Giuseppe
Emeritus
[Source: Antimicrobial Agents and Chemotherapy, full page: (LINK). Abstract, edited.]
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A Trial of Discontinuation of Empiric Vancomycin Therapy in Patients with Suspected Methicillin-Resistant Staphylococcus aureus Healthcare-Associated Pneumonia
John M. Boyce, MD 1,2↴, Olivia-Fabiola Pop, MD 2, Odaliz Abreu-Lanfranco, MD 3, Whitney Y. Hung, PharmD 4, Ann Fisher, MD 2,3, Afshin Karjoo, PharmD 4, Benjamin Thompson, DO 5,6 and Zenon Protopapas, MD 5,6
Author Affiliations: <SUP>1</SUP>Hospital Epidemiology and Infection Control Program, Yale-New Haven Hospital, New Haven, CT; <SUP>2</SUP>Department of Medicine, Yale University School of Medicine, New Haven, CT; <SUP>3</SUP>Northeast Medical Group, New Haven, CT; <SUP>4</SUP>Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT; <SUP>5</SUP>Department of Diagnostic Radiology, Yale-New Haven Hospital, New Haven, CT; <SUP>6</SUP>Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT
ABSTRACT
Background:
Healthcare-associated pneumonia (HCAP) guidelines recommend de-escalating initial antibiotic therapy based on results of lower respiratory tract cultures. In the absence of adequate lower respiratory cultures, physicians are sometimes reluctant to discontinue empiric vancomycin given for suspected methicillin-resistant Staphylococcus aureus (MRSA) HCAP. We evaluated a strategy of discontinuing vancomycin if both nasal and throat cultures were negative for MRSA when lower respiratory cultures were not available.
Methods:
An antimicrobial stewardship team identified patients receiving empiric vancomycin for suspected or proven HCAP, but for whom adequate lower respiratory cultures were not available. Nasal and throat swab specimens were obtained and plated on MRSA selective media. If both nasal and throat MRSA cultures were negative, the stewardship team recommended discontinuation of empiric vancomycin. Demographic and clinical aspects, a clinical pulmonary infection score (CPIS) on the day of the stewardship recommendation, and mortality of patients for whom vancomycin was discontinued were obtained by retrospective chart review.
Results:
A convenience sample of 91 patients with nasal and throat cultures negative for MRSA in the absence of adequate respiratory cultures had empiric vancomycin therapy discontinued. A retrospective review revealed that 88 (97%) of patients had a CPIS ≤ 6 on the day of the stewardship recommendation. In-hospital mortality (7.7%) was similar to a previous study of de-escalation of antibiotics in pneumonia patients without adequate cultures.
Conclusion:
In the absence of adequate lower respiratory cultures, it is reasonable to discontinue empiric vancomycin HCAP therapy in patients with negative MRSA nasal and throat cultures and CPIS <6.
FOOTNOTES
Corresponding author: John M. Boyce, MD, Hospital Epidemiology and Infection Control, Yale-New Haven Hospital, 20 York Street, New Haven, CT 06510-3202 Tele 203-688-4634, Fax 2-3-688-2823, Email: John.Boyce@ynhh.org
Copyright ? 2012, American Society for Microbiology. All Rights Reserved.
-John M. Boyce, MD 1,2↴, Olivia-Fabiola Pop, MD 2, Odaliz Abreu-Lanfranco, MD 3, Whitney Y. Hung, PharmD 4, Ann Fisher, MD 2,3, Afshin Karjoo, PharmD 4, Benjamin Thompson, DO 5,6 and Zenon Protopapas, MD 5,6
Author Affiliations: <SUP>1</SUP>Hospital Epidemiology and Infection Control Program, Yale-New Haven Hospital, New Haven, CT; <SUP>2</SUP>Department of Medicine, Yale University School of Medicine, New Haven, CT; <SUP>3</SUP>Northeast Medical Group, New Haven, CT; <SUP>4</SUP>Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT; <SUP>5</SUP>Department of Diagnostic Radiology, Yale-New Haven Hospital, New Haven, CT; <SUP>6</SUP>Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT
ABSTRACT
Background:
Healthcare-associated pneumonia (HCAP) guidelines recommend de-escalating initial antibiotic therapy based on results of lower respiratory tract cultures. In the absence of adequate lower respiratory cultures, physicians are sometimes reluctant to discontinue empiric vancomycin given for suspected methicillin-resistant Staphylococcus aureus (MRSA) HCAP. We evaluated a strategy of discontinuing vancomycin if both nasal and throat cultures were negative for MRSA when lower respiratory cultures were not available.
Methods:
An antimicrobial stewardship team identified patients receiving empiric vancomycin for suspected or proven HCAP, but for whom adequate lower respiratory cultures were not available. Nasal and throat swab specimens were obtained and plated on MRSA selective media. If both nasal and throat MRSA cultures were negative, the stewardship team recommended discontinuation of empiric vancomycin. Demographic and clinical aspects, a clinical pulmonary infection score (CPIS) on the day of the stewardship recommendation, and mortality of patients for whom vancomycin was discontinued were obtained by retrospective chart review.
Results:
A convenience sample of 91 patients with nasal and throat cultures negative for MRSA in the absence of adequate respiratory cultures had empiric vancomycin therapy discontinued. A retrospective review revealed that 88 (97%) of patients had a CPIS ≤ 6 on the day of the stewardship recommendation. In-hospital mortality (7.7%) was similar to a previous study of de-escalation of antibiotics in pneumonia patients without adequate cultures.
Conclusion:
In the absence of adequate lower respiratory cultures, it is reasonable to discontinue empiric vancomycin HCAP therapy in patients with negative MRSA nasal and throat cultures and CPIS <6.
FOOTNOTES
Corresponding author: John M. Boyce, MD, Hospital Epidemiology and Infection Control, Yale-New Haven Hospital, 20 York Street, New Haven, CT 06510-3202 Tele 203-688-4634, Fax 2-3-688-2823, Email: John.Boyce@ynhh.org
Copyright ? 2012, American Society for Microbiology. All Rights Reserved.
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