Risk Factors for Systemic Vancomycin Exposure Following Administration of Oral Vancomycin for the Treatment of Clostridium difficile Infection

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/110766/1/phar1538.pd

Impact of the sequential implementation of a pharmacy-driven methicillin-resistant <i>Staphylococcus aureus</i> (MRSA) nasal-swab ordering policy and vancomycin 72-hour restriction protocol on standardized antibiotic administration ratio (SAAR) data for antibiotics used for resistant gram-positive infections

Objective: Vancomycin is often initiated in hospitalized patients; however, it may be unnecessary or continued for longer durations than needed. Oversight of all vancomycin orders may not be feasible with widespread prescribing and strategies to enlist other clinicians to serve as stewards of vancomycin use are needed. We implemented 2 sequential interventions: a protocol in which the pharmacist orders MRSA nasal swab followed by a protocol requiring approval from pharmacists to continue vancomycin for >72 hours. Methods: In this single-center, retrospective, quasi-experimental study, we evaluated vancomycin use after implementation of a pharmacy-driven MRSA nasal-swab ordering protocol and a vancomycin 72-hour restriction protocol. The primary outcome was the change in the standardized antibiotic administration ratio (SAAR) for antibacterial agents for resistant gram-positive infections. We also evaluated the impact on antibiotic utilization. Results: Following the MRSA swab protocol, the SAAR decreased from 1.26 to 1.13 (P Conclusion: Implementation of a pharmacist-driven MRSA nasal-swab ordering protocol, followed by a 72-hour approval protocol, was associated with a significant reduction in the SAAR for antibiotics used in the treatment of resistant gram-positive infections and a reduction in vancomycin utilization. Leveraging the oversight of primary service clinical pharmacists through these protocols proved to be an effective strategy.</p

Documenting Penicillin Allergy: The Impact of Inconsistency.

BACKGROUND:Allergy documentation is frequently inconsistent and incomplete. The impact of this variability on subsequent treatment is not well described. OBJECTIVE:To determine how allergy documentation affects subsequent antibiotic choice. DESIGN:Retrospective, cohort study. PARTICIPANTS:232,616 adult patients seen by 199 primary care providers (PCPs) between January 1, 2009 and January 1, 2014 at an academic medical system. MAIN MEASURES:Inter-physician variation in beta-lactam allergy documentation; antibiotic treatment following beta-lactam allergy documentation. KEY RESULTS:15.6% of patients had a reported beta-lactam allergy. Of those patients, 39.8% had a specific allergen identified and 22.7% had allergic reaction characteristics documented. Variation between PCPs was greater than would be expected by chance (all p<0.001) in the percentage of their patients with a documented beta-lactam allergy (7.9% to 24.8%), identification of a specific allergen (e.g. amoxicillin as opposed to "penicillins") (24.0% to 58.2%) and documentation of the reaction characteristics (5.4% to 51.9%). After beta-lactam allergy documentation, patients were less likely to receive penicillins (Relative Risk [RR] 0.16 [95% Confidence Interval: 0.15-0.17]) and cephalosporins (RR 0.28 [95% CI 0.27-0.30]) and more likely to receive fluoroquinolones (RR 1.5 [95% CI 1.5-1.6]), clindamycin (RR 3.8 [95% CI 3.6-4.0]) and vancomycin (RR 5.0 [95% CI 4.3-5.8]). Among patients with beta-lactam allergy, rechallenge was more likely when a specific allergen was identified (RR 1.6 [95% CI 1.5-1.8]) and when reaction characteristics were documented (RR 2.0 [95% CI 1.8-2.2]). CONCLUSIONS:Provider documentation of beta-lactam allergy is highly variable, and details of the allergy are infrequently documented. Classification of a patient as beta-lactam allergic and incomplete documentation regarding the details of the allergy lead to beta-lactam avoidance and use of other antimicrobial agents, behaviors that may adversely impact care quality and cost

Documenting Penicillin Allergy: The Impact of Inconsistency

Background: Allergy documentation is frequently inconsistent and incomplete. The impact of this variability on subsequent treatment is not well described. Objective: To determine how allergy documentation affects subsequent antibiotic choice. Design: Retrospective, cohort study. Participants: 232,616 adult patients seen by 199 primary care providers (PCPs) between January 1, 2009 and January 1, 2014 at an academic medical system. Main Measures: Inter-physician variation in beta-lactam allergy documentation; antibiotic treatment following beta-lactam allergy documentation. Key Results: 15.6% of patients had a reported beta-lactam allergy. Of those patients, 39.8% had a specific allergen identified and 22.7% had allergic reaction characteristics documented. Variation between PCPs was greater than would be expected by chance (all p Conclusions: Provider documentation of beta-lactam allergy is highly variable, and details of the allergy are infrequently documented. Classification of a patient as beta-lactam allergic and incomplete documentation regarding the details of the allergy lead to beta-lactam avoidance and use of other antimicrobial agents, behaviors that may adversely impact care quality and cost.</p