Vancomycin and Home Health Care

Thomas G. Fraser; Valentina Stosor; Qiong Wang; Anne Allen; Teresa R. Zembower

Disclosures

Emerging Infectious Diseases. 2005;11(10) 

In This Article

Abstract and Introduction

The Hospital Infection Control Practices Advisory Committee published guidelines for prudent use of vancomycin to combat increasing resistance to antimicrobial drugs. Studies examining compliance with these guidelines primarily involve hospitalized patients. The growing practice of home use of antimicrobial drugs led to this retrospective cohort study that evaluated parenteral vancomycin use in patients receiving it through a homecare agency. We found that 39.2% of outpatients received vancomycin outside the guidelines, mainly because of prolonged empiric therapy, dosing convenience, and prolonged use after surgery. Patients were more likely to receive vancomycin appropriately if they were >65 years of age, had a history of malignancy, or were discharged from a medical service. In addition, obtaining wound cultures and attempting a microbiologic diagnosis led to more appropriate vancomycin use. Recommendations for prudent vancomycin use are often overlooked when selecting antimicrobial drugs for home infusion. The public health impact of this practice remains unknown.

Vancomycin is an important agent for the treatment of serious infections caused by gram-positive bacteria.[1] Over the past 3 decades, its use has steadily increased because of increasing prevalence of β-lactam-resistant nosocomial pathogens, particularly, methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci (CoNS).[2,3] A consequence of this increased use has been the emergence and spread of vancomycin-resistant enterococci, the isolation of S. aureus with reduced susceptibility to glycopeptides, and, most recently, reports of infections caused by vancomycin-resistant S. aureus.[4–6]

Antimicrobial stewardship guidelines have been developed to ensure that vancomycin is used appropriately and retains its viability in the therapeutic armamentarium. The most broadly accepted benchmark was published by the Hospital Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention.[7] These guidelines and most efforts to control use of antimicrobial drugs target the hospital setting.[8–12] However, the prevalence of drug-resistant pathogens in outpatient and ambulatory settings is increasing, as demonstrated by the prevalence of penicillin-resistant pneumococci and recent emergence of community-onset MRSA.[13,14] With an increasing number of patients receiving home infusions of antimicrobial drugs, the appropriateness of choices of drugs for outpatients warrants scrutiny. Guidelines for the administration of outpatient parenteral antibiotic therapy (OPAT) noted this and encouraged adherence to HICPAC guidelines.[15]

We conducted a retrospective cohort study of patients discharged from an academic medical center to complete a course of intravenous vancomycin at home. The main objectives were to describe the epidemiology of outpatients receiving vancomycin through a home healthcare agency, determine the appropriateness of outpatient vancomycin prescriptions according to HICPAC guidelines, and examine factors associated with outpatient vancomycin use that conformed to HICPAC guidelines.

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