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

Results

During the study period, NMHHC received 323 patient referrals for continuation of parenteral vancomycin therapy after hospitalization. The records of 27 patients (8.4%) could not be located and were not included in the study. Thus, the final analysis included 296 patients. Table 2 summarizes the criteria that determined whether vancomycin was prescribed within HICPAC guidelines. One hundred eighty patients (60.8%), 5 of whom met >1 criteria for appropriate use, received vancomycin within guidelines. A total of 118 (65.6%) were treated for infections caused by β-lactam-resistant, gram-positive bacteria. Sixty-seven patients (37.2%) received vancomycin for a reported allergic reaction to β-lactam antimicrobial drugs. Although only the first referral for home vancomycin was analyzed for each patient, 44 (14.9%) were referred multiple times to receive vancomycin as outpatients (2–8 referrals per patient) during this study.

Of the 296 patients, 116 (39.2%), 8 of whom met>1 criteria, received vancomycin outside HICPAC guidelines. Eighty-four (72.4%) cases were for continued empiric treatment of presumed infections in patients whose cultures were negative or not obtained. This practice was prevalent across all services. Dosing convenience led to the use of the drug in 18 (15.5%) patients, 12 (67%) of whom were admitted to a medical service. In 13 patients (11.2%), home-infusion vancomycin was continued after major surgical procedures involving implanted devices. This practice occurred exclusively in orthopedic and neurosurgery services. Finally, in 9 patients (7.8%), vancomycin was used to treat infection with a CoNS isolate from a single blood culture.

Demographic and clinical characteristics are shown in Table 3 . Patients whose use of vancomycin followed guidelines were older than those whose use did not follow guidelines (mean age 53.6 years vs. 48.9 years, p = 0.016). No significant differences were noted in sex or ethnicity, although African-Americans showed a trend toward receiving vancomycin within guidelines (p = 0.054). Appropriate vancomycin use was more likely after a longer mean hospital stay (12.2 days vs. 9.5 days, p = 0.007). No significant differences were noted in the mean Charlson comorbidity score or frequency of diagnosed coexisting medical conditions between the 2 groups with the exception of a history of malignancy (21.7% vs. 10.3%, p = 0.012) among patients who received vancomycin according to guidelines. Insurance status did not differ between groups.

Compliance with HICPAC guidelines varied according to the inpatient prescribing service. Appropriate prescriptions for vancomycin were more likely to be preceded by discharge from a medical service (60.0% vs. 37.9%, p < 0.001). This finding was true both for discharges from general medicine and medical subspecialty services, with the exception of hematology/oncology. More episodes of vancomycin infusion outside guidelines followed discharge from a surgical service (59.5% vs. 37.2%, p < 0.001), namely, orthopedic and neurosurgery services (35.3% vs. 17.2%, p < 0.001). Inpatient consultation by an infectious diseases specialist did not affect the appropriateness of home vancomycin prescriptions by managing services (p = 0.641).

The infection diagnoses of patients referred for home infusions of vancomycin are outlined in Table 4 . Patients were more likely to receive vancomycin per guidelines in the setting of bloodstream (33.9% vs. 13.8%, p < 0.001) and urinary tract infections (20% vs. 11.2%, p = 0.042). The microbiologic investigations undertaken and the organisms identified during hospitalization are delineated in Table 5 . Appropriate use of vancomycin was more likely to follow an attempt to make a microbiologic diagnosis (96.1% vs. 77.6%, p < 0.001). More blood, urine, and wound cultures were obtained in this group, and the number of cultures obtained was higher when vancomycin was used appropriately.

Results of the multivariate analysis are shown in Table 6 . Patients <65 years of age were less likely to receive appropriate vancomycin (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.26–0.94). Appropriate use of vancomycin was more likely to occur after discharge from a medical service rather than a surgical service (OR 2.62, 95% CI 1.53–4.48). Although discharge from a hematology/oncology service was not associated with appropriate use of vancomycin, patients with a history of malignancy were more likely to receive vancomycin within HICPAC guidelines (OR 3.02, 95% CI 1.40–6.53). Obtaining a wound culture was associated with appropriate use of vancomycin (OR 2.08, 95% CI 1.19–3.64). Finally, patients who underwent any microbiologic evaluation were more likely to receive appropriate vancomycin through home care (OR 5.93, 95% CI 2.26–15.54).

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