Curtailing unnecessary vancomycin usage in a hospital with high rates of methicillin resistant Staphylococcus aureus infections

Abstract

Aims: To implement and monitor the effectiveness of a strategy to curb unnecessary use of vancomycin and teicoplanin for inpatients in a teaching hospital/tertiary referral centre where 33% of S. aureus isolates (72% from ICU patients) were methicillin resistant.

Methods: A sample of 182 vancomycin/teicoplanin inpatient prescriptions surveyed, revealed that only 31 (17%) conformed with Centre for Disease Control (CDC) guidelines. Following education (ward-rounds, bulletins) on appropriate CDC based guidelines for prescribing glycopeptides directed at relevant clinicians, 'Immediate Concurrent Feedback' (ICF) was gradually deployed throughout the hospital. This entailed review of respective inpatient records on the next working day. If the indication was deemed not to conform with our guidelines, the prescriber was issued a memo (copied to the supervising doctor). Each memo detailed the 'errant' incident, listed appropriate indications and explicitly advised desisting from such prescribing and suggested alternative therapy if necessary. Corresponding glycopeptide usage data for our hospital and others in Hong Kong were retrieved and analysed as were samples of records of our inpatients with staphylococcal septicaemia (pre and during ICF).

Results: Compared with baseline values, during 2 years of ICF, inpatient prescribing of vancomycin and teicoplanin deemed to conform increased to 71% (773/1086); difference 54% (P < 0.0001, 95% CIs 47-62%). Corresponding average monthly usage (DDDs/1000 admissions) decreased from 76 (pre-ICF) to 45; mean difference 31 (P < 0.0001, 95% CIs 24, 38). Mortality from staphylococcal bacteraemia remained unchanged. No comparable changes in glycopeptide usage ensued in comparator hospitals.

Conclusions: ICF can be used safely to curb irrational overuse of vancomycin and teicoplanin in a hospital with high methicillin resistant S. aureus infection rates.

Figure 1

Vancomycin and teicoplanin usage per month. (a) Department of Medicine (excepting ICU and BMTC) (□) and Orthopedics and Trauma (), where the ICF programme was first implemented from August 1997. (b) Other departments in the hospital (▪), where the ICF programme was only introduced gradually over several months starting in January 1998. |→–– represents initiation of immediate concurrent feedback (ICF).

Figure 2

Vancomycin and teicoplanin usage in major Hong Kong hospitals, 1997–1999. Consistent with the highest level of tertiary activity in HK (management of the vast majority of patients with complex haematological disorders and renal, bone marrow and liver transplants), in 1997, Queen Mary (QM) hospital exhibited the highest usage of glycopeptides; about 30% more than Hospital I which ranked second highest. Despite continuing the same order of tertiary activity, by 1999 corresponding QM usage had decreased to the same level as in Hospital I, but usage elsewhere increased or remained unchanged.