%-50% of antibiotic use in hospitals is unnecessary or inappropriate. The coronavirus disease 2019 pandemic further complicates antibiotic use leading to greater initiation of empiric antibiotics. The result is antibiotic overuse and increased duration of unnecessary therapy. Vancomycin is a drug of last resort, primarily relegated to the treatment of Methicillin-Resistant Staphylococcus aureus (MRSA). De-escalating vancomycin can mean waiting on MRSA culture results, which may take up to 96 h. Nares screening for MRSA is shown to possess high negative predictive value for ruling out suspected MRSA pneumonia, intra-abdominal infections, and bacteremia.
Methods:
This before-and-after study examines the impact of vancomycin therapy de-escalation due to absence of MRSA colonization detected via PCR assay of nares swabs. An intervention with providers using SMART goals was designed to increase nasal swabbing for MRSA and ultimately decrease vancomycin use at a large, tertiary-care urban hospital.
Results:
There was a significant increase in use of vancomycin nares swabs (28/150 vs 48/100, p = 0.040) in the immediate pre/postintervention period, and significant decreases in vancomycin usage days/1,000 patient days of 2.34% per month (p = 0.039) over a two year period after the intervention.
Conclusion:
An intervention using PCR nares swabs to detect MRSA led to significant, lasting decreases in vancomycin usage at this hospital. Similar interventions should be planned at hospitals experiencing overuse of this antibiotic.
Insights
Implementing nasal swabs for Methicillin-Resistant Staphylococcus aureus (MRSA) screening significantly reduced unnecessary vancomycin use in hospitals. This strategy aids in de-escalating antibiotic therapy and optimizing antimicrobial stewardship.
Area of Science:
- Infectious Diseases
- Clinical Pharmacy
- Antimicrobial Stewardship
Background:
- Antibiotic overuse, including vancomycin, is a significant issue in hospitals, exacerbated by the COVID-19 pandemic.
- Vancomycin, a last-resort antibiotic for Methicillin-Resistant Staphylococcus aureus (MRSA), is often used empirically.
- De-escalating vancomycin therapy can be delayed by the need for culture results, which take up to 96 hours.
Purpose of the Study:
- To evaluate the impact of vancomycin therapy de-escalation guided by MRSA nares screening.
- To assess the effectiveness of an intervention aimed at increasing MRSA nasal swabbing and reducing vancomycin use.
Main Methods:
- A before-and-after study design was employed at a large, tertiary-care urban hospital.
- An intervention utilizing SMART goals encouraged providers to increase MRSA nares screening via PCR assay.
- The study examined changes in vancomycin usage days and MRSA nares swab utilization.
Main Results:
- A significant increase in the utilization of vancomycin nares swabs was observed post-intervention (28/150 vs. 48/100, p = 0.040).
- Significant monthly decreases in vancomycin usage days per 1,000 patient days were recorded (2.34%, p = 0.039) over two years.
- The intervention demonstrated lasting reductions in vancomycin consumption.
Conclusions:
- PCR-based MRSA nares screening effectively reduces vancomycin usage.
- This intervention offers a sustainable strategy for optimizing vancomycin therapy and antimicrobial stewardship.
- Hospitals facing vancomycin overuse should consider implementing similar MRSA screening protocols.
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