Administrative Memos

199913

FROM: Theodore O. Will, Chief Executive Officer
DATE: Sep 22, 1999
SUBJECT: Trends in Vancomycin Utilization in Selected New York State Hospitals - 1995 & 1998
IPRO CONTACTS:

Marguerite Shaffer, R.N., Director Downstate, Improvement Strategies QI - Ext. 356
Barbara Shields, R.N., Director Upstate, Improvement Strategies, (1-800-233-0360)

Enclosed please find the report entitled "Trends in Vancomycin Utilization in Selected New York State Hospitals- 1995 &1998." This report shows evidence of an improving trend in vancomycin utilization that is consistent with Centers for Disease Control and Prevention (CDC) guidelines.

Unfortunately, a majority of vancomycin use still appears to be inconsistent with the CDC recommendations. Bacterial resistance to vancomycin is an emerging public health threat and is associated with imprudent vancomycin prescribing practices. The CDC recommends the formation of multi-departmental, multi-disciplinary committees to develop a comprehensive strategic plan to detect, prevent, and control infection and colonization with vancomycin-resistant organisms.

Potential strategies which institutions may consider include the use of antibiotic ordering forms that require justification for vancomycin use; systematic monitoring of vancomycin usage in surgical prophylaxis, automated links between pharmacy and microbiology to permit identification of patients who may benefit from alternative antibiotic regimens; or utilizing an infectious disease and/or pharmacist consultation before vancomycin is released from the pharmacy.

Should you have any questions about this report or project, please feel free to call one of the above-mentioned contacts.

EXECUTIVE SUMMARY

"Trends in Vancomycin Utilization in Selected New York State Hospitals: 1995 & 1998" presents the results on the use of vancomycin in 16 hospitals which volunteered in 1996 to work with IPRO on this quality improvement project. The goal was to increase vancomycin use consistent with the guidelines of the Subcommittee on the Prevention and Control of Antimicrobial-Resistant Microorganisms in Hospitals of the Center for Disease Control and Prevention=s (CDC) Hospital Infection Control Practices Advisory Committee (HICPAC). Hosptials participated in response to a growing national concern with increasing vancomycin-resistant infections, particularly vancomycin-resistant enterococci (VRE) and most recently the emergence of Staphylococcus aureus with reduced (intermediate) sensitivity to vancomycin (VISA). These bacteria constitute a major component of all nosocomial infections, particularly among the most critically-ill hospitalized patients. Vancomycin frequently represents the drug of last resort in treating these two organisms. Increasing vancomycin resistance is associated with increased morbidity, mortality and hospital resource consumption. Vancomycin resistance is a major clinical and public health problem world wide.

Sixteen New York State hospitals volunteered to participate in the initial phase of a hospital-based retrospective chart review performed on January- June, 1995 discharges to ascertain vancomycin utilization patterns. The analytic sample for the 1995 data consisted of 1019 records. Fifteen of these hospitals participated in the impact, which were based on a retrospective analysis of discharges during the time period January-June, 1998. The analytic sample for the impact period included 703 records.

The unweighted proportion of vancomycin usage consistent with HICPAC guidelines for the 16 participating hospitals in the 1995 sample was 26%. The overall range for assessed vancomycin usage consistent with HICPAC guidelines among the 16 participating hospitals was 17-51%. The unweighted proportion of vancomycin usage consistent with HICPAC guidelines for the 15 hospitals that submitted data for the 1999 impact increased to 32% (p=0.01). The overall range for assessed vancomycin usage consistent with HICPAC guidelines among the 15 hospitals submitting impact data was 0-60%. These data should be interpreted cautiously as two impact hospitals with low HICPAC guideline adherence (less than 20%) had very small sample sizes of (less than 10). Also one of the 15 participating hospitals had a very large sample size, 233 of the total 703 cases.

The impact results are consistent with a literature that shows a wide variation in the ability to influence vancomycin utilization. HICPAC recommends the formation of a multi-disciplinary committee to develop a comprehensive strategic plan to prevent, detect and control infection and colonization with vancomycin-resistant organisms. Approaches that rely solely on education are ineffective. Potential strategies which institutions may consider include the use of antibiotic ordering forms that require justification for vancomycin use; automated links between pharmacy and microbiology to permit identification of patients who may benefit from alternative antibiotic regimens; or utilizing an infectious disease and/or pharmacist consultation before vancomycin is released from the pharmacy.