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

Methods

Northwestern Memorial Hospital (NMH) is a 725-bed teaching hospital in Chicago, Illinois. Northwestern Memorial Home Health Care, Inc. (NMHHC), the home healthcare agency affiliated with NMH, receives >200 annual referrals for home infusion of antimicrobial agents.

This study included all inpatients at NMH referred to NMHHC to complete a course of intravenous vancomycin therapy from December 1997 to April 2002. Patients were excluded if they were <16 years of age, admitted to the hospital already receiving vancomycin, discharged to any other facility, or received care from another homecare agency before referral to NMHHC. For patients with multiple referrals to NMHHC for vancomycin therapy, only their first treatment episode was included. During this study, although vancomycin use guidelines were published and distributed within NMH, no formal enforcement policy existed within the hospital or homecare setting. The institutional review board of Northwestern University reviewed and approved the study protocol.

All data were originally collected as part of routine patient care. For this study, clinical data were abstracted retrospectively by review of existing inpatient medical records, home health referral forms, and the inpatient pharmacy database. The data abstractor had no part in the original data collection. The following data were abstracted: demographic information, length of hospital stay, admitting service, insurance status, allergy to β-lactam antimicrobial drugs, level of serum creatinine on the day of discharge, history of end-stage renal disease requiring dialysis, infectious diseases consultation, use of vancomycin in the hospital, reason(s) for vancomycin use, and discharge diagnoses per ICD-9 codes. ICD-9 codes were used to calculate a mean Charlson comorbidity score for each patient.[16,17] With 1 exception, the presence of infectious syndromes was determined by review of ICD-9 diagnoses. A diagnosis of bloodstream infection was assigned if multiple positive blood cultures were documented, regardless of coded diagnoses. Because of the retrospective nature of the evaluation, all recorded allergies to β-lactam antimicrobial drugs were considered potentially serious.

The microbiology records spanning the length of the hospitalization for each patient were reviewed. A microbiologic evaluation occurred if cultures were obtained that reasonably corresponded to the infectious diagnosis requiring the use of vancomycin. Record review focused on collection of cultures from blood, other sterile sites, urine, sputum, intravenous catheters or other foreign bodies, and wounds or tissues. Bacterial isolates that were specifically recorded were gram-positive organisms whose treatment might prompt or warrant the use of vancomycin, including methicillin-susceptible S. aureus, MRSA, CoNS, streptococci, ampicillin-resistant or -susceptible enterococci, and Corynebacterium jeikeium.

HICPAC guidelines served as the basis for determining whether patients received parenteral vancomycin per guidelines or outside guidelines ( Table 1 ). The guidelines pertaining to prophylaxis for endocarditis (1C), surgical procedures (1D and 2A), and low-birthweight infants (2G) did not apply and were disregarded.

In addition, vancomycin use was determined to fall outside HICPAC guidelines for the following situations: 1) treatment of CoNS from superficial wound swabs, or respiratory or urine specimens unless they occurred in the setting of bacteremia; 2) dosing convenience defined as initial treatment with a β-lactam antimicrobial drug during hospitalization with a therapeutic change to vancomycin within 24 h of discharge that was not dictated by culture Results or allergy; 3) prolonged administration of an antimicrobial agent after implantation of prosthetic materials; 4) treatment of cellulitis without identification of a β-lactam-resistant pathogen (additionally, the empiric switch to vancomycin because of slow resolution of cellulitis was considered noncompliant use); and 5) ongoing treatment of infection in a patient with a history of MRSA colonization in the absence of a diagnostic culture. If the use of vancomycin met>1 of these specified criteria, each was included in data collection.

Data were collected on a standardized form and entered onto spreadsheets (Excel 2000, Microsoft Corporation, Redmond, WA, USA). To evaluate predictors for compliance with vancomycin use guidelines, discrete variables were described by percentages and compared by using chi-square or Fisher exact tests as appropriate. Continuous variables were described by means and evaluated by using Student t test. Variables with a p value <0.05 by univariate analysis were evaluated by stepwise logistic regression for inclusion in the final model. SAS version 8.2 for personal computers (SAS Institute Inc., Cary, NC, USA) was used for statistical analysis.

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