CITATION: Peto RR. 1997. Examining vancomycin use in hospitalized Medicare patients in the United States. APUA Newsletter 15(3):1-2.

Recommendations for Preventing the Spread of Vancomycin Resistance. Recommendations of the Hospital Infection Control Practices Advisory
Committee. 1995.
MMWR 44(RR-12):1-13.

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Examining vancomycin use in hospitalized Medicare patients in the United States
Randolph R Peto, MD, MPH
MassPRO, Waltham, Massachusetts, USA

Is it too late to try to reduce the use of broad-spectrum antibiotics in American hospitals? A government coordinated project in the eastern portion of the United States is based on the hypothesis that it is not too late. The Health Care Financing Administration (HCFA) brought together a group of quality improvement organizations to examine vancomycin use in hospitalized Medicare patients (the vast majority of whom are 65 years and older). This is one of many projects in the Health Care Quality Improvement Program (HCQIP), initiated by HCFA in 1993 to apply state-of-the-art tools of quality measurement and quality improvement to services provided to Medicare patients. Other current HCQIP infectious disease projects include the early diagnosis and treatment of hospitalized community-acquired pneumonia, diagnosis and treatment of urinary tract infections, and use of pneumococcal and influenza vaccines.

The project to examine vancomycin use was built around guidelines from the Hospital Infection Control Practices Advisory Committee (HICPAC)
1. The committee, in conjunction with the US Centers for Disease Control and Prevention, focused particularly on suggestions to prevent the spread of vancomycin-resistance.

The guidelines summarize situations in which vancomycin use is "prudent," "appropriate" or "acceptable" and include:

  1. treatment of serious infections caused by beta-lactam-resistant gram-positive organisms.
  2. treatment of infections caused by gram-positive microorganisms in patients who have serious allergies to beta-lactam antimicrobials.
  3. when antibiotic-associated colitis fails to respond to metronidazole therapy or is severe and potentially life-threatening.
  4. prophylaxis, as recommended by the American Heart Association, for endocarditis following certain procedures in patients at high risk for endocarditis.
  5. prophylaxis for major surgical procedures involving implantation of prosthetic materials or devices at institutions that have a high rate of infections caused by methicillin-resistant S.epidermidis or methicillin-resistant S. aureus.

Using these guidelines, the HICPAC project is assessing the levels of "unsupported" vancomycin use among hospitalized Medicare patients. To date, the project has completed baseline data collection from patients hospitalized in the first half of 1995. The overall results have not yet been published in the peer-reviewed literature. However, this article presents preliminary information from 550 patients in six participating hospitals in Massachusetts only (one of 14 states and U.S. territories participating in the overall project). Analysis of the Massachusetts data suggest significant opportunities for improvement.

The range of unsupported use in each hospital varied from about 40% to 60%. Up to 80% of the surgical use did not meet guideline criteria. It appears that up to one-half of the unsupported use in surgery could be eliminated if prophylactic coverage was discontinued after a maximum of two doses. Much of the rest of the unsupported use might be eliminated if vancomycin was restricted to situations in which serious allergy to beta-lactam agents was unmistakable. For example, the project did not consider gastrointestinal side effects (diarrhea, nausea, etc.) from beta-lactams to be serious allergies. However, fear of potential medical malpractice liability may account for reluctance of U.S. physicians to prescribe antibiotics if the patient history suggests any type of side effect, not just a serious well-documented allergic reaction.

Instances of unsupported use were more numerous with medical therapy (e.g., treatment of suspected serious infections) than in surgical prophylaxis. Vancomycin was used in about 10% of cases with cultures positive for Gram-positive organisms and sensitive to beta-lactams. These findings suggest a failure to reevaluate antibiotic therapy when culture and antimicrobial sensitivity studies are complete.

The guidelines do not support, but also do not refute, the empiric use of vancomycin for suspected serious infections while awaiting the results of cultures. In the HCFA project analyses however, most empiric use is considered unsupported if 1) cultures were never obtained or 2) culture results were negative for gram-positive organisms. Responding to the baseline results of the study, some infectious disease physicians in the participating hospitals appear unwilling to withhold empiric vancomycin therapy while awaiting culture results. In fact, the study was not designed to be able to resolve this area of contention fully. The study only examined vancomycin uses in each hospital. Other antibiotics prescribed for suspected cases of serious gram-positive infections were not examined.

The guideline authors do not suggest ways to enhance compliance with the recommendations, stating, ". . . Further study is required to determine the most effective methods for influencing the prescribing practices of physicians. "As part of this HCQIP project, participating quality improvement organizations will remeasure hospital vancomycin use after individual improvement plans have been carried out. Project leaders plan to share innovative intervention strategies and lessons learned after the next phase of the project has been completed. This cooperative effort should help in reducing "unsupported" vancomycin use in the future.

Note: The analyses upon which this publication is based were performed under Contract number 500-96-P601, entitled, "Utilization and Quality Control Peer Review Organization for the State of Massachusetts," sponsored by the Health Care Financing Administration, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services. The author assumes full responsibility for the accuracy and completeness of the ideas presented.



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